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.