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This month, the great minds of emergency medicine are debating the issue of pain management. I have never done a fellowship in pain management, but I have been taking care of people with pain for almost 40 years. There are things you learn over that period of time which are obvious. As Bob Dylan said, “You don’t need a weatherman to know which way the wind blows.” And after almost 40 years of dealing with patients in pain, you do pick up some generalities that guide the practice. First and foremost, pain is not a simple issue. Injuries which should be of minimal pain in the eyes of the physician may be of maximal pain to a patient. Is there any easy way to know? Not really. When I ask a patient if they have pain, I am basically asking them to reflect on how a disease condition or traumatic process is affecting them. There is no simple way to look at the pulse rate, the respiratory rate, the blood pressure, etc… and know the degree of pain that exists.

The first area that I’d like to comment on is the pain score. This seems to be a holy grail for administrative types and those running institutions like the Joint Commission. If there’s ever been less science in medicine, I’d like to see it pointed out. A scale from 0 to 10 is asked of people who have absolutely no scientific training. They have no way to stratify pain. Emergency physicians and nurses always poke fun at the patient with “10 out of 10” pain. Actually, the “12 out of 10” pain evokes even more humorous comments. In truth, I think it’s difficult for the patient to know how to utilize the scale. What I’ve learned is that the only thing that’s of use is the amount that their pain has changed. If a patient says that they start out with “10” ­– and most of them do – if it’s now at “5” I’m probably making some progress. But to say that it’s any more useful than a very general guide is to give it considerably more scientific validity than has ever been proven.

Secondly, there is no hot button in emergency medicine like the evil term “drug seeker.” It absolutely clouds our thinking about the patient and their problems. As soon as the label of “drug seeker” has been applied by the staff, all intelligent inquiry stops. We start to put up a wall, really for no good reason. It is always interesting to talk to physicians about whether they had a “good shift” or a “bad shift.” It almost never has anything to do with the actual disease entities that were presented. Often, it’s directly related to the number of patients they thought “really didn’t need pain medication.” I think that we put far too much stress upon ourselves when we start to feel that we are the gatekeeper to pain medications. It is interesting to note that when a patient comes back to the emergency department with recurrent pain, we refer to them as a drug seeker. We don’t refer to a patient with asthma who has come back for more treatment as an “oxygen seeker.” Exactly why is this a problem? I think to a great degree the personalities involved. Physicians and nurses are, by definition, type A personalities who do all, bear all, go through all, without whining or complaint. We long for the era of wooden ships and iron men when patients were grateful for care and kept their mouths shut. Anyone who has significant pain not relieved on the first attempt probably doesn’t deserve our care. This mentality becomes cyclical and frightening.

There are extenuating circumstances, however. As soon as we use “pain” in the same sentence as the word “cancer,” any therapy becomes acceptable. It doesn’t have to be a cancer from which a patient is dying. Somehow, adequate pain therapy for a cancer patient is OK. Why don’t we think that adequate pain therapy for a sickle-cell anemia patient is OK? Is this because they tend to be a more ethnic population? Is this because they tend to challenge our own sense of who deserves pain relief? There are considerable studies that show that the giving of pain medication in emergency departments is related to ethnic types. This is a black mark on the profession.

Another aspect of pain management is the fact that drug addiction is a ubiquitous problem in this country. No matter where I go and no matter where I teach, everyone starts out the drug-seeker conversation the same way. That is, “You don’t have all the drug seeking patients that we do.” News flash: It’s exactly the same everywhere. Rural, urban, north, south, east, west, black, white or Hispanic. It doesn’t make much difference. There’s going to be a certain percentage of patients at each ED who are going to be considered “frequent flyers” on pain. Is this a problem? Yes. Is it always appropriate to confront them? No. Having done this for a number of years, I view addiction as a complex problem involving both the psyche of the patient and whatever they’re addicted to. Addiction is a form of obsession and no obsession is amenable to instant therapy. Whenever I wonder whether I should or shouldn’t be giving a dose of pain medication, I always remember this: I’ve never created an addict by giving one shot of pain meds, and I’ve never cured an addict by withholding it. These are complex issues and I can’t always sort them out in the emergency department. There’s no question that there’s heavy pressure from the nursing staff to deny certain patients medication. The snide comment that “you’re not going to give them pain medicine, are you, Doctor?” has, more than once, intimidated and dissuaded otherwise compassionate physicians from acting. My philosophy on this is simple. I’d rather treat ten patients who don’t really need the pain medicine than deny the one patient who really does. The complexities that go along with making these decisions are much more than the number of visits and their underlying disease entities. It is a reflection not only of the patient, but of the doctors and nurses involved. Are there too many medications given in this country? Without question. But it’s not because of the emergency departments. Prescription drug abuse is a national phenomena and we should not be beating ourselves into thinking that we are the cause of the misuse of pain medications in this country.
 
Lastly, pain management is totally individualized. The dose that works for one patient does not necessarily work for another. I have long gotten over the idea that 6 mg or 8 mg of morphine is enough. You know what’s enough? The amount that works. I have no problem, if I’m going to use a narcotic, with using an adequate amount of that narcotic to solve the problem at hand. We need to ask this question: What’s the goal? What’s the end point? I’ve found that if I’m ultimately trying to give adequate pain medication and assuage a patient’s fear, there’s nothing better than to look them in the eye and say, “I have more pain medicine than you have pain. I can take care of the problem.” And I always assure each patient that there are no points given in my emergency department for suffering. If we’re not adequately treating your pain, let us know. We are not mind readers. But at the end of my career, I’d rather have over-medicated a couple patients than denied the many the adequate treatment for their suffering.

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Comments   

# MDERDoc 2009-03-11 09:02
I approach drug seekers with the same mantra I've heard from our legal system: I'd rather give narcotics to ten drug seekers than deny meds to one person with legitimate pain.

If you fail that one legitimate person, you are not doing your job. I do have a backbone and the blatantly obvious seekers, I have no qualms about denying them narcotics and showing them the door.

I've never lost any sleep over giving pain meds to someone who is potentially a seeker. I have over ones I blew off and wondered if I did the right thing.
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# Response to ERDocChris Carpenter 2009-03-12 00:00
I agree with your philosophy. Until some genius invents an objective, reliable point-of-care pain test, I lack confidence in my ability to distinguish drug-seekers from true pain relief seekers. I've also lost sleep over those I have previously denied and do not want to do so again. The blatantly obvious seekers are easy, but in my practice they also seem to be the minority.
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# Flip side of treating narcotic seekersPaul Bock 2009-03-12 09:27
Though I do agree with most of your article, and have been known as "the candy man" at my ER due to my willingness to treat pain, I have noted the dramatic increase in what I would call "ER abusers" rather than narcotic seekers. Many of these patients are chronic pain patients, with NO objective findings after months of multiple visits, who take the ambulance and clog the department, demanding IV narcotics even though nothing has changed. Many of these patients come in over and over again until we finally start refusing to treat them with narcotics and instead refer them to their primary care doctor. How can we, as responsible health care providers, help reduce the drain placed on our suffering health care system by these people?
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# Just say no.Jeffrey Thewes 2009-03-14 08:40
Having had a friend and fellow ER doc who just killed himself over addiction problems and having just taken care of a nurse who almost died from a narcotic od, who had her 5 year old daughter open the door for paramedics and had been seen multiple times in the ER for Flank pain and diagnosed as "recently passed stone". I am affronted by your statement and cavalier attitude in dispensing meds to "drug seekers". We are killing these patients, from Heath Ledger to my friends listed above. Our job is to "do no harm", giving narcotics to those who don't need it is more deadly that giving antibiotics to a virus, though there is no perfect way to tell its a virus and not a bacteria. Why don't we just give antibiotics indescriminantl y. We use our clinical judgement in withholding antibiotics and sometimes we are wrong. It takes the same faith in our abilities and experience in denying potentially harmful narcotics to patients who don't need them.
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# MD PhDMCO 2009-03-15 01:06
Greg is such a generous guy, giving himself a pat on the back for being compassionate. Unfortunately, you have missed our dilemma. The problem for the average pit doc is not weather or not to give pain medication to an unknown patient reporting pain, but what to do with the patient whom recurrently comes to the E.D.complaining of pain, and creating a scene on arrival, screaming and demanding immediate attention despite $5 million of testing documented in the computer medical records which have demonstrated no pathology. Feed the stray cat and they will return, but hopefully on Greg's shift and not mine.
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# To give or not to give?ERGO 2009-03-17 05:43
The population in the ER I work in is heavy in the 20-30 age group. Many are unemployed "kids" with poor role models and too much time on their hands. Narcotic drug abuse is relatively safe compared to homemade illicit drugs. The word on the street is/has been that if you want drugs, go to our particular ER (this alone creates a waiting room full of people with illegitimate complaints, taking our time and attention away from those who really need us). If we continue to feed this generation of young people who want Vicodin for a paper cut, or lie time and again about their nonexistent or imagined dental pain to three different ER docs in one week, we will have no one to answer to when that generation cannot take responsibility for their own actions, and we in turn one day end up spending our government resources to fuel rehab programs/put them through the legal system for trafficking/put our social services to work for the families that people with addictions destroy. Why do we want to create our own monster? Why don't we think of the repercussions of our decisions as health care providers since they will come full circle?
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# Skepticjb 2009-03-18 04:40
Certainly with broken bones I am liberal, but when some guy travelling through with back pain and a Toradol, Tramadol, all NSAIDS, celebrex allergy who "cannot get anymore CT scans because he had too much radiation already" comes in at 2 A.M. with flank pain, I am mildly hostile.
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# Two more things...JJS 2009-03-19 13:19
Well thought out and beautifully written. I would add two additional points:
First, we all know -- or should know -- the proper way to manage pain; relatively smaller doses given parenterally (therefore intravenously) at relatively shorter intervals, with the patient understanding we will keep giving medicine until their pain is addressed. This avoid the fruitless and frustrating negotiation that often occurs when a patient is convinced that one IM dose is all they'll see for the next four hours. Titrating analgesics to pain is also safer. Nineteen times out of twenty, you'll get away with 2 mg of Dilaudid IVP (equivalent to 175 mg of Demerol, BTW) to an unmonitored patient tucked in a corner or hallway somewhere; it's the twentieth time that worries me. True, this entails more work for the nurses, who are often hampered by rules that won't let them hold onto to leftover Rx for any length of time. But, as I used to teach my residents, whenever in doubt, the best first question to ask is "What's best for the patient
Finally, when I have suspected drug seeker, I usually follow Dr. Henry's advice initially. But after a reasonable time and dosage, I'll stop chasing their pain. I simply tell them, "Look, you've gotten 4 mg of Dilaudid and 60 of Toradol, and you still can't move. It's best to admit you." 90% magically improve; the other 10% end up coming for intractable pain, which is probably the correct diagnosis.
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# What's really best for the patient?MP 2009-03-19 15:15
Having just coded a 17-year old who died of prescription drug abuse two days ago, I tend to agree with the comments from "just say no" above. I don't lose any sleep over ONE shot of pain medicine, but certainly the generous prescriptions for narcotics requested by many of these patients is too much. I'm thankful my institution has a guideline for repeat ED chronic pain visits which limits narcotics to the ED only when a patient has failed to follow up with willing pain management providers. And I insist on a photo ID so I know who I'm dealing with, for any patient going home with a narcotic prescription.
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# ER doc in MexicoAdan R Atriham 2009-03-21 02:24
After almost a decade of practice in the US, I recently relocated back to my home town in Mexico. To my surprise, the pain management issue here is dead on water. The idea of giving morphine to a patient with a broken ankle with the part of the tibia sticking out is a big deal here b/c very few people know how to give narcotics. The threat of respiratory depression or complication limits patients from appropriate pain control. I totally agree with Greg, we do a crapy job on relieving pain in most cases and we should get better at it. The flip side is the abuser who just wants the drug. I don't think there is magic bullet on this issue and will continue to be the cross for most of us in the front line.
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# Dr. HaldolDr. Haldol 2009-03-21 15:29
God invented Haldol for a reason. If they are asleep, they are not in pain.....

50mg of sit your a$$ down and 100mg of shut the bleep up
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# Disagree with Dr HaldolER doc in Mexico 2009-03-22 18:30
Pts who receive only Haldol or just sedation with no pain control will have more pain after the procedure or when they wake up. They may not remember what happened but that doesn't mean they didn't feel it. Your approach of "sit on your a$$" and "shut the bleep up" to treat patient's pain is a disgrace to the profession. If that is what you would do to your son when he brakes his arm, that means your should have never become a father either.
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# Detecting substance abuse in the EDKen Solis, MD, MA 2009-03-30 15:39
I concur with the great majority of assertions that Dr. Henry makes in “What’s Your Pain Philosophy.” However, he seems to disavow any role in confronting and redirecting a person who is even /known/ to be abusing a controlled medication. According to The National Center on Addiction and Substance Abuse at Columbia University, prescription drug abusers outnumber cocaine, hallucinogen, inhalant, and heroin abusers combined – a substantial number of which obtain their medications of choice through the healthcare system. Perhaps more importantly, controlled medications are involved in about 30% of drug related deaths. To wash our hands of any responsibility in trying to address a patient’s addiction is to violate that “primum non nocere” clause.

Dr Henry is correct in stating that there we must also be careful about the potential harms in stigmatizing a patient with the label “drug seeker” or even a more carefully worded diagnosis like “behavior consistent with controlled medication seeking behavior.” These diagnoses should only be made when you have a high degree of certainty and not mere suspicion. Obtaining the solid evidence to determine that a patient is abusing controlled medications typically requires a careful history regarding controlled medication use and then corroborating the offered history with discovered facts. A call to the patient primary healthcare provider, local pharmacy (just type in their address and “pharmacy” on “Google Maps”), a call to a national pharmacy chain with a database like Walgreen’s and CVS, or your state’s controlled medication database, if it has one, can often determine if the patient is getting multiple prescriptions from multiple providers in a short period of time. Conversely, the background check can make you and the staff a bit more comfortable in prescribing the controlled medication if your suspicions are allayed. I’m not advocating this medical detective work for the great majority of patient presenting with painful conditions, but for those who exhibit the typical warning flags, many of which are listed on the DEA website at http://www.deadiversion.usdoj.gov/pubs/brochures/drugabuser.htm.

Also, we must concede that some people DO have chronic pain that is not being properly managed and present recurrently to the ER. If possible, they should be referred to a pain specialist, or at the very least, have one physician managing their pain. Managing chronic pain through an ER is fraught with the same shortcomings as trying to manage other chronic conditions like diabetes or hypertension. Also, occasionally a patient will admit to having an addiction problem when confronted with the evidence, or will do so on a future presentation. This admission allows you to direct them to the appropriate rehabilitation facility if your community is so fortunate as to be blessed with one.

In short, while we have a duty to effectively treat pain, we also have a duty to not contribute to the harms from controlled medication abuse. I must admit that as much as I intensely dislike doing the detective work and ultimate confrontation with a patient that is clearly abusing controlled medication, I am compelled to do so. In the rural setting where I have worked, it is perhaps easier to notice the obituaries of some of our patients, with a drug seeking history, that die at an awfully young age – I’d rather not contribute to that outcome if possible.
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# Still trying to understand Dr. Henry's philosophy...Gary Giorgio, MD, FACEP 2009-03-30 15:42
For years I have appreciated the wisdom and experience that Dr. Greg Henry has shared with his fellow EPs and I’ve even attended one of his outstanding medicolegal courses. That being said, I am still trying to understand Dr. Henry’s thought process as it pertains to treating pain in the ED. [What's Your Pain Care Philosophy? - March 2009] In particular, I was perplexed by the statement, “I'd rather treat ten patients who don't really need the pain medicine than deny the one patient who really does.” I found it odd that he would prefer to treat ten people inappropriately to ensure that one patient gets the proper treatment. I can think of no other scenario where we would consider this practice pattern to be consistent with the standard of care. I am certainly in agreement with aggressively treating pain with adequate doses of narcotics. However, I also make every effort to ferret out the drug seekers and doctor shoppers who lurk in our EDs looking for narcotics to feed their addiction or to divert on the street. I use every tool at my disposal including reviewing electronic medical records, visit histories, a statewide prescription database, and criminal records. Deception to obtain narcotics is a felony and I do not wish to be complicit in the crime, knowingly or unknowingly. Deaths due to opioid analgesic poisonings are on the rise and it is imperative that every physician use all the tools available to make sure they are not part of the problem. Of the top 10 individual prescribers of controlled substances in Ohio, nine are EPs so we clearly have a stake in this issue. Undoubtedly, some of the narcotics implicated in overdose deaths originated from a prescription written by an EP.

In addition, the comparison between “drug seekers” and “oxygen seekers” was hardly analagous. We have a host of tools at our disposal to objectively measure a patient’s need for supplemental oxygen. Just the opposite is true when trying to quantify pain. To assume every story is true and a 1 to 10 scale objectively measures pain is naive and potentially dangerous. While some would argue that my heightened suspicion for deception will deprive those in legitimate pain of compassionate treatment, I believe it is my responsibility to both treat pain aggressively and root out the criminal element that preys on our compassion. I believe both can be done and done well.
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# ARNP-CPamela Sims, ARNP 2009-06-27 12:35
Quick effective communication skills with your patient's subjective presentation and then actually doing a problem focused assessment in a nonjudgemental approach can help identify drug seeking behavior. Pain can be real for that patient due to many intrinsic or extrinsic factors and our goal is to resolve their acute pain and provide the appropriate referral. Unfortuately the appropriate referral may not be one that they can afford to pay for because most physicians now what cash up front to see that patient. So then they come back to the ER when their symptoms return because they have not been able to find a physician that will see them, they can not find a physician taking new patients or the only doctor that will see them is in another city. I have found that we as ER providers need to listen to our patients and have a list of resources available in our community for those patients so they feel like you care. Be it treatment for a behavioral seeking behavior, addictive seeking behavior, chronic pain behavior or acute pain. I believe that we should treat each patient with respect and even if it is their third visit that month we should approach their pain in a nonjudgemental manor. We should treat the acute pain and explain why it is important to find a primary physician to manage their long-term symptoms. Sometimes if the patient actually thinks we care then they may take control of their own healthcare. Self worth can help to decrease pain. We need a positive approach when dealing with the variety of patients we manage.
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# My point of viewNot The Doctor 2009-08-12 17:09
I've worked in a private medical practice, for a chiropractor and as a licensed massage therapist. I also abused painkillers when I was young. I have observed many things that could help weed out drug seekers.
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# My point of view continuedNot The Doctor 2009-08-12 18:32
I wanted to be sure this would post before writing it. First of all, as a former abuser of narcotic pain meds. I can spot an abuser a mile away. Many other former or recovering addicts report the same ability. Of course it is easier for me since I'm not a caregiver.

However, one of the biggest excuses used is back or neck pain because it is very hard for an ED or private practice MD to tell if the person is really in pain or malingering. These doctors could eliminate nearly all of the seekers by opening their minds to how chiropractors and massage therapists are able to spot pain through palpating the spine.

It is quite easy to do and all the doctors need is to read a good massage therapy textbook and keep it on hand for reference. It wouldn't hurt to actually examinate the muscles they claim to be hurting, keeping in mind the specific actions of the muscle groups.

I would guess that the greatest majority of drug seekers do not know muscle orgins, insertions and actions. A thorough exam can confirm pain of a suspected abuser. It may not rule it out, but wouldn't it be nice to know you didn't give narcotics to a malingerer?

People in legitmate pain are being denied proper pain relief. Addicts who are in recovery are taught to be honest and accountable to all prescribing doctors. But, if they are, then they are often denied proper treatment. This causes the recovering person to not mention they are in recovery. Then they end up with a prescription for too many pills. Now, they are no longer being honest or accountable for recovery.

I've had the same medical doctor for nearly a decade. He was the doctor I picked to establish a relationship with after my opiate abuse. I told him on the first visit that I had been to treatment for abusing pain medication. I asked him to make an agreement with me. I proposed this: From now until the end of time, do not prescribe me any opiate medications unless it is a true emergency. If a true emergency arises, do not give me more than a three day supply or have it dispensed in daily increments. He liked the idea, agreed and that was the end of it. Thankfully, I have never needed a narcotic since then. I do get back pain from time to time. Sometimes it can be quite intense. I use 800 mg ibuprofen and a muscle relaxer, then immediately book a massage and/or chiropractic appointment and continue until the pain is gone.

Lastly, it is a big mistake to rx Ultram as an alternative. There are people who abuse this drug. It's pharmacology is far more dangerous to an abuser than the harder stuff.

If anyone doubts what I have said, I suggest using Google and then visiting the pain pill forum at addictionrecove ryguide.com Search the topics or post questions to the people there without revealing your profession.
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# sometimes even doctors miss "pathology"bryan 2010-12-09 01:29
i was not diagnosed with my condition for years. whhy? because i thought i had lung pain. was seeing pulminologist. finnaly one day a pulmonologist discovered that i had a spine deformity. i was labled as a drug seeker, and had to go else where for meds.
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# Pain management issues Lois Charnelle Lee 2012-04-03 12:38
I am an emergency room nurse, graduated in 1984, and also have a master in nursing education which I use to teach at a local university. My son is an army disabled veteran, who lost his right eye in Iraq during a battle. His head is full of metal. He suffers from chronic headaches for which the VA manages him for with opiod therapy, NSAID's etc., Since his return from Iraq he is 100% disabled because of his injuries. This last week he ran out of some of his opiods, either due to overuse or mistakes within the system. He went to the emergency room for help. They refused to medicated him with the regimen that works. And of course I am sure you have an idea that he obtains relief from Dilaudid 4 mg ivp, with 2 mg IVP following if needed. He receives a bag of saline and oxygen. As a nurse and as a mother I wonder what to do. The emergency room where I work once or twice a week as a per-diem nurse feels like he is a drug seeker. They want him to go to his primary care provider which is in Tuscon Arizona. The chronic pain is treated by a practicitoner there. He is two and a half hours away from there. The VA here referred him there and will not deal with his chronic pain scripts. My son was normal when he went to Iraq, and he has had his life ruined by this problem. So what is the answer here? A decorated war veteran with a purple heart is being refused care because the emergency room physicians don't believe in treating chronic pain in the ER. The local VA doesn't want to deal with it. His insurance will not cover him for a local pain management specialist. Hmmm. Military service is not all its cracked up to be. I would like your opinion and advice. I want to deal with it at the administrative level and look up research that shows that he needs to be treated appropriately. I am trying not enter the fray without all the information I need.
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