28 October 2006

Oh, the pain of it all! Oh, the pain!

With Apologies to Dr Zachary Smith. . .

The first seven patients I saw today were in the ED for:

  • Dental Pain (ongoing for three years)
  • Back Pain (third visit in one month, 18 in 2006)
  • Migraine Headache (six visits in a month, and second ED visit in 18 hours)
  • Back Pain (this one was legit)
  • Chronic Recurrent Abdominal Pain (ran out of Oxycontin and doctor "out of town")
  • "Cyclic Vomiting Syndrome" (in which only narcotics stop the vomiting)
  • Oxycontin withdrawal
Sometimes I wonder why I bother. I occasionally wish my job demanded something more than a valid DEA license, and decision-making skills beyond "yes narcs" and "no narcs." It just drains the carpe right out of your diem to start the day off in a series of ugly little dogfights over drugs with people whom, to put it charitably, you have concerns about the validity of their reported pain.

Now please don't jump to conclusions here. Pain sucks, and in the common event that I know to a reasonable certainty that someone is suffering, I am quite free with the narcotics. That's a big part of my raison d'etre. The problem is that increasingly, it seems that the chronic pain complaints far outnumber the acute pain complaints, and treating chronic (or recurrent) pain in the ED is fraught with difficulty to say the least. You don't know the patient, they come to the ED over and over for the same thing, they are demanding (both in terms of time expended and emotional energy), some are dishonest, there always seems to be some barrier to treatment which requires ED therapy ("Doctor out of town," "Lost prescription," "Only a shot works," "Threw up my pills," etc), and there is never objective evidence of physical disease.

These folks are colloquially referred to as "drug seekers." I wasn't trained in how to deal with them, and haven't seen any good educational/research on the topic. That which I have seen seems to have been infected by the Pain Thought Police, whose first law is that "Only the patient can tell you if the pain is real," and whose second law is "All pain is real." (You can see the problem there, at least from my point of view.) So of necessity, my approach to these folks is sort of ad hoc.

Off the top of my head, I would describe most of the "problem patients" as falling into a few distinct groups:
  • Malingerers: Want drugs for diversion or recreational use
  • Organic pain superimposed on narcotic addiction
  • Organic pain superimposed on psychiatric condition
  • Minor injuries in individuals with poor pain tolerance
  • Primary psychogenic ailments
These probably comprise 80% of the repeat visitors we see for narcotics. I commit heresy -- The Pain Thought Police would have us believe that organic pain and narcotic addiction can never co-exist. Any ED doc will tell you the truth. The real problem for me is that there are a couple of other categories:
  • True organic pain of long duration
  • Acute pain in a narcotic-habituated individual
And my job is to sort out the wheat from the chaff, so to speak. I try to find a way to say "no" to the first group of "seekers" in a manner that is therapeutic, honest, defensible, and not too much of a pain in my ass, while acurately sorting out the occasional individual who looks like a "seeker" but in fact is "legit."

It sucks. You wind up feeling judgemental and mean, you have to make people cry, and when you are wrong, you feel absolutely horrible -- and you always have that nagging doubt in your head, "Was I too harsh?" This is honestly the most emotionally challenging thing I have dealt with as an ER doctor -- not as hard as having a child die on you, but more of an every-day sort of low-level emotional parasite. Some ER docs say "Why bother?" Give 'em what they want -- it's easier and everybody's happy." No complaints to administration that way, either. We euphemistically call these docs the "candy men," but in truth I feel like a more honest appellation would be "pushers."

When I came home, my wife cheerfully greeted me and asked brightly, "So how many lives did you save today?"

Oh, the pain of it all. . .

[PS -- Don't miss the Follow-up to this post.]


  1. So true.Ha, ha, ha. I sometimes wonder at how people justify their want and desires and turn them into my "emergencies.

  2. Oh, you're bringing back such fond memories of the shifts at your hospitals. I'm sitting here trying to figure out which facility this shift occurred at. :0)

    Have a great day, doc.

  3. Thanks for your insight into this part of the job; I knew that ED staff had very little patience for "seekers," but had never really appreciated just how complicated the problem is.

    Oh, and as a Tolkien fan, I love the "Shadowfax" handle!

  4. Amen, brother, what else can I say?

    We had a "seeker" recognized by a nurse as being from the opposite coast! The nurse had been a traveler on the east coast and had actually cared for this same woman 3000 miles away!

    And then to top it off, the patient came in with her central line already accessed, co-incidentally with the exact tubing that we use. Turns out that she did not realize the hospital she had just walked out of was connected to my hospital by computer.

    It's was a two-for-one GOTCHA!

    It's nice when it is that easy....

    PS - link going up on Emergiblog, how did I miss that before! Ugh!

  5. Why would you refuse pain relief for minor injuries in individuals with poor pain tolerance?

    Just out of curiosity, do you impose pain relief on individuals with major injuries and high pain tolerance who don’t want meds for their ‘pain’?

    I’m not a wimp, but I know people who are and I know other people who are so pain insensitive that they are a danger to themselves. Why would a doctor make a moral judgement about pain tolerance and convert it into a medical judgement? What’s the connection?

  6. Alison,

    It's a fair question. It's always judgement. For example, I had a 17-y/o male who punched a wall. He has an x-ray -- no fracture. He had a bruise on his hand. He got angry when I did not give him vicodin, per his request.

    Minor injuries are not best treated with powerful narcotics. They sensitize you to future pain, and they are very addictive. So I am not just trying to make a moral judgement that I think learning to cope with minor pain is a virtue (though I do think it is), but I am actually trying to do what is in the patient's best interest.

    And, yes, I will occasionally encourage someone who is being excessively stoic to take narcotics, as well. I don't force the issue, but I will recommend it and make sure that they go home with a prescription, whether they intend to take it or not. Pain sucks, and there are no medals given for heroism when there is a real injury or organ dysfunction.

  7. You left out a category: those seeking a prescription so that they can sell the pills on the street for a hefty little profit...

  8. this is exactly why I wont EVER go to the Er.
    I blew out my back and had surgery and it failed and blah, blah and sometimes I have so much pain it makes me vomit but I would rather vomit ten times and wait for my primary then go to the ER and be treated like a felon. I am a nurse by the way.
    You may think you are being fair etc but your face gives it all away..I went only once and got my shot of Toradol and went home. I never asked for narcotics only for some ressurance that I could double up my antiseizure meds that I use for nerve pain..I got treated like a leper and they gave me my Toradol Im..I later learned that is a "punishment" for drug seekers because it is so incredibly painful they never come back.
    This was done to me in my own hospital..I later wrote out a complaint and my doctors wrote one out too..nothing was done to the doc.
    Chronic pain has become an epidemic..if you knew anything about it you would know most chronic pain is NOT treated with narcotics and you do have a huge arsenal of drugs that make pain better..gabapenten, tegretol, some NSAIDs, massage and rest..some times an antianxiety can get them through....you don't have to reach for narcotics if you learn a little about treating pain..but ofcourse you may be still using demerol for pain for all I know.
    Some doctors still believe demerol is a pain medication if you can believe that.

  9. Adventures,

    Thanks for sharing. You are right that demerol is a crappy pain med (and addictive to boot) and I led the drive to get it off our formulary. You and I agree that chronic pain is best treated a) with non-narcotic meds like neurontin and b) in a setting other than the ER. Sorry your ED experience was no fun. . .

  10. I had an absolutely visceral response to your perceptions of the "Pain Patient"...!I know them too well...as a chronic cancer pain patient. Although treated through a highly regarded pain clinic where the clinician is an excellent and compassionate educator as well as practioner...the clinic staff continues to treat all comers as 'seekers'. It is humiliating...and my anger with their un-considered judgement of me is enormous. Like "Adventures" said...I ALWAYS wait to see my appropriate practioner...get my prescribed meds on time...and avoid all other medical practioners for this part of my care. Unfortunately...even when I am a courteous, educated and honest drug avoiding pain patient...I am still, all too often, treated like a "seeker." May you never have to experience this yourself! I happen to know, trust and love Shadowfax. I am very glad to hear that he wrestles with this issue and allows himself to be upset by it. True pain patients are just as frustrated with "seekers" since they taint the treatment that we get! Wrestle on, Doc...and learn more about pain management if you want to be a more compassionate, accurate diagnostician of pain!


  11. I ALWAYS wait to see my appropriate practioner...get my prescribed meds on time...and avoid all other medical practioners for this part of my care. Unfortunately...even when I am a courteous, educated and honest drug avoiding pain patient...I am still, all too often, treated like a "seeker."


    I am on fentanyl and morphine. I wouldn't even consider going to an ED in my condition - [secondary addisons - pituitary tumors]. Even when I cannot control my pain level, I fear there isn't much else they are willing or able to do for me. Before Fentanyl I tried to escape some excrutiating adrenal pain (acute crisis, unbeknownst). Three 15mg Morphine IR and my innards were immoblized. Not a good time to go to the ER. Instant drug seeker diagnosis!


    Hell, I didn't know crying would exonerate me! I've had a constant headache since April of 2004. So bad that I had a spinal leak and didn't notice for two weeks; my vision would chatter and my gait faltered if I walked too far... *I think something is wrong here..* lol

  12. Hey there, your blog is great! Maybe you'll be interested about Reverse Cell Phone so just visit it if you have time.

  13. Sorry to contribute so late, but I just found your blog...

    As a chronic pain sufferer, I find "seekers" to be horrible people. To all the dr's out there that have to deal with them, I'm truly sorry. I'm also truly sorry that they give people like me a bad name.

    As someone who wouldn't even take an advil for sore muscles when I was a college athlete, a few years later I now find myself on strong narcotics everyday for the horrible chronic pain that came about when I was only 22. Dr's can't solve it. Half think I'm faking because they can't "see" my pain. I end up in my local ED 5-6 times/year due to pain level of 9/10. Toradol, morphine, demorol, etc. don't work. The only thing that can bring down my pain level to a point that I don't want to commit suicide is 2mg dilaudid. It kicks my butt - I'm in bed for 1-2 days afterward. It bring my pain down enough to make me a partially functioning person again. I go to the ED to get this despite the looks. Despite the eye rolls. Despite all of the s*^& I get from Dr's who think I'm seeking.

    Please, please keep in mind that, even though you're seeing seekers and people who may just be asking for vicodin to sell it on the street or whatever else people do with pain meds, YOU ARE SAVING LIVES of people like me. If I'm in so much agony that I can ask someone to take me to the ER, and deal with skeptical docs, just to get my pain level down to a manageable level, imagine what could happen if you refused to help me...

  14. y9ou are a fucking asshole i was just at the ER cause i threw my back out and the doc was a ass just like you and guess what im sittin here suffering ppl like you should burn in hell

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  16. I am someone who, for many years, has used my local ER to "treat" my various pain/s. I've gone in with migraines, sexual benign headaches, bursitis in both hips, and back pain. Every single time I have gone in with a legitimate pain issue, I have been treated like a criminal/drug seeker.
    Since finding a primary care doctor and a pain specialist, I have since found out that I have Degenerative Disc Disease in my spine and knees, bone spurs in knees, bulging disc/s, and fibromyalgia (which DOES indeed exist and is VERY real).
    My pain is real. It is being treated with opioid pain medicine, after YEARS of using OTC NSAIDS, yoga, stretching, exercise/diet changes, physical therapy and just plain sucking it up..The opioids help my pain be tolerable enough so I can exercise and move around. I would very much like to go show my Xrays to all of these ER doctors who tried to convince me that I was either a)crazy and it's all in my head or b)a drug-seeking fiend.
    I understand that you face this growing problem with who you see at the Emergency Department..but not everyone is faking it. The real chronic pain sufferers really should not be made to pay a price for these people who choose to visit the ER in hopes of getting "high".. What ever happened to treating the pain?
    is that such a far-fetched idea nowadays?

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  18. I realize this is an old post, but I wanted to comment. In the Dental Office where I work, we see some (but not a lot) of seekers. Most are trying to get Vicodin, but the Drs in the office are pretty set - antibiotics plus motrin & tylenol. Generally, its only in cases of numerous extractions are they going to go with something more, and its usually 10 tabs of Tylenol 3.
    As few seekers as I see, when I developed appendicitis, I didn't feel comfortable accepting Dilaudid in the ER until the appendicitis was confirmed (several hours into the visit) and the ER doc said "its okay to take it."
    Then when I was back in the ER two days after surgery, with what was determined to be an ileus, I was still afraid to accept anything! Even though the pain was, in my mind, worse than ANYTHING I had ever experienced, I knew it wasn't a "visible" pain, and I was afraid to be labeled a seeker.

  19. This is so sad. I have a rare disorder that causes extreme pain, nausea, vomitting, etc. However, most of the time when I have to go to the er they treat me like a drug seeker. Truly, due to the vomiting I can not hold anything down. My illness is well documented, I always have my stack of med records with me. It's just a shame that ER docs and nurses assume the worst of people. Isn't it reasonable to expect most or a lot of ER patients are in pain - that if they werent in pain they'd wait til morning to go to the primary care - or the two months it takes to get an appt? I am so grateful for Docs and Nurses who do not treat me like a felon. Matter of fact, I find I need LESS pain meds when I'm treated well due to the lower degree of stress and the faster administration of the medications. Even though you all say you are not judging - you are! I've had MD's give me half of what I need to get better - not 1 mg more - and why? what is it that is so bad about giving 2mg vs 1mg? It is the doctor control/god complex. I do hate people that pretend to have my sickness but maybe it isn't the MD's job to pass judgement - it is their job to treat. I prefer to get a prescription if I don't have pain meds at home, but understand if the MD doesn't want to give one. I don't understand why not IV meds - if I wanted to get high it certainly wouldn't be in an ER! Please try to treat your pain patients with more compassion and as an individual. For real pain patients life feels so hopeless anyway - being judged as a drug seeker by MD's and being unable to get help makes it even worse.

  20. I am wondering why no one has mentioned the cost of all this ? I have had a persistent headache for about 2 months now . It costs me $20.00 every time I go see my Primary plus any prescriptions . The 2 times I ended up in the ER because I ran out out of medicine while he was closed and I was ready to jump off a cliff , it was $75.00 for each visit , not to mention several hours of my day . Why would anyone do that on purpose and how could they afford that ? I could have had a nice spa visit by now with all the money I've spent being poked and prodded ....

  21. I would like to see a study where UDS are done on adult cyclical vomiting patients. In my experience, the vast majority are positive for cocaine or amphetamines, and the vast majority have just ran out of their oxycontin. My thoughts.

  22. I went to the er a week after giving birth and having my tubes tied because I was still in alot of pain and had run out of the medication they had given me.They spent hours poking and prodding me at 3am before they finally gave me something, the whole time giving me that " your just crazy there is nothing wrong look".The doc came in after I had been waiting over an hour and was talking on the phone with his wife making plans for their vacation during the examination.After 7 hours in the er and about 5 min with the doctor(2 of which he was on the phone), they gave me what I was "seeking" pain relief.What about that situation makes me a bad person? or a drug addict?Doctors have no right to judge patients for anything other that their medical condition, after all they are just people not god!


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