pain in the ass

I read an interesting post over at Musings of a Dinosaur called Drug Seeking in Primary Care. In it, the writer discusses encounters with different types of pain med seeking patients. He makes an excellent distinction between "the patient legitimately seeking to form a new doctor-patient relationship for management of a chronic condition requiring controlled substances" and what are traditionally called "drug seekers" (but which more properly could be called "drug scamming addicts").


While looking over the responses to his post, I came across Cathy's Place, and her recent post describing a visit to her doctor's office where they had recently hung a sign in reception stating "Do Not Ask for Pain Medication". Cathy's initial response to the sign is similar to what I think I myself would experience were I to find myself face to face with such a notice. Reading her post made me consider how pain has been handled in my medical history.

Here's a patient perspective on just some of the problems presented by "drug seekers" (that is the "drug scamming addicts" kind). They take up time and resources which should more appropriately be used for patients who have a legitimate medical complaint or concern. Their habits, narcotic and interpersonal, can serve to establish or confirm any underlying health care provider approach of doubt or suspicion of patient complaints and patient interactions. In short, their behavior creates risks for compromised care of all patients.

But Cathy's post raises an interesting point. Given the acknowledged dangers (for providers and patients alike) of creating or feeding a narcotic addiction, it seems the general tendency would be towards caution - either zero tolerance type caution of a type the "Do Not Ask for Pain Meds" sign suggests or sensible discretionary caution, as seems to be described on Musings, where long term pain medication can be approved but only in limited circumstances, such as when a continuing, confirmed painful condition cannot be otherwise treated. And yet this is not the case. Not by Cathy's experience and certainly not by mine.

My own recent experiences with this come from both outpatient and ER care. I'll go with the ER one first.

I have migraines, had them since I was in my 20s. They had been mostly menstrual, and I had been taking Frova in what is apparently an off label manner premenstrually to keep them at bay. Last summer, they changed in frequency coming any old time of the month and sticking around for days. I made an appointment to see the doctor for a reassessment, and he increased the frequency of the medication. Then they changed in character. In addition to the photophobia and over sensitivity to sound, I had tingling in part of one hand, near blindness in one visual field of one eye, some creepy cognitive changes, and one episode of vomiting. I took my migraine meds and rested, waiting. It seemed to abate some a few hours later, so I got up and started making dinner. The usual dull rotten feeling of the pain came back and brought with it a novel sensation of a series of sharp lancing pains in the occipital/temporal area which were so intense they left me gasping for breath. I went to the ER. I went because I have the misfortune to have studied stroke patient case histories in my grad neuropsych courses, I'm over 35, I smoke, and I have a family history of cerebral vascular disease. Hence, I felt the smart thing to do was to make sure this wasn't something worse than a migraine.

In the ER, I got an IV, and antiemetic, and an offer of pain meds. They offered morphine I think, but remembering something about this possibly raising intracranial pressure, I asked for something else. I can't remember what they gave me, not morphine but possibly also not something which was a non-narcotic. What I didn't get was any imaging, which I found a little troubling.

Then there's the GI doctor. Good old fired GI guy. I came to his service under one of his colleagues after diarrhea and post-prandial intestinal cramping cost me about 20 pounds in less than a year. For a while, levsin and loperamide got the symptoms controlled enough that I was finally digesting the food I ate, regaining weight, and not in so much pain. Then the symptoms started getting worse again. I started losing weight. I went for a re-evaluation and ended up with the now fired GI guy. Fired GI guy's response was to prescribe Ultram. "Isn't that addictive?" I asked. "Oh no" he assured me.

Meanwhile, he worked me up as if I were a 50 year old man and found nothing which would explain the symptoms. Had I remained under his care and his recommendations, I would have been taking Ultram for the pain, a higher dose of loperamide and levsin for the the diarrhea and apparently quite rapid transit of food through my gut, something else for the nausea that I inevitably had when on a higher dose of levsin and loperamide, and possibly another drug for to increase my appetite so I would want to eat more even if eating anything caused pain and nausea.

Now to me, these treatment plans and decisions don't sound like they come from people who are worried about perhaps unnecessarily creating a drug seeker. The ER doc? How about a head CT? I know at the weetiny-ville community hospital I went to that night they may not have been able to do an MRI that night, but a CT could have happened. Instead I got "treat it and beat it". The GI doctor never took into account that endometriosis might have been causing or exacerbating an underlying irritable bowel. Rather than allowing himself to think of my whole body (or even proximal organs) in an attempt to find (and treat) a probable cause for the symptoms, he retreated to a diagnosis where the only option is to treat the symptoms.

In both of these cases, I went in looking for answers, looking for identification either to rule out something terrible or to ultimately (hopefully) treat of the cause of the symptoms. In both cases, happy drugs were the only answer I was offered. Sometimes the only choice is between the lesser of two harms - harming someone by allowing chronic pain to go unchecked or harming someone by making them dependent on a narcotic. This choice should be a last resort, one weighed only when other means or options have genuinely failed.

What I'm realizing in thinking about these cases in the context of the drug seeking patient issue is that too many times I've not had the assistance of doctors in ensuring that we've exhausted the other options. I've managed to skirt treatment which could result in my being labeled as or in my becoming a drug seeker (in the nicer or less nice sense) only by being a total pain in the ass - that is only by insisting on a higher standard of practice than these doctors were willing or able to give.