Pained: Folie a Deux

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

Marla was in pain. 

Pain is subjective. Heart rate and blood pressure tend to elevate with pain, but this is not definite. We attempt to quantify pain by using a scale of 1 to 10, with a "10" equivalent to childbirth or the passage of kidney stones. Again, this is subjective. It can be a challenge to evaluate and manage pain, especially with the growing issue of narcotic abuse.

Marla rated her pain as "100 out of 10", and writhed in pain as I obtained her medical history. Her pain was generalized -- she couldn't verbalize a specific part or region that aggravated her. Her husband held her hand, and interjected responses designed to guide my decision making. She needed pain medication, he said. Surely I understood. Marla looked at her husband before answering my questions.

I observed their interaction as I listened to her tachycardic heartbeat. Her husband was agitated, and rambled about getting rich from filing million-dollar lawsuits against the hospital. They had visited numerous emergency departments in the area, and one one understood their predicament. She was hesitant. Was she afraid of him?

Gut feelings are hardly admissible as objective medical findings or evidence in a courtroom, but I was suspicious of Marla's husband. I examined her carefully, searching not only for the source of her pain, but for signs of domestic violence. Her abdomen could be concealing a pregnancy or inflamed appendix, but could also hold welts. Her eyes may have the recession of dehydration or the pallor of anemia, but may also reveal the jaundice of healing bruises. Her bare arms were tattooed, but may have also been burned by cigarettes. I found nothing. 

Marla's husband grew impatient. He yelled in my face, demanding a prescription for Dilaudid to relieve his wife's pain. She flinched as he raised his voice. Was he using her to obtain narcotics? Did he force her to come to the ED?


I escorted her to the restroom with a specimen cup. Before she shut the door, I whispered the SAFE screen. Did she feel Safe in her relationship? Had her husband ever threatened or Abused her? Would her Friends or Family know if she were hurt by him? Did she have an Emergency plan? Her responses centered around the supportive nature of her relationship. She told me she would have never survived without his support. Her eyes were dull, but she begged me to believe her witness.

Still, I wasn't convinced. Were my suspicions valid? Perhaps my reaction was transference from my prior violent relationship, and I identified with Marla. Perhaps I was searching for the real reason for her vague symptoms and intense pain. Should I refer her to the police? A social worker? What would I say to them? I had no evidence to support my suspicions. I also had no evidence to support a prescription for narcotics.

I watched as they left the hospital, arm in arm, commiserating about the unfeeling doc who wouldn't give her Dilaudid. 

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."