"So," I say into the phone. "You were in the ER last night."
"Yeah," he replies. "I felt so sick. They sent me home after a while, though."
"Do you know that your urine came out positive for cocaine and alcohol?"
"Well, yeah. Let me be truthful," he replied. "I was in New York with my cousin, I was stressed out, and I did some cocaine. No lies, OK? Urine tests don't lie, and if I lie to you, I'm really just lying to myself, right?"
I took a deep breath. "Yes, that's right. Now, the other problem is that your urine came back negative for opiates. We've been prescribing you morphine for pain, and your urine should be positive for morphine. What happened there?"
"OK, OK. Like I said, I was in New York and forgot to bring my morphine. That led to me stressing out and doing the coke and alcohol. I know you're not gonna trust me now. I'll do any urine test you want, any day you want. I want to earn your trust back." He was pleading now.
"You just have to understand," I explained. "When we prescribe you morphine, we expect to see it in your urine. When your urine comes back negative for morphine and positive for cocaine, what do you think we suspect that you're doing with the morphine?"
"Selling it on the street to buy cocaine?" he answered faintly.
"Exactly! And that's a big no-no in our book, I'm afraid." I pause for effect. "The last thing a doctor wants is the medication he prescribes to end up being sold at the bus station, and believe me, alot of what we prescribe IS sold at the bus station."
He was worried now. "Look, I'm so sorry. I'll do whatever you want, but you can't cut my morphine off. My pain is still so bad. Tell Dr. ___________ that he can order any tests he wants. Please."
"Don't worry, we're not cutting you off yet. That would be cruel. But you've got work to do." I continued my diatribe. "There will certainly be urine tests, but they'll be random. And you can't say you can't make it when we call you to come down to the clinic. You signed a pain contract, so now you have to honor it."
"OK, OK. I'll do it. Tell the doctor I'll do it. I'll show you that this was a one-time thing."
"OK, just relax, and we'll talk to you soon. And stay out of trouble, y'hear?"
"Yeah. I'll talk to you soon." He hung up first.
I hung up the phone and took a deep breath. I hate these conversations. I also hate dealing with narcotics. I hate the whole system. Pain management is a total drag for the tired Nurse Care Manager, and narcotic diversion onto the streets haunts us daily. These are the times I play Good Cop/Bad Cop, and it's no fun for anyone, including me.
Was he telling the truth? Can I trust him? Will his subsequent toxicology screens be negative? My sense of hope and faith say yes, but only time (and urine) will tell.