"Sometimes it's the patients with elegant clothes and three kids who call a week after a filling and say they need pain medication. That's when my radar goes up," says George Kivowitz, a dentist in New York City and Newtown, Pa. Insisting that the patient come in to be re-examined usually ends the conversation, he says....Sometimes it's a guy in a 3-piece suit and sometimes it's guy who says "dude."
"I always ask a patient, 'How are we going to show that this intervention has helped?' " says Scott Fishman, president of the American Pain Foundation who wrote a widely used guide to responsible opioid prescribing. "The person who is just trying to get opioids will say, 'Ah, later, dude' and go somewhere else."
July 5, 2011
"Even When Patients Describe Pain in Vivid Detail, Doctors Have Few Tools to Determine What's Real."
How is a doctor supposed to tell who's for real and who's a drug abuser/reseller?
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47 comments:
"Pain don't hurt."
Is this a Rush Limbaugh hit piece? IMO Doctors do try to help suffering people, and writing pain drug Rx's are very legitimate. But the opening here to create another massive Federal Bureaucracy to criminalize the practice of medicine and save the world from evil is too tempting.
I have a neighbor whose marriage is breaking up because he has been on pain medication for years due to a severe auto accident. His mood swings widely and he is angry all the time. She gave him the ultimatum of changing his meds or moving out, so he moving out.
I can go on and on with similar stories. Friends of mine with work related "back problems" (legitimate ones) who needed greater and greater medication doses and who get more angry and depressed over time.
Are they in pain? Most definitely. Are they addicted to those drugs? Most definitely. Are those drugs helping any more? No. They are not helping. They have become the problem.
I had another friend of my who broke his legs, ribs, hip, and shoulder in a bad fall. Almost died twice in the hospital. Lung collaspe both times. Massive amounts of pain killers (and he needed them). He said when they weanned him off those drugs (they did it under doctor supervision in the rehab facility he was in) it was almost as bad as the accident. He is okay now, but suffers short term memory loss which he is sure is a side effect of the drugs.
There are legitimate reasons to take such drugs. But you have to watch them.
Yes this will always be messy. but if your patient:
-frequently "loses" his/her prescription
-regularly asks for refills before they should be out
-has multiple sources of the prescription
-has a continuing accelerated need
-has a strong history of drug/alcohol abuse
then there may be some problems.
Some tools for use in chronic pain patients on chronic opiods:
-pain contract
-periodic drug screen (looking for substances of abuse) with the patient's consent
-inquiry of pharmacy
Rush fell into that trap too. And then douchebags from Florida tried to go after him criminally. I would suggest this sort of drug trap, while similar to other drugs, is different and needs to be treated as a health crisis and not a criminal matter (provided there is no criminal behavior beyond trying to get the drugs).
And the reason patients can describe the pain in vidid detail is because they are in fact in pain.
I am not for nanny stating this problem. I am for counseling patients up front the dangers of prescription drugs and how to avoid falling into the trap. Unlike other addicts, most people in this situation do not want to be there.
An ounce of prevention is worth a pound of cure.
When I was still living in PA, The Blonde slipped in my basement and ripped her knee, occasioning a trip to the ER. When she asked for something for the pain, the doctor on duty was extremely skeptical (she'd already popped the leg back into place (it was sticking out at a right angle to the left)) and accused her of drug-seeking.
Medical people, nurses as well as doctors, are on the lookout for any signs of this kind of behavior and, as the above example proves, can go a bit overboard.
As to station in life, some of the best markets for illegal drugs are those hyper-affluent burbs.
Presciption-drug abuse is the upper, middle-class drug problem. More respectable, more reliable and, until recently, more available.
Something similar happend to me in ER when I had a kidney stone attack. They didn't believe me (I guess this is a common complaint of guys who are looking for a fix). Also I came from the City of Chicago to a hospital on the north side of Evanston (which is where my doctor practiced) so that also looked suspicious. Anyway, I finally got some meds when they got a hold of my doc. but it was very painful for a long time.
Here in South Florida - there are the twin industries of pain pill dispensing and drug addiction rehabilitation. They appear with about the same density as taverns in Wisconsin.
My primary care physician told me about how everyone in healthcare down here has to be on guard to discern pain medication seeking behaviors. One thing his office does when they suspect that a patient is making a phony claim of soft tissue injury (or one of the other frequent ploys to get oxycodone/oxycontin, etc.) is run a drug test on the patient, to see what they are already doing. The nurses just about have to frisk the patient before they enter the bathroom to generate a urine sample. This is because drug seekers will take a pin, prick their fingertip and add a couple of drops of blood to the urine sample. Apparently this confounds some of the tests - and when the "no result" report comes back, rather than schedule a retest, someone on the MD's staff will just mark it as a pass. Drug seekers know this, and have many other ploys to get what they crave.
Doctors love inflicting pain on patients. They get off on it.
Pendulums swing both ways. I have a family member who was an out of control opiate addict for decades. Finally, the docs woke up and stopped prescribing. Professionally, I have seen many malingerers who are plaintiffs in personal injury suits. The motivation is usually $. Now, I have worked cases for plaintiffs attorneys and I know most plaintiffs don't fit this category. But having found a niche in surveillance, most of the cases I worked since the early 90's were malingerers or flat out fraud...it's usually malingerers to varying degrees. What I've seen also are people who are primarily motivated to be a victim so they can get pain meds..the $ being secondary.
Our culture swings wildly back and forth. Docs eventually saw they were being conned, and justifiably tightened script writing. Now, some are too restrictive, not writing scripts for people who really need them. Good docs don't get conned too often and don't have the wide swings either way. Finally, in order to combat this epidemic[I believe it is] some states have databases tracking patient scripts. It is somewhat Orwellian and a debatable solution to this problem.
Bottom line is it's blatantly evil and immoral to deny suffering patients the meds they need because doctor's prefer to take the easy route. There is a special circle of hell for those doctors.
Fred4Pres said...
"Are they in pain? Most definitely. Are they addicted to those drugs? Most definitely. Are those drugs helping any more? No. They are not helping. They have become the problem."
This is really well said. As a nurse who has spent time in a variety of areas (including ER) I just couldn't agree more.
This makes me remember a previous post on the Althouse blog; about UW's Integrative Medicine program. If I remember correctly the comments (including those from Althouse herself) weren't too favorable.
The truth is, meditation, acupuncture, massage, and natural anti-inflammatories along with traditional therapies can help people with pain and ultimately, their pain medicine addiction.
The bottom line is, we've got to look at all the options for managing people's pain, what we are doing for "chronic pain" just isn't cutting it.
You don't have a right to pain relief.
And I care if druggies get drugs why?
Give them to anyone who wants them. I don't care if someone wants to drug himself to death. I do care that people who are truly in pain are not denied painkillers.
Remember that Rx addiction is self-resolving due to liver damage. There is no free ride.
Alex said,
"Remember that Rx addiction is self-resolving due to liver damage. There is no free ride."
No, this doesn't make sense.
This's an awesome article. I like you'r article.
No, this doesn't make sense.
Then why does my Tylenol bottle say I can't take more then 3 doses in 24 hours or I risk severe liver damage?
My sister blog, Panda Bear, M.D., used to deal with those kinds of questions all the time. (Panda's taken time off.)
If you can't figure it out, you can always be like most NewAgers and use the watermelon man,...
And of course there's those people who, when asked to rate their level of pain on a 1 to 10 scale, will casually say, "Oh, yeah, this is like easily a 9 or a 10. It hurts a lot." When really if you're at level 9 or 10, you would barely be able to speak.
Thankfully most hospitals have those neat little charts, with the little faces going from happy at level 1 to morose at level 5 and sweat-dripping, teeth-grinding pure anguish at level 10. I guess the doctor can pull the chart down and compare his patient's face to the chart.
Alex said,
"Then why does my Tylenol bottle say I can't take more then 3 doses in 24 hours or I risk severe liver damage?"
Tylenol is hard on the liver. I'm pretty sure these people aren't addicted to tylenol :)
I guess if people take a bunch of percocet (tylenol and oxycodone) they could end up with liver damage, so that is a fair point.
Most people with significant addictions are sticking with the straight stuff (just the narcotics themselves). Rush was addicted to oxycontin right? no tylenol there.
Here is another point though: even if some took a bunch of percocet (or another Rx with tylenol) and damaged their liver, they only need to be free from abusing it for 6 months before they are eligible for a liver transplant. Same with a liver destroyed by alcohol or with hep C contracted by shooting drugs.
6 months clean, that is all you need.
I know a doctor who, when faced with a suspicious and difficult-to-check claim of pain (kidney stones were always popular), would deliberately first suggest a very mild pain killer, just to see if the patient protested. If no protest, the doctor would "change his mind", and write a prescription for something stronger.
Alternatively, you can use the approach a pain medicine doc I know and his assistant use - be ex-junkies. It is very, very difficult to fool someone who used to be addicted to the stuff themselves.
Doctors need to remember that they are front line soldiers in the War on Drugs, and patient welfare is a secondary consideration at best. If I ever go to a hospital in a lot of pain, I know I want the doc to say, "Oh, yeah? Prove it, junkie scum!" Because it's better for a hundred people to die in agony than one person to get high.
Drug induced liver disease
Because it's better for a hundred people to die in agony than one person to get high.
This isn't the fault of the doctors. If somebody decides they have been giving out too many pain meds they risk their license. It's just the stupid drug war bleeding over into legal drugs, with predictable and dumb consequences.
I mean, the pain score is a series of happy faces. Pretty hard to determine who is trying to get high from that, versus those acutally in pain.
Some time ago my wife had very painful dental work. The Dentist gave her a powerful pain killer which let her sleep very well from the first night. She took them for three days, realized that she really liked them and threw the rest away. The following week the Dentist called to follow up and offered another prescription. It ain't always the patient.
You really don't know what pain is like for another person. And there is a big subjective element. One of the values of having the prescription -- say after a dental procedure -- is that you know you can control it if you need to. That feeling of control may be all you need, and you don't even take the drug after the first or second dose. That's what I've found. But if I were in a situation with pain and no medication, I think I'd focus on it and worry. The fear of increasing pain would make the existing pain worse.
Next thing we know, doctors (or the government) will require a lie detector test to determine the level of pain and the need for relief. Or would an addict be able to fool the box?
A friend of mine works in pediatric hospice. A few years ago, at a fundraiser for the hospice, a doctor gave a talk about that difficulties of managing pain for pediatric patients. Apparently, it's a lot more complicated subject than it appears to an outsider.
Chronic pain can ruin people just as surely as any drug addiction. And apparently today's doctors are a lot more sympathetic about helping addicts than treating "suspicious" patients who can't actually prove they're in pain.
Hmmm... I read "Pain" as "Palin" and immediately thought it was a legit headline from the MTM... :)
Ann is right - pain is too subjective, no one can know the pain of another person. Most folks do not believe I am in pain all my waking hours. The degree of pain varies, but it's always there and has been since birth when a serious orthopedic condition was diagnosed. My first surgery was at 3 days and my last was at 13 years.
In the late '80s, I was in a car crash and had to see a neurosurgeon for insurance claims. He hooked me up to an electrical torture device that sent increasing amounts of electricity through my body to determine the level of pain I was in. His instruction to me was simple, "Tell me to stop when the pain gets to be too much." He had to stop because I had exceeded the capacity of the machine.
I don't look like I'm hurting. I live with my pain as I have all my life having learned by myself to control the pain through meditation. I have used meds for pain that was more time compressed, incessant, than it was painful. A little pain all at once is harder to deal with than a lot of pain over a long time. Aspirin has been my longest lasting friend and has been more help than the morphine injections given when the talus bones were removed from left foot, but sometimes something stronger is needed.
I know the risks of addiction to pain meds, even aspirin. And I know how to control pain to a tolerable level without medications, but that's come from a life time of experience with pain that physicians just cannot know. Doctors must simply trust me when I say the pain is too much as I trust them to treat me appropriately.
Yes this will always be messy. but if your patient:
-frequently "loses" his/her prescription
-regularly asks for refills before they should be out
-has multiple sources of the prescription
-has a continuing accelerated need
-has a strong history of drug/alcohol abuse
Maybe some of this, but I have a friend who falls into most of the categories and has real pain, ultimately resulting from 5 or 6 bad disks from an auto accident (5 of 6 have been replaced, the other one is sketchy).
The memory problems are a result of medical malpractice after a surgery - heart stopped as a direct result, resulting in permanent brain and vision damage. And, when you lose your pain meds, many of the rest of those naturally follow.
Some tools for use in chronic pain patients on chronic opiods:
-pain contract
-periodic drug screen (looking for substances of abuse) with the patient's consent
-inquiry of pharmacy
One of the reasons for the drug screens, which this friend has to routinely undergo, is to make sure that the opiods are being consumed and not sold. The street value of these meds is many times the pharmacy price, even without insurance.
The flip side is that stealing such meds is endemic. TSA people have done so more than once. Indeed, I think that this person's pain meds have been stolen maybe a half dozen times in the last 3 or 4 years - the last time maybe a month ago.
My mother-in-law recently retired after 53 years of nursing, the last twelve of which were in north Florida.
She commented on how you see the very same people back in the ER, week after week. With black women it's always non-specific abdominal pain. Intolerable, of course.
The men, black or white, did indeed have "kidney stones." Regular as clockwork.
The docs knew the gig and would write 7-day scrips just to get the poseurs out of the way in what was a generally busy ER -- gunshots, drunks falling off a balcony, stabbings, and so on.
Nice town.
Obviously our management of pain engenders a lot of opinion and emotion. From the Doc's side of things, they do feel squeezed between the twin demands of adequate pain control and limiting prescription drug abuse and diversion. At any one time some states are passing new stringent laws to punish docs who "over-prescribe" opioids and other states are encouraging docs to adequately control pain in pain patients such as cancer patients.
And as the discussion demonstrates, there are more than just medical issues here.
Its also more than just "not having an objective measure of pain". People widely vary in their "tolerance" for pain.
What a professional football player experiences daily would generate gobs of opioid scripts in the "real world"
@Indigo Red My heart goes out to you. My grandmother complained of pain and had a suitcase full of medicines, and everyone considered her a hypochondriac. (I learned that word when I was a little child.) In fact, she had a painful disease that was not diagnosed and which she died of. (Scleroderma.)
My mother did just about the opposite, enduring a very advanced cancer while insisting that her doctor told her she did not have cancer. One day I caught a look at her when she didn't think I was looking, and, realizing that she'd been hiding what she was going through, I made her go to the doctor the next day. A real doctor. She had been seeing a homeopath as her doctor, without telling us that either. She really believed in that, she told me, and she accepted his assurance that she was going through the ordinary pains of aging.
I've been in chronic pain for the past 23 years. It is a constant, achy, pain that I've learned to tolerate over the years. In fact, my pain tolerance level has risen a LOT in the past 23 years. I used to be a real wimp about pain.
I was on NSAIDs for quite some time until I developed an ulcer. Now I can't take the NSAIDs or aspirin. I'm now on Tylenol #3's and regular acetaminophen.
I do my best to take the meds only when the pain gets acute and the levels rise above 5 or 6 on the scale.
Codeine is converted to morphine in the liver. I was once prescribed Tramadol (a synthetic morphine) but I couldn't tolerate it. It made me throw up.
Now the FDA is lowering the amount of acetaminophen in combo drugs (Vicodin, Percocet, Tylenol #3 and #4) because of potential liver damamge. But the FDA insisted on the inclusion of the acetaminophen in the first place to keep people from becoming addicted to the opiods...
"I don't care if someone wants to drug himself to death. I do care that people who are truly in pain are not denied painkillers."
This. If we're really going to legalize pot (someday) why not make opioids available OTC? I can't see how people could be libertarian about one drug, but restrictionist on everything else.
Hell, let us grow opium poppies, climate permitting.
But the FDA insisted on the inclusion of the acetaminophen in the first place to keep people from becoming addicted to the opiods...
This really irritates me. People still become addicted to opiods, it's just that they now have liver problems in addition to whatever was originally wrong.
When you get a prescription they always give you a five page sheet with side effects and directions in five point type. Most of the side effects aren't real. They all say "don't take with alcohol", even when it doesn't matter. So people don't read them any more.
We ought to err on the side of believing the patient. At least things have changed for the better over the years - 20 years ago in Santa Barbara there was a series of damning newspaper articles regarding the local hospice. Terminal cancer patients were spending their last days in intense pain because the DEA was putting pressure on the doctors for "over prescribing". At a hospice!
Pain is not a scientific fact. Neither is consciousness for that matter. This may seem counterintuitive, which of course it is, but intuition is not science. Science is limited to phenomena that are directly observable by more than one observer.
For those of you who don't know the blog, www.theangrypharmacist.com has a great rant up about a customer who picks up her [TAP tries to disguise the customer's sex, but at one point he slips] diabetes meds, but doesn't take them, because "she knows her own body." Picking them up is the price she has to pay to get her Percocet. (The only price, as apparently she's on Medicaid or something equivalent.)
wv: adaver. What a diabetic who doesn't take meds will become: A cadaver, minus a bit.
I think the doctors should err on the side of believing the patient.
Why? Because it's better that 100 drug abusers O.D. than that one legitimate patient be denied adequate pain relief.
IMHO
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