The patient said he was transfer-ring his care from an HIV clin-ic in Brooklyn to ours, which

was closer to his home. The paperworkhe brought us consisted of a raggedpiece of paper extracted from his backpocket that listed his medications. Hesaid he needed to see a doctor rightaway.

When our administrator asked why,he said, “so I can get my meds.” “Yourother doctors weren’t giving them toyou?” she asked. “Look,” he said. “I justwant my meds.”

He was a vigorous man in his late30s. He lived with a girlfriend andworked odd jobs unloading boxes forlocal stores. Medicaid covered his med-ical care. He had been using intravenousheroin every two or three days since hewas a teenager. He didn’t consider hisdrug use a problem, and had never beeninterested in methadone or any othermeans of curtailing it.

The unfathomably random godswho parcel out HIV infections had beenkind to this man. Infected for ten yearsor more, he had never had health prob-lems from HIV, and his immune systemwas still in reasonably good shape. Hehad a very modest level of HIV de-tectable in his blood, suggesting that hewas at low risk of developing HIV-relat-ed health problems any time soon. Hehad no other medical problems.

But you wouldn’t know this from thelist of medications in his back pocket.He did not take antiretroviral drugs—his immune system was fine withoutthem—but his list contained just aboutevery other drug prescribed for the per-son ailing from AIDS. It included ap-petite stimulants and anti-nausea med-

ications, powerful narcotics for pain,sedatives and anti-anxiety drugs, anabol-ic steroids for energy, skin emollients,even the antibiotics prescribed to keepopportunistic infections at bay. And, ofcourse, Viagra.

“You need all of these?” I asked—forthe unfathomably random clinic admin-istrator who parcels out new patientshad assigned him to me.

“Sure,” he said. “My docs told me Ihad to take them all or I would getsick.”

“You actually take all of these?” Iasked.

“Sure,” he said. And sure enough, theshopping bag he was carrying containedempty vials for all of them, prescribedby a doctor in Brooklyn.

I had been down this road before.There was probably a chance this manwas taking every single one of thesemedications. There was a considerablyhigher chance that he was taking veryfew of them, and selling the rest on thestreet to finance his habit.

Thousands of words have been writ-ten about ethical issues raised in the careof HIV-infected patients. Most datefrom the days when the illness was uni-formly fatal and illuminate issues ofdeath and dying, withholding and with-drawing treatment, and the care of con-tagious patients. With the developmentof effective antiretrovirals, discussions ofresearch ethics and access to medicalcare have become paramount.

But one issue has gone largely un-mentioned for the duration of the epi-demic: the shotgun marriage this virushas forced between the medical commu-nity and the world of illegal drug use.Perhaps this issue appears relatively

minor next to the larger ones. Still, theepidemic grinds on, and those of us inthe trenches are as troubled by it as ever.

Nationwide, drug use has fueledabout 25 percent of the AIDS epidemic.In some places, such as New York City,the figure is closer to 50 percent, and insome neighborhoods in New York, thefigure approaches 100 percent. No dis-ease is more common in the drug-usingcommunity. And while many of thosewho acquired HIV through drug useabandoned the habit long before theirHIV diagnosis, and others immediatelyupon diagnosis, still others continue ac-tive use. This percentage varies fromstudy to study but is generally reason-ably high—high enough to support thefrequent finding that needle exchangeprograms limit HIV transmission.

Drug use is an expensive habit, andAIDS is an expensive disease. The al-ways-obliging street-corner marketplacelinked the two early on. AIDS patientsare treated with dozens of prescriptiondrugs with high street value—not onlythe notoriously expensive antiretrovirals,but other medications intended to keepthem vigorous, pain free, and emotion-ally intact. Anyone doubting the extentof the black market in prescriptiondrugs need only consider the 2002 Na-tional Household Survey on DrugAbuse, in which an estimated 14.7 mil-lion Americans reported illicit use ofpain relievers or psychoactive drugs inthe course of a year, in contrast to the6.3 million who reported using heroinor cocaine.

These pills do not fall off the back ofa truck. Most were presumably pre-scribed by a physician and were at somepoint thereafter diverted into the illicitmarketplace.

What is a doctor to do?In twenty years of caring for HIV-in-

fected drug users, I have had my pre-scriptions altered to change the numberof pills prescribed from fifty to 250, orto mandate the dispensing of brandname medication (far easier to sell thangenerics). I have had prescriptions ex-pertly forged de novo on home comput-ers. I have seen desperately ill patientsfurtively exchanging the amber vial of

8 H A S T I N G S C E N T E R R E P O R T September-October 2004

Hijacking Prescriptions

by Abigail Zuger

in practice

H A S T I N G S C E N T E R R E P O R T 9September-October 2004

medication I had just prescribed for awad of bills.

All sources assure me that none ofthese situations is likely to involve me inactual legal jeopardy; I write my pre-scriptions in innocence and good faith.What it does do, however, is change thedynamics of the doctor-patient relation-ship in unexplored ways.

Medical training aims to foster asense of identity between doctor andpatient. Emotionally, students are gen-tly moved along the spectrum of good-will from sympathy to empathy as theyadapt to an ethos in which the patient’swell-being, both physical and mental, isso important it becomes equivalent totheir own.

When a patient alters a prescriptionor sells the prescribed drugs, what hap-pens to this carefully fostered relation-ship of collegiality and trust? Is it auto-matically destroyed? Or is it possible tocreate some kind of a theoretical con-struct that allows both parties to carryon the mutual project of health care?

I certainly have no such construct tooffer for review. But I do have questionsI hope brains wiser than mine willsomeday address.

First, how does the inevitable dis-honesty of the inevitable confrontationaffect any analysis of the issue? This ishow it goes: “Are you selling yourmeds?” “No.” “What happened to yourprescription?” “This guy I know took it,then he gave it back.” There is really nosuch thing as full disclosure in thisarena; it just doesn’t happen. Whichmeans, among other things, that there isalways some doubt as to what has actu-ally taken place, and whether the viola-

tion occurred as perceived. And supposethe violation has not yet taken place, aswith the patient in my office. Does oneforestall it, or wait for the script to playitself out?

Second, should the prescription begiven its full symbolic value in theseevents, or is it just a piece of paper? In-variably, the first emotion a doctor feelson seeing a forged prescription is utterbetrayal. Our prescriptions symbolizean array of intangibles, including ourprofessional competence, our good in-tentions, our belief in the tenets of or-thodox medicine, our good standing inthe community, our roles as custodiansof public funds budgeted for drugs. Adefaced prescription can feel like an ac-tual personal attack. But, in fact, oncethe prescription is signed and handedover, it and the drugs it procures belongto the patient, who is seldom aware ofthese overtones. Patients are selling theirown drugs, not the doctor’s. No spiritu-al violation is intended; it is a simplebusiness decision. How are these dis-parate views of a commodity to be rec-onciled? Suppose a patient sells hismedications to buy not drugs, but foodfor his children. Does anything change?

Third, what about the nature ofAIDS itself? Controlling the diseasemandates that a patient establish andmaintain a close connection with thehealth care system. Banishing an HIV-infected patient from a health-care set-ting has weightier implications than itdoes for an uninfected patient. Drugusers are a disenfranchised populationwhose suspicions of orthodox medicineand its strictures are difficult to over-come. One picks one’s battles carefully

in their care, trying to bend enoughrules to maintain a relationship that willeventually spawn some trust. In thisarena, how are limits to be set?

What about the personal ethos of thephysician? Should doctors’ own views ofthe current drug laws affect their re-sponse to the patient who defies them?Should doctors who work together ad-here to a consistent policy, or may eachfollow his or her conscience? Whatabout doctors who live in the same city,or who treat the same illness? Howmuch professional consistency is possi-ble, or even optimal? Do I have anyobligation to write the same prescrip-tions as some unknown (and, I suspect-ed, not very swift) doctor in Brooklyn?Probably not. But does a patient have aright to expect some consistency frommedical providers working three milesapart? In this age of disease manage-ment guidelines, that is a trickier ques-tion.

Over the years I have seen doctorsreact in every possible way to the hijack-ing of their prescriptions, from ignoringthe events completely to banishing thepatient immediately from the site ofcare. No solution ever seems to be en-tirely right.

The patient in my office was jigglinghis leg, impatient to be done. I lookedat his list of meds and wrote him pre-scriptions for half a dozen of the sim-plest and least expensive that seemedleast likely to harm him or others. I toldhim I could not fill the rest. He accept-ed his prescriptions and left, broke hisnext appointment, and I haven’t seenhim since.