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
*This blog post was originally published at Movin' Meat*