Dr. Edwards is here for his monthly post and I thought his topic of choice was very timely. He sent me a piece on dealing with chronic pain patients in the ED. This is a problem for every ED… including pediatrics.
In the past two years, I’ve been shocked by the number of chronic pain patients we are seeing in those under the age of 18. If you’re writing an in-depth novel with an ED worker in the center, this is one area of conflict you could explore.
How do we deal with these patients? Is there a component of drug addiction in this patient population? To say no for all cases would not be the truth either.
I think this trend bodes for some introspection on all of us. Here is Dr. Edwards post. On Wednesday and Friday this week I’m going to explore this topic more in depth and why there might be such an explosive prescription drug abuse problem in the US… and believe me… there is.
Desperately Seeking
Frank J. Edwards, MD
I hadn’t been practicing emergency medicine very long when I saw this particular patient, a thin woman in her mid-seventies wearing an old fashioned lace-collared evening gown.
“Doctor, I’ve passed another kidney stone,” she said.
My mind’s eye narrowed. Was this a narcotic seeker? Kidney stones are like white-hot ice picks thrust into one’s flank and violently twisted, over and over again. Marine drill sergeants cry with kidney stones. But there she sat smiling. I was young. Did she take me for an easy mark?
“Oh really,” I said. “Are you looking for some medication, ma’am?”
“Heavens no,” she said. “I thought you might like to see it. I have these things all the time.”
“See it?”
Out of her cloth handbag, she fished a chunk of coarse roadbed gravel and plopped it in my hand. Driving in the hospital entrance that muggy Sunday morning I had noticed a pile of similar stone.
“You can keep it if you like, doctor,” she said.
Since then, I’ve seen hundreds of patients feigning illnesses, but unlike the lady of the road gravel, they definitely want something more than the smidgeon of attention and sympathy she needed. They may have headaches, back spasms, abdominal cramping or severe pelvic pain, but kidney stones do remain a common theme. And, unlike her, they come in writhing and wincing. When asked to give urine, they may prick their fingers and squeeze a drop of blood into the sample so the dipstick comes back positive.
The typical drug seeker will have a genuine history of a disease characterized by recurrent episodes of agonizing pain. Along with kidney stones, such conditions include migraine headaches, lumbar disc disease, fibromyalgia, inflammatory intestinal disorders (Crohn’s disease, for example), and pelvic problems such as endometriosis and interstitial cystitis. Thanks to the powerfully addicting properties of the narcotics used to treat their pain, a handful gradually awaken in the labyrinth of Morpheus, from which escape is very hard.
These patients generate a swirl of negative emotions in healers. You want to give everyone the benefit of the doubt, but you do not like the sense of being manipulated. You do not want to reinforce their addiction, but on the other hand, you understand they are suffering. You just do not really know how much of the suffering is physical pain and how much is . . . whatever. And, Lord help the healer who pigeonholes a drug seeker and misses something disastrous. Drug seekers get sick too.
So you examine them carefully and maybe run some tests, and you look for the usual clues. Drug seekers often frequent many local EDs. They’ve had multiple work-ups that never reveal anything new. If you are blessed with the ability to look up records on the Internet (an innovation which can’t come too soon), you may discover they were in the ED at a hospital down the road just last week and neglected to mention it. They are allergic to all the non-narcotic pain relief options and they know exactly which agent on the menu works best. They demand the dose IV and require amounts that would kick most opiate virgins into a coma.
I know some healers who pretty much give in and give the drug seeker whatever he or she wants just to sweep them out quickly, and who may even discharge them with substantial prescriptions for more narcotics (a real mistake). Other healers get angry and point to the door immediately. Most of us are in the middle somewhere, but it is never a happy situation. At some level, you feel like a drug dealer. I assuage my conscience by counseling them on the dangers of secondary addiction, and try referring them to pain centers. I’ve also stopped calling them drug seekers. They are chronic pain patients until proven otherwise, which removes some of the tendency to pass judgment.
Regarding the danger of cynicism, not long ago, a doctor going off duty passed me a back-pain case. His plan was to give this young man a single shot and send him packing in the hope he wouldn’t darken our doorway again. The patient had admitted to visiting an urgent care center the day before and had furthermore confessed to heroin abuse in the past.
Slam dunk drug seeker, right? Wait a minute. How many of them volunteer a history of heroin abuse? That’s either a pretty dumb drug seeker, or a rare instance of honesty. I sat down and listened to his story, got a sense of his personality and observed the concern of his girl friend. Then I re-examined him and ended up ordering a CT. The next morning he had surgery for a severely herniated lumbar disc.
Then, there are the true professional patients—few in number and slippery—who ply their ailments to score drugs for the street trade. One patient I recall from many years ago made a circuit of EDs from Florida to Virginia. He had a draining bone infection—chronic osteomyelitis of the tibia—from a motorcycle accident. If he took his antibiotic, the wound would start to heal. If he stopped taking his antibiotic, the wound would boil and drain pus. He could literally shut it off and on like a faucet.
It was very hard to argue with such an ugly wound, and he reeled me in like a catfish on Valium. Until I saw him again a few months later at an ED on the far end of North Carolina. With a different name.
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Frank Edwards was born and raised in Western New York. After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester. Along the way he earned an MFA in Writing at Warren Wilson College. He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.
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1. You are having suicidal ideation. Suicidal ideation means you are having thoughts/feelings of hurting yourself and either you have presented or someone has brought you to the ED. This is fairly standard to see what might be in your system. What also will be added will be an acetaminophen (Tylenol) and salicylate (Aspirin) level. These are blood levels.
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