Pained

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **

Last night was my first night on call. Halfway through the night, we got a call from the ED to admit Tom, a 25 year old man complaining of chest pain. As I made my way to his room, I was already envisioning his presentation and thinking of labs to order and supportive measures to keep him comfortable. What I found in the room was not a cardiac case. 

Tom was diaphoretic, hypercapnic, and writhing in pain. He attempted to sputter out a history, but kept pleading for a Percocet. He didn't complain of any chest pain; in fact, his pain couldn't be localized to any specific location. His skeletal body was folded into a fetal position. Tears were in his eyes as he begged me to do something for his pain. He vomited on the floor at my feet. I have never witnessed such anguish.

I reported the findings to my resident. She requested a stat drug screen, which was positive for opiates. He reported daily consumption of a smorgasbord of prescription narcotics. We started him on anti-nausea medication and tried to extract details about where he got the pain medicine from. He promptly had a grand mal seizure. 

After he recovered, we questioned his plans upon discharge. Was he interested in rehab? Was he going to wean himself off opioid pain medications? He again emphasized his need for Percocet due to a degenerative joint disease. The suggestions of physical therapy, NSAID therapy, and alternative treatments were all rebuffed. Tom was indignant that he needed these pain medications to ever feel better. No other solution was feasible in his eyes. 

I have never witnessed a severe drug withdrawal of this nature. Tom was in unrelenting pain. As we filled out order forms and wrote progress notes, I wondered how many Toms are created every day. Some may be created out of malpractice and negligence by overzealous practitioners. Others may have good intentions, but may inadvertently create opiate addictions in patients who could have been managed in other ways.

Pain management has always been a "hot topic" in medicine, due to the variable response to treatments, risk of addiction, and of publicized celebrity prescription abuse. Recent emphasis has been placed on the treatment of chronic pain, to reduce associated physical and mental comorbidities. In 2006, the American Board of Medical Specialties added palliative care to their list, perhaps signifying the need to further investigate and improve the treatment of chronic pain without creating dependency.

So, what will happen to Tom? He is ensnared in a vicious cycle of addiction and withdrawal. He needs pain medication to avoid withdrawal, but the medication heightens his tolerance. When he runs out of pain medication, he will delve into withdrawal, requiring higher and higher doses to prevent seizures and excruciating pain. During rounds, as we left Tom in his room knees-to-chest, wailing in pain for his Percocets, our attending commented, "The doctors who prescribed his medications need to visit their creation."