Hem > English > Go on and fool me

Go on and fool me

I have a low threshold to pain. When I walk by a room and happen to see a patient squirming and crying in pain, I feel a compulsive urge to make sure that someone is dealing with the matter. As mostly, the best source of information is the patient, so I put my hand on their shoulder and say – I can see that you are in a lot of pain. Is anyone helping you out here?

If the answer is no, I offer a warm blanket and go and ask the nurses to provide some analgesia. Sometimes that means paracetamol or ibuprofen, sometimes it means opiates. For patients in severe pain it can mean all of the above and in high doses. For heroinists I order doses that the nurses refuse to administer.

The same goes for patients who need prescriptions for their pain medications. Some of them have incredulous explanations for needing one, like being robbed of all their pills. Or they have pain that I can’t find an anatomical or physiological explanation to. I don’t care. I send them home with a small prescription or with the amount of pills they need until they should be able to get hold of their regular doctor or primary care physician.

I try my best not to judge how credible or trustworthy my patients are when it comes to describing their pain or their need for medication. Because that judgement will undoubtedly be based on my prejudices. And I would rather be a fool than a bigot. I know that my suspicions of drug-seeking behavior would be directed towards men of non-Swedish origin with low education, making me a sexist, snobbish racist. That is not who I want to be. So I choose to trust my patients.

Before I send the prescription, however, I check my patient’s medical records. Our system covers most of the clinics in Stockholm, so I can count how many pills have been prescribed in total. Sometimes there is a note, or even a warning, that the patient seems to be over consuming pain medicines. I have never seen that statement followed by a treatment plan, or even a discussion with the patient about the problem, though.

So I tell the patient that he or she seems to be using more pills than ordered, and maybe even more than what they have just told me. I inform them that it says in their medical records that they might have a dependency problem. Often I’ll apologize on behalf of our health care system for putting them in this situation. I understand how living with chronic pain wears you down, both mentally and physically. How the pills, which offer some relief at first, stop working and how easy it is to increase the dose in desperation, until suddenly the pills themselves have given you another problem. Like far too many other patients they have not been given the holistic, team based care they need. Instead some doctors have prescribed large quantities of addictive drugs. And now when that suspicion of overuse and dependency has been raised, it’s going to be very difficult for them to get any medicine at all.

If the patient admits that they have a problem, I offer them a referral to a dependency clinic. When they don’t want that I strongly recommend them to make sure that they only ask for prescriptions from their primary care physician and that they limit their usage to the doses prescribed. Then I document this conversation in their records.

It is very rare that the patient gets upset about my way of handling this. To the contrary, they often thank me for treating them with kindness and respect. It could, of course, be that they are just being manipulative and happy that they got what they came for. So maybe I’m fooled from time to time, but I know that I’ll never mistrust and mistreat that patient in severe pain who can’t speak eloquently enough for herself.

  1. maj 1, 2015 kl. 8:52 e m

    Reblogga detta på Lessons Learned in Life and Medicine och kommenterade:
    Thoughts on how we approach pain management in the ED

  2. maj 2, 2015 kl. 3:12 e m

    Great post, Katrin.
    When the overseas hospital my patient claimed she had received cancer treatment at turned out not to exist, she self-discharged and the nurses were surprised I had been so generous with intravenous analgesia.
    I would prefer to be fooled by a hundred patients with dubious backgrounds than deny someone the analgesia they truly need.
    More on appropriate analgesic doses for dependent patients coming soon at St Emlyns too…

  3. maj 3, 2015 kl. 7:58 f m

    I got this email from Sergey Motov from http://www.painfree-ed.com and gave his permission for me to publish it here. Thank you Sergey for taking the time to reply! /Katrin

    Thank you very much for such insightful post on your approach and experience of ED pain management!
    I applaud your humanistic qualities when it comes to pain- nobody should suffer!
    However the centuries proved concept of ”first, do no harm”as more applicable to current state of ED pain management as ever.
    While managing severe acute pain in the ED with all possible analgesics, their combinations with higher doses is totally fine, the choices must be individualized and may not even include opioids as a first line.
    I have a bit of an issue of giving patients what they want even in the small quantities as opposed to what they truly need! A quick fix in the ED with few pills to go home with in the hope the follow your directions does not work very well in my shop and in the U.S and in all honesty, will not address patients pain.
    These leads to doctor shopping and even diversion!

    Not everyone needs a pill: patients with fibromyalgia need understanding of their
    Disease from a doctor, not a prescription! Patients with DNP or PHN do not need opioids. Patients with aberrant drug-related behaviors need specialized treatments that do not include an offending agent.

    I do exactly what you do : I do take time to talk to patients in pain, to understand their true needs, their problems with meds, etc.
    But… I do not give them what they want just by honoring their request. If their conditions warrants specific medication that they are asking for, sure I give it. Most of the time I explain the risks and benefits of the analgesic they want and offer them what they need.
    The main goal is not to deny the treatment, but use the most appropriate analgesics. And if it’s not what patient wants, so be it!

    Do I make patients angry? At first, yes!
    But once they understand I care about their wellbeing and do acknowledge their pain, they feel better. And so do I!
    And I don’t feel like bigot or a torturer because I took control of their pain by combinations of analgesics that were not included in their request.

    In the ED- Not everyone needs a quick fix, not everyone needs an opioid prescription, not everyone gets what he/she wants.
    They need compassionate and caring doctor( such as yourself) who takes care of their pain!


  4. maj 3, 2015 kl. 8:29 f m

    I fully agree that opiate dependency is a serious problem and I definitely don’t want to contribute to anyone getting into that vicious circle. But I see many doctors making it too easy for themselves, taking pride in just denying patients acute pain relief or a prescription, without even telling the patient why. Pain is much more complicated that a noxious stimulus and the perception of pain is worsened by fear. One of those fears is not being taken seriously, which might make the patient exaggerate. I think we have all seen those patients screaming in pain, who will calm down once you sit down and talk to them. That is not malingering! It is an indication that the patient needs to have a plan for how to handle their pain and they need to be involved in the process.

    All my patients don’t get a prescription. Those who have kids I might even report to social services. But I try my best to treat everyone with respect and honesty. I consciously wrote my blog post in a provocative way to spark a discussion on how we can provide good care for this patient category. Treating pain includes teaching and helping the patient to cope with their pain, something I have never been taught myself.

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