WhiteCoat

The Great Pain Debate

There’s another war being fought between the chronic pain patients and the physicians who fail to treat them over at Scalpel’s blog.

Healthcare providers who treat patients with pain repeatedly complain about all the drug-seeking pain patients who clog up the emergency departments and suck up health care dollars trying to score a few Vicodins or Percocet tabs (“Vikies” or “Perkies” as Nurse K calls them). Chronic pain patients then respond by calling the health care providers heartless and cruel, and then by imploring any available deity to inflict massive amounts of pain on the healthcare providers, their families, their pets, and their unborn children so that the healthcare providers “know what it feels like.”

This is getting to be like an abortion or gun control debate. Enough already.

Chronic pain should not be treated as an emergency.

If you abuse drugs and get busted by your current physician who will no longer prescribe you narcotics, don’t come to the emergency department looking for your next fix.

If you forget to refill your pain medication prescription, don’t come to the emergency department on a Friday night and expect that the overworked ED physician is just going to blindly write another narcotic prescription to get you out of his or her hair. Ain’t going to happen. You can see that your pills are getting low. You have a phone. Call your doctor and get a refill. Lack of planning on your part does not constitute an emergency on the emergency physician’s part. Plan ahead next time.

There are always exceptions to every rule, though. If you have chronic pain and haven’t been to the ED in a long time, I’m going to look upon the situation a little differently than if your mail starts getting forwarded to our hospital because you are here so much. I know that pain sucks, and I’m going to try to help you. But I’m not going to become an enabler that allows you to be reckless with your chronic medical condition.

If I don’t know you, I will personally call your physician and ask about your medication use. If you are from out of town, I will personally call the hospital ED in your home town. I’ll also call your pharmacy to get your medication history. If I can’t verify your history, you may get an overnight supply of medications, but it will only happen once. Your chart will get tagged so that if you come in with the same modus operandi in the future, everyone will know about it. If you have lied to me, you’re done. Not only do you get Tylenol for your current visit, you get put on “the List” so that all the docs in our ED know that you have previously lied in an attempt to get pain medications. Does all this take longer? Of course. But it serves a purpose by discouraging people from registering for “headaches” when they are really just looking for a quick fix. Because I regularly make these calls, I have a small contingent of patients who will not register in the ED if they find out that I am working. To me, that says a lot about their motives.

Those few docs who do write pain prescriptions to get patients out of the ED eventually end up shooting themselves in the foot. First, they get a reputation. Then the chronic pain visits start to increase. So they end up making more work for themselves. Eventually the patient with a chronic pain medication refill may actually be sick. By assuming that the patient is just there for more medications and giving the patient pain meds without much afterthought, you can miss a deadly disease.

Legitimate chronic pain patients and migraine patients should be upset that they are sometimes looked upon as “drug seekers” when they come to an emergency department. But here’s where a lot of you are off the mark: You’re blaming the wrong people.

Let me give you an unrelated example to illustrate my point (i.e. don’t send me hate mail and talk mean to me because your agenda may be furthered by stating that I am comparing chronic pain patients to vicious animals).

A friend of mine has a nice lovable pit bull. He’ll come up and lick you, he’s great with the kids, and he’d never hurt a thing. But anyone who doesn’t know the dog is scared to death of him. Some people won’t even come over to my friend’s house because they are so afraid of the family pit bull.
Now who is to blame for the bad feelings that people have about this wonderful dog? Is it the people who are scared because they don’t know the dog? Or is it the many other pit bulls who have maimed and killed people and who, in the process, have given pit bulls in general a bad reputation?

Just a couple of days ago a young patient came in to the ED with a bunch of symptoms. Everything was wrong with her. She complained of nausea and vomiting, headaches, chest pain, abdominal pain. Her vital signs were abnormal. She just happened to have moved to town a couple of weeks before her visit and couldn’t remember her physician’s name or the name of the hospital where she used to go. She was on narcotics for four years because of a complication from gastric bypass surgery and “constant” abdominal pain.
I treated her symptoms. She got phenergan for her vomiting and a couple of liters of IV fluid. She got Toradol for her pain. An amazing thing happened – she felt and looked better in a couple of hours. But still had this nagging abdominal pain.
Then came the “Oh, by the way.” Seems that she thought she was in “withdrawals” after being off of her methadone and Percocet for the previous week. I told her I would not refill her narcotics prescriptions but would give her some medication to help with her withdrawal symptoms until she could follow up with the on-call physician. Her response? “F$*% this. I’m going to my sister-in-law’s house to get some heroin, then.”

Over time, when you see patients like this over and over again, you’d be silly if you didn’t begin to wonder whether people with chronic pain are just out to get some physician-approved “heroin”.

I think any ED physician or ED nurse who has been in the business for a few years gets to be pretty good at picking out the real pain patients from the “fake” ones. Based upon the survey I did (admittedly nonscientific), it seems that even people without medical training can pick out patients who are exhibiting drug-seeking behavior. You may get upset about some of the things that Scalpel has to say, but I think I know Scalpel well enough to say that if you’re legitimately in pain, he’ll take good care of you. If you’re looking for a fix, chances are that he’ll bust you.

Whether you agree with Scalpel or not, all of you upset chronic pain patients need to start pointing your pitchforks, waving your torches, and casting your evil spells on the mean pit bulls, not at the docs who are hesitant to treat the nice ones.

12 Responses to “The Great Pain Debate”

  1. #1 Dinosaur says:

    I don’t disagree with anything you’ve said. But then there are stories like these to make you wonder. Anecdotal, of course; but still troublesome.

  2. WhiteCoat says:

    Everyone would agree stories like that shouldn’t happen. But I also don’t think a story like that would happen in most places.
    Before we can fix the problem, we have to figure out why the problem exists. In my opinion, the flippant care of patients in pain exists because too many people are “crying wolf” in an attempt to get narcotics. http://www.msnbc.msn.com/id/22202803/
    These people are not only increasing the cost of providing care in this country, but they are giving those with patients with legitimate pain a bad rap.

  3. Steve says:

    So the story of the lady with the kidney stones is suppose to “prove” that healthcare workers are uncaring, suspicious and generally loutish folks?
    If you want to prove a point you can ALWAYS find one example. But #1 Dino….you obviously don’t GET THE POINT!!!! Those of us that have spent oh say more then 3 hours in an ER have seen numerous examples of DRUG SEEKING BEHAVIOUR!!!! Yes #1 Dino, there are people out there that do have a penchant for narcotics. They will do anything possible to “score” some narcotics. And unbelievable as it may seem, they use these narcotics in a multitude of ways to GET A BUZZ!
    And those of us that have spent months or years in the ER, have run into more DRUG SEEKING SCUM then polite, suburban, “once in a lifetime” type people.
    So those of you that are of the sensitive type and you want to save those poor people….GET REAL!!! You are part of the problem. You have helped create this atmosphere of “have it your way” medicine. You in your unbridled stampede to save the lost from themselves, have created this societal pool of crap that is sucking the life out of the medical industry!
    Go back to your granola and fair trade coffee houses! Leave the real world to us…the hard working, underpaid, overtaxed middle class!

    Steve

  4. SeaSpray says:

    Oh my Gosh -I don’t know where to begin!!

    Excellent post Whitecoat!

    I read Dr Val’s post and can not fathom myself or anyone else EVER treating a kidney stone pt like that or any other pt for that matter. I felt like I was reading something from the Twilite Zone. I understand this was a friend of the doctor and she is reporting this truthfully but it is so foreign to my experience both as someone who has worked in this medical setting and as a pt. Maybe it is because I am used to community hospitals verses dealing with the masses in the larger city hospitals but still…under no circumstances and no matter what I really thought…I would NEVER treat a pt that way.

    1st of all how dare that clerk to be so rude and condescending! Obviously ignorant too! And just what degrees/certifications does he hold that gave him the medical expertise to make that judgment call? If I were his supervisor, after some “constructive” reprimanding, I would send him to a customer service workshop or whatever would be appropriate. I would also keep my eye on him. That behavior would never fly at our hospital! (I’m sorry Whitecoat…and this is rare but I feel a rant coming on!)

    2ndly, I thought it was the law that a pt HAS to be triaged first before any paperwork is done. It is in NJ. I liked it better when we could just push them through (excluding the emergent ones)because waiting for them to be triaged bogs the process down.

    And 3rd- the medical staff wasn’t much better! What about the pt’s demeanor (facial/body doubled over)? Diaphoretic? Pulse? Urine? Vomiting? Whatever other means you use to make the diagnosis?

    And the triage nurse should have made his own assessment regardless of what the registration person said.

    They are all lucky she didn’t have something more emergent going on where time was of the essence! Maybe each one of them should have the pox of the kidney stone put on them – seriously!

    Ya don’t have to be a rocket scientist to figure out that someone has symptoms for a kidney stone. Shoot…I could tell as soon as they came in the door, called triage and our staff always came out as quickly as possible and always treated the pts with respect. I tried to help them be comfortable and was compassionate toward them. I saw enough of these that I knew instantly what was wrong when I got my 1st kidney stone in 2004.

    My husband drove me both times but I walked in while he parked the car. I was nice too, although I did snap at the girl when she told triage that I “thought” I had a kidney stone and said “I KNOW” I have a kidney stone because I wanted triage asap.

    Every encounter she had was seriously flawed. I feel badly that happened to her and I DO hope she contacted administration over that event! YIKES!!!

  5. SeaSpray says:

    Oops…I went off topic and should have put this over at Dr Val’s.
    Sorry…it appears that easy going SeaSpray saw RED!

  6. GeorgeH says:

    I don’t disagree with you, but there are a bunch or ER bloggers who say things like “What kind of wussies have you become that you can’t handle pain?” or who spend far more time high fiveing each other for turning away someone they think is a junkie than they ever will talking about saving a life. I think many are sadists, far more entertained by inflicting pain than interested in helping anyone.

  7. emmy says:

    So I pray to the gods to send a pox on all the evil addicted drug seekers and stick pins in voodoo dolls to make them all experience real pain…but how does that help me get relief from real pain or better yet, get someone to take it seriously enough to find out what the problem is so that maybe it can be prevented from happening in the first place? The problem is that I considered guilty and no-one is even considering that maybe I might be innocent.

  8. GuitarGirlRN says:

    If you have a problem that has been causing you pain for months, and you’ve been to specialist after specialist, your problem will probably not be fixed in the ER. The ER is a place to get treatment for acute conditions, and acute exacerbations of chronic conditions. Your private doctor or specialist or pain clinic is the place to go for information on preventing and treating your chronic pain.

    I know a lot of nurses, and I don’t think anyone is “high-fiving” after “turning away someone” in pain. Believe me, it’s very satisfying to help someone who one minute is gasping and moaning, doubled over with renal colic, and the next minute, after administering some Toradol, is able to rest comfortably (if not completely pain-free) and wait for their CT scan. It’s also very discouraging to deal with patients who appear to be lying about what exactly is going on with them in order to get heavy duty narcotics. These patients send ED staff scurrying around to try to find a way to deal with them, and they cause delays in seeing and dispositioning truly sick people (who are also experiencing pain and discomfort).

  9. Steve says:

    A quote from “The Physician Executive” on Dec. 15, 2007 should be posted throughout Americas ER’s, printed on every piece of patient education material and printed across each and every prescription note.

    “The expectation of a painless existence is no longer a credible or reasonable expectation for you.”

    I love it!!! Somebody actually “growing a couple” and stating what most healthcare folks already understand!
    Our society needs to start teaching people to get “over themselves” and to realize the world doesn’t spin around just themselves!!!

    Steve

  10. WhiteCoat says:

    George -
    I think that the impression that the healthcare providers are giving each other “high-fives” is more that they are able to catch the losers who use a false complaint of chronic pain as a way to procure narcotics. It has really become a game of cat and mouse – separating the wheat from the chaff. More and more chaff is showing up in the EDs.
    I don’t condone the stance that some docs take by blowing off all patients with chronic pain, but it really is an issue that many drug seekers are ruining it for the few that have legitimate pain. As much as the bloggers describe it, you can’t appreciate how much chronic drug seekers wear you down until you experience it first hand. Not too long ago I had a shift where the first SEVEN patients I saw ALL had exacerbations of their chronic back pain. Several had near monthly ED visits. How should the ED staff respond to situations like this?

    Emmy -
    The deck is stacked against you. The best bet you have is to be honest with the staff up front. Often (but not all of the time) the ED staff will be very forgiving for someone that is in severe pain but that is not there “all the time.” If you provide the staff with all your information and a way to contact your physician up front, you are much more likely to get the help you need than if you become upset, cuss at people, and demand that the staff provide you with a specified treatment/medication, etc. For example, telling the nurse/doctor “I have chronic pain from “x” condition and am on “y” medications at home for it. I have been taking my prescribed medications and just can’t get relief tonight. I know this may sound like I am looking for pain medications, but I haven’t been in the ER since ___. I contacted my doctor tonight who recommended that I come to the emergency department for treatment. His number is “zzz-zzz-zzzz” if you want to confirm this with him. Telling the staff that you aren’t looking for a prescription, but that you are only looking for help getting over your painful crisis might help, also.
    If you are always in the ED for pain complaints, this may not work. If someone came to me with acute exacerbation of their pain, and gave me information as above, I would have no problem giving them whatever they needed to make them comfortable.
    Thanking the staff if they help you and even a thank you note (we post all of ours on a bulletin board) might get you labeled as one of the “nice” patients rather than a “not nice” one. http://whitecoatrants.wordpress.com/2007/11/27/the-tale-of-two-toothaches/

  11. [...] reading WhiteCoat’s post The Great Pain Debate, it really made me think about the drug abusers out there who use the ED to get another high with [...]

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