I knew this patient would be difficult.
He had a long relationship with heroin. He was in the hospital because of complications from unmanaged diabetes. And he was suspected of drug-seeking behavior in past visits to the hospital.
Knowing all this, I still made a mistake I hope to never make again, but I’m sure I will. My patient said he was in pain, and I didn’t know whether to believe him.
From the outset, this man was combative and rude. I’m a fourth-year medical student at Brown University and was there to help, but he refused to answer my questions. He demeaned members of the team caring for him. He arbitrarily declined blood draws and tests and often disregarded our advice. He wouldn’t tell me if he had a home. He wouldn’t clarify if he had any family or friends who could help him manage any of his complex medical conditions. And, despite the track marks on his arm, he refused to talk about his drug use.
So midway through his hospital stay, when he started to complain about an unexpected, debilitating pain in his finger, and then clamored for oxycodone, I was suspicious.
Every day, nearly 4,500 Americans begin using prescription opioids or heroin non-medically. About 80 percent of heroin users, like my patient, first start with prescription opioids and then transition to heroin because it’s cheap and easy to get.
It’s hard to treat these patients when they tell us they are in pain. Do they want pain control, or do they want drugs? Patients with opioid dependency experience and tolerate pain differently. And doctors sometimes end up stigmatizing our patients in pain, much as society does. We’re less likely to manage their pain well, and that’s exactly what I did.
Compounding this difficulty? My patient wouldn’t elaborate on his symptoms or allow me to examine the finger in question. When I asked him if he had dealt with anything like this in the past, he announced he was done talking about it.
Eventually, he relented, but the tests we ordered were normal, and an expert could find no source. My team and I decided that the patient was drug-seeking again, and we offered him ibuprofen.
But as four more days went by, the patient’s pain only worsened, and he constantly and bitterly complained about it to anyone who would listen. It got so bad, in fact, that he even asked me to examine him. While I was still suspicious, I happily agreed, hoping to bring my team some evidence that we were right to be skeptical. To my surprise, though, he really did have difficulty bending his finger.
For the first time during his hospital stay, his pain became real to me, and I realized I had wronged my patient by not taking his complaints more seriously. We gave him an opioid for his pain, and, slowly, the pain in his finger improved.
We’re taught in medical school not to undertreat pain, yet we do it too often in our zeal to not promote addiction. But many people who misuse opioids started out seeking pain treatment. We’re not doing enough, but what more can we do?
Don’t get me wrong. We absolutely need to continue to ask questions. We need to be more responsible when we prescribe these powerful drugs. And, yes, we need to remain vigilant for any signs of drug-seeking behavior.
That said, we have to be a little more trusting of our patients when it comes to their pain. Getting better control of their pain may help them recover faster and stay healthier longer.
A few weeks later, my patient was back. He was still in pain, and this time, he let my team do a thorough work-up. It turned out he now had a serious bone infection that was going to be difficult to treat.
True pain, it turns out, never lies.
Kunal Sindhu is a fourth-year medical student at Brown University Alpert Medical School.
I get 2 or 3 severe migraine attacks per year that are worthy of a trip to the ER and more often than not, this usually entails having to suffer the indignity of being called a drug seeker bc of how I present. If I’m in the ER, it’s because SQ Imitrex and IM torodol arent working, which is where ER docs like to start. I cant tolerate ragland, compazine or haloperidol even with benadryl or ativan and they cant do DHE within 24hrs of the imitrex. ER docs find this suspicious and I’m automatically labeled a drug seeker DESPITE THE FOLLOWING: I take SQ imitex and IM torodol to treat my pain at home. There isnt a single controlled drug on my pharmacy records and my tox screens are always negative but the moment that I say dilaudid works, I’m a drug seeker. Theyll use the BS excuse that narcs cause rebound headaches to justify denying the pain meds bc they dont expect me to know that rebound phenom is caused by habitual narcotic use, not a few IV rescue doses a year. It’s a nightmare and idk what I’d do if my pain was more frequent than 2-3x a year. When I’m in the midst of a severe attack, I literally get mad at God for giving me a pain condition that I cant prove…lol
Thank you for sharing Dr. Sindhu.
I can certainly identify with being under treated for a traumatic digit injury. My story: a finger on my dominant hand was nearly torn off. I was given percocet* (readers: oxy with acetaminophen*). For the first few days after the accident, it took the edge off for about 2 hours but eventually, the pain was so severe, it was effective for only 20 minutes or so. I began supplementing with ibuprofen – up to 800 mgs every 4 hours because the pain became intolerable while a severe infection began brewing. I was denied a refill of the opioid. 60 days of antibiotics and weeks of trying to control what consumed my life, was debilitating. Don’t know how my liver has fared through it all, but there should have been a better way to manage the pain.
“We” do know that everyone metabolizes pharmaceutical compounds differently based on their own genetics. Physicians can now test a patient to determine how well they metabolize a drug – or not – prior to dispensing. This paves a path for personalized precision medicine. .
Knowing how effectively a patient metabolizes compounds and having a way to measure how pain is experienced, can “move the needle” in medicine – rather than witnessing this opioid crisis which condones “self-administration with a needle”. The time is now to harness technological developments and incorporate them into what can become Best Practices.
With all the research showing the evidence for spinal manipulation controlling back pain (see the recent study in JAMA as one), it baffles me that more MDs don’t refer patients for chiropractic care.
Wow ! I’m impressed. Another perspective about pain
. Outstanding ! !
I don’t think you made an error in refusing to prescribe for someone who refuses to be examined. Once he acted rationally you responded appropriately. I hope this is the feedback you got from your preceptors.
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