19 February 2010

Friday Flashback

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.]

Originally posted 28 October 2006


  1. I don't envy you. I'm surprised that there isn't more education around it for doctors- it seems like most of the doctors that I've come in contact just recognize drug seekers (when they want to). It's not good for anyone- certainly not the doctors and ER, but also for the people who genuinely suffer pain and need help.

    Some places do seem to encourage it though- I'd sprained my ankle badly once, and went to the ER to make sure that it wasn't broken. The doctor I saw gave me a prescription for 80 percocet with 3 refills...WTF- it hurt, but we get Tylenol3 over the counter here which was more than ample for the first couple of days... Percocet definitely was not called for. My guess is that it takes one "obliging" doctor to make any ER a magnet.

  2. gosh, in our ED, all of those type pts go to the PAs.

  3. That post just summed up everything that's draining about working in the ED and with demanding patients. You're always left with that hint of doubt no matter how much others may back you up.

  4. I'd like to honestly ask what the problem is? Serious question, not a joke or an attempt to start a fight. Why not just give the person narcotics if he or she can pay for them?

  5. I think the key here is that doctors need to remember that enabling drug addicts may be easier but its not what is best for the patient. The reason why you are required to have a DEA license to prescribe narcotics is because you're supposed to use judgment,not just hand them out like candy to get patients out of your hair and to keep from having your Press Ganey scores fall.

    Even if someone is having real pain, narcotics may not be in their best interest. Escalating use of narcotics do have an end point as much as some "pain" doctors would like to believe otherwise. After a certain point the patient is still experiencing the same level of pain but they're just chasing the buzz.

    Look at the damage oxycontin addiction has done to large segments of our population. In some depressed areas entire swathes of the populations lives have been destroyed by it.

    I've been a nurse for 25 years. Initially we would give people Tylenol #3 for pain, now we've escalated it to oxycontin and IV dilaudid. Migraine headaches come into the ER and demand an IV start and IV Dilaudid for a simple migraine, unbelievable. And the doctors do it for them. Sometimes the same patient will get it 2 times within 24 hours and then 5 or 6 times a month. Obviously any migraine treatment that requires that sort of repetition isn't working.

    Why not tell the patient "I don't treat this type of injury [illness] with narcotics"? My husband is a PA and that's what he tells people. When they give him the "i'm allergic to NSAID's, imitrex, wind, the direct east, etc" he says "i'm sorry, I can't help you then." Saying no really isn't that difficult.

  6. Well,
    OK, on the wipeout to whole communities due to use of oxywhatever but I'd like to see like, you know, proof of that statement?

    What exactly is the cure for migraines? In my 49 years of life to date I had just one that I know of about 6 years ago. Other than that one, never have headaches but I wasn't aware that science had come up with a preventative or cure for migraines.

  7. I think that you are a good person. That is why you go through all these motions.

  8. What's with the re-runs Doc? Is someone on vacation? Or did you feel the pain/narcotic gatekeeper issue warranted revisiting?

    Just curious.

  9. Reticent. R E T I C E N T. Reticent.

    I am the sole controlling authority. You have no recourse except through me.

    Can any of you justify this? Will you?

    You're under no obligation.

  10. Anon -- Not on vacation (though I was) just thought that since I have 4 years of posts it might be fun to mine the archives and repost some of the ones I liked.

    They're running every Friday.

  11. Looks like you are revisiting this post by bringing it to the front page.

    What I did know before reading these blogs is that ER rooms are being used for common illness and not emergencies. This is a problem that we are made aware of by watching the news or reading the news. Drug seekers are a new one on me. I had no idea until I ran across a med blog and then another. Turns out it's a huge problem and I would probably be safe in saying most of the general public is not aware of this problem.

    That being said, there has to be some middle ground for those folks that really need to have their pain manage in an emergency situation. About a year or so ago, I had a really bad tooth ache. It was horrid. I knew I needed to see a dentist but we were really busy at work. I was putting in 12 or more hours at the office and working weekends. I planned on making an appointment soon. I did not know I had an infection. One night, it hit me like a train. It was about 11:00 p.m. and I was in agony. The only medication I have at home is aspirin so I started popping aspirin like it was candy every half hour. Then I did the unthinkable about 2:00 a.m., I started drinking wine. I would have done anything to get rid of that agony in my mouth.

    I don't know how much aspirin I went through but it was a LOT. I realized that I had to stop when my ears were buzzing like there were bees in my head. My ears were buzzing and I was drunk. Fortunately, between the pain, being drunk and buzzing ears, I had the presence of mind to quit popping the aspirin and put the bottle of wine away. And still no relief. It did not occur to me that the ER was an option. Honestly, it did not enter my mind because if it had, I would have gone. At least at that point, I did not know that ER docs would have taken the position that I was a possible drug seeker. OY, can you imagine if I had shown up drunk with all that aspirin in my system, I might have found myself talking to a shrink. Oh the horrors when all I wanted to do was get rid of that agony in my mouth.

    To make matters worse, I ended up doing something else (called a friend who gave me one of his Vicodin -- that's the first time I have ever had a Vicodin in my life) -- at with all that I had already done, it could have really harmed me. I was desperate, you have no idea. Turns out why it was so bad is that the infection had made its way into my jaw bone and was traveling up. The oral surgeon ended up prescribing Vicodin and antibiotics before he could do the surgery a week later. Thank God he didn't take a blood test for he probably would have been horrified at what he found.

    Just saying that there has to be some middle ground so that those that really are in need of pain medication.

    The few times I have been to the ER for things like a broken leg, y'all have been great. They managed the pain without me asking. That's the only time I have ever experienced such agonizing pain and if I ever were to experience something like that again, I would like to be able to have it managed until such a time when I could make an appointment for proper treatment. Thank God I did not cause any permanent damage to myself while trying to relieve my pain. There really needs to be a way to weed out the drug seekers versus those that really need help.

    Just something to think about.

    p.s. An irony or coincidence but the word verification is "ingst" I had to laugh at that one.

  12. As a chronic pain (migraine) patient, I am very, very grateful to hear about an ER doctor like you. I've never had to hit the ER and I hope I never do, but my pre-existing opiate prescription for intractible pain (we literally have tried everything, both preventative and abortive) already makes calls to on-call physicians unpleasant.

    Thank you for committing to the brutal labor of trying to figure out who the patients are among the drug-seekers.

  13. "Sometimes the same patient will get it 2 times within 24 hours and then 5 or 6 times a month. Obviously any migraine treatment that requires that sort of repetition isn't working. "

    That's right. That's why that patient is in the ER, because her treatment isn't working. I have a dear friend with chronic and intractible migraine. She lives in a major city with teaching hospitals. She's seen some of the best migraine specialists around. Her specialist has prescribed a protocol for what to do when she goes to the ER, including immediate IV opiates, because aborting a pain cycle can keep her from days of misery.

    She takes a lot of abuse from ER doctors who can't understand why just a Tylenol 3 won't do, even though she has a chart, with doctor's orders from a respected specialist, explaining what's necessary. She tries to stick to one ER now, where they (mostly) know her by name and know her story.

    It is wrong to undertreat a patient whose migraine treatments don't work, just as it would be wrong to undertreat an uncontrolled diabetic who's a frequent flyer. There are people for whom all the best medical care in the world simply won't control the disease, and some of those need opiates.


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