The Secret Language of Doctors

by Brian Goldman

  In the world of drug seeking, the roles are reversed. The drug seeker—a con artist with a nose for a doctor’s psychological weak points—is the suave professional. And the doctor, more often than not, is the vastly outmatched dupe. The dilemma for doctors on the front lines is that the patient whose story sounds legitimate might be a well-rehearsed, lying con artist. Or he might look like a criminal but be telling the truth. Or maybe he’s a little of both.

  I know a lot about drug seekers because more than twenty years ago, I was one of the first ER physicians to become fascinated by “drug diversion”—the movement of legal narcotics and other controlled substances (the ones controlled by government legislation) from regulated professionals such as physicians and pharmacists to the street. I’ve written articles and book chapters and have given hundreds of lectures and workshops on how to recognize drug seekers. Long before actor Hugh Lawrie said it on the TV show House, I was teaching colleagues how to be lie detectors.

  To me, there was always something deliciously refreshing about the idea that book-wise yet emotionally dumb MDs could be outfoxed. In some ways, I’ve always enjoyed pulling people’s legs by telling a good fib myself. Besides, there was a gap in our education. I could not find a single textbook that paid any attention to drug seeking. That lack attracted me.

  In the politically correct world of hospital medicine, you’re not allowed to be pointedly contemptuous with even the most difficult of patients—unless they’re drug seekers. I suspect it’s appealing for many of us to be able to disrespect patients we don’t understand and certainly don’t like.

  “Most seasoned ER docs come to automatically suspect malingering whenever unknown patients present with symptoms of this ilk,” writes ER colleague Dr. Donovan Gray in Dude, Where’s My Stethoscope? “This attitude is unfortunate, because it undoubtedly causes us to treat some bona fide sufferers with less compassion than they deserve.”

  To Dr. Stephen Bergman, a psychiatrist by training with a long career treating patients with addiction, the attitude seems all too familiar. Back when he was inventing medical slang in the 1970s, one dreadful acronym was already in use by health professionals: SHPOS, for sub-human piece of shit. “It seemed even too cruel for us, but it was New York, you know,” Bergman recalls. “That was cringeworthy.”

  Berman says SHPOS was used to refer to the criminals, drug addicts and gang members who frequented Bellevue Hospital Center, a well-known and well-respected psychiatric facility in New York City. “When an alcoholic or a drug addict comes into the ER and is going to die but you know how to save him, you know it’s going to take a lot of work,” says Bergman. “But you also know that you’ll see him back next week. It makes you so angry at these people. You’ve spent your whole life getting trained to save people, and these people seemingly don’t want to save themselves.”

  * * *

  Like the ER physician or the GP who gives drug seekers whatever they want, it’s easy for a doctor to get a reputation in prison as an easy mark.

  “If you’re an easy mark on the inside, word travels fast in our small town of 900 convicted felons,” says Puerini. “To work in a prison, you have to be smart.”

  One woman who long ago figured that out is Nicole Donaldson. For eight years, she worked as a nurse at the Vancouver Island Regional Correctional Centre in Victoria, British Columbia. The facility was called the Saanich Prison Farm when it opened back in 1913—so-named because it’s located in the District of Saanich, which is named after the Saanich First Nation. Although renovated in the 1980s and ’90s, the correctional facility retains its Edwardian-era brick façade and courtyard. Donaldson says the whine line is alive and well at Canadian correctional facilities.

  “We had that a fair bit,” Donaldson recalls. She says inmates complained of back aches or pain from injuries sustained in motor vehicle accidents, to get prescriptions for narcotics. Some said they had anxiety to get Lorazepam, a sedative. Try as they might, the inmates she saw never got a thing from her. “They usually went to the softies,” Donaldson says in reference to her more empathetic colleagues. She says many convicts also complained of toothaches. She acknowledges that a lot of them probably had tooth pain—much of it due to illicit drug use. For instance, methadone is known to cause dental decay.

  “I wasn’t very sympathetic because the pain was self-inflicted,” she says. “It wasn’t like we held them down and made them do that. I never ever caved on anything. Never.”

  Occasionally, a clever inmate would set up a more elaborate scam to get drugs. Donaldson says some inmates injured themselves deliberately to earn a trip to the local ER. “They’ll break their own finger so that they can go to the hospital because their girlfriend’s going to leave them some coke or something in the toilet paper roll on the second floor in the bathroom by the ER,” says Donaldson. “If they put that energy to work [on the outside], they’d be millionaires.”

  Donaldson says she was rarely fooled because she learned a valuable lesson from a nurse I’ll call Brad. She says Brad told her that “if I learn nothing else from him, to please learn that if their lips are moving, they’re lying.”

  Donaldson says she didn’t follow Brad’s advice blindly. “I would go and research those requests for pain meds,” she says. “Almost 99 percent of the time it was all lies. So you kind of get tainted.”

  * * *

  A 2006 study by the U.S. Bureau of Justice Statistics found that nine out of ten inmates with mental illness abuse alcohol or drugs. So it’s hardly surprising that much of the lying that Brad taught Nicole Donaldson about involves the acquisition of drugs or alcohol.

  Jailhouse booze is known as squawky or pruno; whatever you call it, it’s a mash made from water, bread (for its yeast content) and fruit. “It smells horrible,” says Jeff Keller. “So most of it is caught because the deputies or correctional officers smell it and track it down.”

  When it comes to drugs, sooner or later, many of the drug seekers who plague ERs get caught forging scripts, robbing pharmacies or committing other crimes to pay for their drug habit and end up in jail or in prison. Many are addicted to narcotics such as OxyContin; correctional physicians put these inmates through a detoxification program to get them off narcotics. Occasionally, inmates continue to receive regular doses of a narcotic for chronic pain or they receive methadone (a synthetic narcotic that’s given to ward off withdrawal symptoms) as part of a drug-maintenance program.

  Those exceptions aside, narcotics simply aren’t given out very often. Inmates will look for any medication with mood-altering or sedating properties that can be used as a substitute for their drug of choice. Jeff Keller says antidepressants including doxepin, amitriptyline and trazodone are favourites. So is the over-the-counter antihistamine Benadryl. Inmates can use these drugs. If they’re really clever, they can sell them to fellow inmates.

  At the Wilkinson Road Jail in B.C., Nicole Donaldson says, inmates traded drugs such as methadone and Seroquel, also known as Quetiapine, which is prescribed for psychotic symptoms. It is also prescribed as a nighttime sedative for elderly patients with dementia who have a tendency to get agitated. “They’ll trade any kind of medication,” Donaldson says.

  Also in demand are Ventolin puffers—also know as inhalers—which contain Ventolin and Salbutamol and are prescribed to patients with asthma. Inmates believe that, when snorted, Salbutamol produces a speed-like effect. “We have to be very strict on puffers because those little monkeys will spray medication onto a counter, scrape it off and then snort it,” says Donaldson. “They will snort anything that can be crushed.”

  Trading drugs in prison takes some planning. Instead of prescriptions, inmates receive their doses one pill at a time and are watched as they swallow. Some use quite ingenious methods to hold the drug in their mouth while pretending to swallow it. Inmates and the doctors who look after them call that “cheeking.”

  “You can hide it in
your cheek, but there’s a lot of ingenious ways of doing it,” says Keller. “There’s sleight-of-hand, like a magician; you palm it so it never gets into your mouth. One inmate used the space where he was missing a tooth to hide pills. Inmates also use denture adhesives like Fixodent placed high up on the roof of the mouth to hide pills. If we really wanted an inmate to take his pills, we would crush it and watch him take the crushed medication. But Keller knows one inmate who would stick a crushed pill on his tongue, pretend to swallow it, then scrape the pill fragments and saliva onto a piece of paper and mould that into a ball, let it dry and then sell it.

  “Inmates are really good at cheeking their pills,” says Keller. “I suspect we only catch about one in ten. A lot of the time, we only learn about it because an inmate has some sort of adverse drug reaction tied to a particular pill. But they aren’t supposed to be taking that pill, which means they got it from another inmate. So we see who else in their dormitory takes that particular pill. Sure enough, once you confront them with the evidence, they confess.”

  Nicole Donaldson says that when she worked with inmates, the nurses would crush tablets into a paste, add it to food and watch the inmate eat it. It was foolproof—or so the nurses thought.

  “I had a fella come up to me at the jail and ask if I could get him on some Seroquel 25 milligrams,” she recalls. “He said it really works. I asked him how he knows it works. He said he’d been taking it for two months.”

  When Donaldson checked the inmate’s file, she discovered he hadn’t been prescribed Seroquel, which is used to treat the symptoms of schizophrenia and other psychotic disorders. She tracked the inmate down in the prison yard and confronted him about where he got the drug. Turns out the seller was a fellow inmate who swallowed the paste, vomited it up onto a piece of paper, let the vomit dry, then sold the dried effluent. Donaldson asked the man how he could stand swallowing the fellow inmate’s barf. “I’m selective about who I buy it from,” she says he told her.

  Donaldson recalls that another inmate who was prescribed methadone while incarcerated managed to throw up the drug into a condom and sell that.

  * * *

  Some inmates are motivated to get drugs; some want light duties or time off work. Others still want to charm corrections employees. Inmates call that “downing the duck.” It’s a slow, painstaking process by which prisoners recruit and seduce correctional staff to do their bidding.

  Not surprisingly, prison nurses and doctors are frequent duck-hunting targets.

  “Inmates talk about the word grooming,” says prison doctor Mike Puerini. “They groom one of the people who work for the prison to get what they want from them. They learn a secret about one of the people who work in the prison. Then they hold it over that person’s head and extort them for pills or sexual favours. They get [prison staff] to share personal information like how their kids are doing. They engage them in conversation about their personal life. Once you start, some of these guys are pretty bright about human nature. They can see when you’re having a bad day.”

  Nicole Donaldson says she, too, has seen inmates manipulate health professionals. “There was an RN that was railroaded out because she was too kind and too touchy with them,” she says. “She was an okay nurse but she was a bleeding heart. When the boys would give her a story, she would buy it. So then it caused the rest of us grief, because she would do these nice things and the rest of us wouldn’t.”

  Donaldson says that, in rare cases, it was corrections officers and other support personnel who cultivated relationships with the inmates. “We had a female officer that would come on nights and she would do aerobics in a mental health ward.” Until staff realized she was exercising within sight of the inmates, “we couldn’t figure out why the boys all got excited and caused her grief all night.”

  Prison employees who get involved with inmates aren’t committing minor indiscretions, says Mike Puerini. “We’ve had situations in Oregon in which health-care workers have gone to prison because they’ve had physical relationships [with prisoners]. It’s especially difficult for health professionals, because a lot of them are women working with men prisoners.”

  And it’s not just about getting drugs or sexual favours. In some cases, corrections officers have helped prisoners escape. But those are extreme examples. In health care, we teach students about maintaining tight boundaries with patients. Outside prison, it’s all about professionalism; inside, it’s often about keeping health-care workers safe.

  Puerini says he once was getting ready to leave on holiday when, “about a week before I left, I saw an inmate who wished me a nice vacation in Hawaii. I was pissed off because somebody let this guy know that I was going to Hawaii. Well, guess what? I don’t want this guy to know I have a family, much less that I’m going to Hawaii. Now he can call his buddy on the street and tell him that Puerini’s going on vacation and see if you can find his address.

  “You always have to have it in your brain,” says Puerini. “If you don’t, you’re going to let down your guard and when you do, you’re going to put people in danger.”

  It’s drummed into every medical student and resident that relationships with patients are strictly forbidden. It’s ridiculous to have to say that goes double when the patient is a convicted criminal. That it ever happens is evidence that some health professionals have psyches that are quite wounded.

  * * *

  The prodigious capacity to tell whoppers is but one thing that separates patients behind bars from the ones I see in the ER. Another is the way jail-bound patients use their anatomical attributes for non-medical purposes that can be quite profitable.

  Jail doctor Jeff Keller set me straight on those who use various orifices to smuggle contraband into correctional facilities. People not familiar with the correctional system use jail and prison interchangeably. But there are some important differences between the two. In the U.S., jails are most often run by sheriffs or a local governing authority and hold people awaiting trial or serving short sentences. Prisons, which are operated by a state government or by the Federal Bureau of Prisons, are for convicted criminals who typically serve longer sentences. In Canada, jails are run by the provinces and their inmates are serving sentences no longer than two years less a day. Canadian prisons, known as penitentiaries, are run by the federal government.

  As far as smuggling is concerned, in the United States, the Supreme Court has ruled that it is illegal for officers to do a body- cavity search on people admitted to jail unless there is probable cause; in prison, such searches are permitted. As a result, people going to jail frequently use body cavities to smuggle everything from drugs to personal items to weapons. Not surprisingly, the medical slang used to describe such activities is rather crude.

  “Inmates refer to that as keestering if it’s in the rectum and cootching if it’s in the vagina,” says Keller. “I’ve also heard it referred to as the prison locker. We doctors call it the pink purse and the brown purse. You can put anything you want in the pink purse and the brown purse and the Supreme Court says that we can’t look for it.

  “Inmates can secrete an amazing variety of things. One woman was caught with a compact case of makeup, a methamphetamine kit that included a syringe and a little vial of meth, a cellphone and a hard pack of cigarettes [in her vagina all at one time]. That was pretty impressive.

  “There was another inmate who wasn’t caught until he stabbed another inmate with a steel rod that was eighteen inches long and sharpened to a razor point that he had smuggled in the brown purse.”

  Not surprisingly, a lot of the pink- and brown-purse stories involve the smuggling of drugs and related paraphernalia.

  “We had a guy come in with cocaine up his backside,” Nicole Donaldson recalls with unconcealed delight. “The man was processed and then transferred immediately into the segregation part of the jail. There, he was placed in a dry cell; the water in the toilet system had be
en turned off to prevent drugs—and everything else—from being flushed away. Every single time he has a bowel movement, they go through the stool. And then they shine a flashlight up his backside to see if there’s more coming. They took eight balls of cocaine out of his backside. And a crack pipe.”

  Few stories can top that of Christie Dawn Harris, a 28-year old dealer in crystal methamphetamine from Oklahoma who reportedly hid a .22-calibre handgun loaded with three live bullets and one spent shell in the case—all inside her vagina. A story in the New York Daily News in March 2013 said that Oklahoma police found the gun after arresting Harris during a drug raid. The story goes on to say that officers found bags of meth shoved up her anus. After pleading no contest to possession of methamphetamine with intent to distribute, gun possession and bringing contraband into jail, Harris was sentenced to twenty-five years in prison for her crimes.

  Recently, a case made the news that tested not only the constitutional powers of the police but the role of doctors in police work. According to a news report by the Knoxville News Sentinel, in February 2010, Felix Booker and his brother were stopped by police as they made their way through Oak Ridge, Tennessee. Catching the aroma of marijuana, the police booked the suspects for felony possession. At the police station, investigators did a strip search. Suspecting that Booker had secreted cocaine in his rectum, police asked him to consent to an invasive search. Booker agreed; however, Dr. Michael LaPaglia, the doctor who carried out the search, found that Booker clenched his buttocks during the search. The doctor then injected Booker with a drug that paralyzed him and then intubated the suspect to protect his airway. Dr. LaPaglia repeated the invasive search and found 10.2 grams of crack cocaine in Booker’s rectum.