Pain and Judgment in the ER
Thank you to those who have commented; the pain topic seems to strike a chord that rings differently for different individuals. Because it is late and I am only now getting to a post that I intended to write hours ago, I’ll use this post to respond to a couple of the comments.
One person believes that pain medications are under-prescribed, and resents the air of suspicion that hangs over legitimate ER visits for painful injuries. I concur and sympathize in regard to the suspicion. The writer mentions that laborers are particularly susceptible to injury and, perhaps in part because of their blue-collar positions or ‘rugged appearance,’ fall under greater suspicion for misuse of pain medications.
I believe that his perceptions are accurate, and agree that doctors tend to separate patients– consciously or unconsciously– into ‘good patients’ who are trusted and ‘difficult patients’ who must earn that trust.
About a third of my practice consists of people with addictions, largely to opioids. I have learned that there is no value in appearance as a tool to detect opioid abuse or dependence. My patients who once presented with opioid dependence work as roofers, construction workers, doctors, and businessmen. If I had to identify over-represented occupations, I have more kitchen workers and attorneys under treatment for opioid dependence than I would expect, given their numbers in the population.
I have asked chefs and other kitchen workers why, in their opinions, the number of addicts in those occupations are so high, and I was told that kitchen work HURTS—lots of bending, standing, and lifting through long shifts with no breaks– and that ‘kitchen culture’ tells a person to medicate the pain and finish the shift. I’ve also been told that the combination of young and old workers, many who move in and out of positions with high turnover rates, contributes to the availability of drugs. As for the reason for so many addicted lawyers, I’ve been afraid to ask!
There is no doubt that a person with a tattoo is less likely to leave the ER with a prescription than is someone carrying a briefcase. And there is no justification for that bias. Along a similar line, I have had a number of patients complain about the treatment they received at the local pharmacy, treatment that also seems influenced by customer appearance or attire.
I realize that pharmacists are often in a difficult position; they are the last line of defense against diversion, charged to keep refills on schedule among other things, often leading to heated exchanges and even threats from patients on the verge of withdrawal. At some point in time pharmacists moved from the person who fills our prescription, checking for mistakes or drug interactions behind the scene, to someone who asks about our personal medical history—often when our nosy neighbors are directly behind us in line!
Patients have complained to me about pharmacists loudly stating ‘you sure are taking a lot of oxycodone,’ or challenging prescriptions that are entirely valid by asking a patient if he REALLY needs all of those pain pills. How many readers have been in the automobile pick-up lane and cringed as the voice from the speaker echoed across the parking lot: “have you taken medicine for constipation before?!”
My only disagreement with ‘Tom’s’ comments would be on the issue of ‘too little’ vs. ‘too much’ pain medication. For short-term conditions, I think he makes a valid point; we have medications that relieve pain, and many times that medication is withheld, causing needless suffering. But for chronic pain conditions, my experiences have led me to believe that people do better avoiding narcotics if at all possible. There are even studies that show a loss of function when narcotics are prescribed for chronic, moderate pain conditions. Then again, my perception is admittedly quite biased, and there are studies that show pretty much everything.
Finally, a different reader commented on a company that works at the forefront of developing new treatments for chronic pain. I was not familiar with the company, but after reading about the company’s product pipeline on their web page, I agree with the writer that there are reasons for optimism in regard to finding new treatments for chronic pain. The medications under development include molecules that activate opioid receptors other than the ‘mu receptor’ where most pain medications currently act. Actions at other receptor sites may provide similar pain relief, with less risk for opioid dependence or for fatal overdose.
I believe that the most promising area for relieving suffering is in finding the mechanism for tolerance to opioids, and then finding ways to prevent tolerance. I fully expect this to occur within my generation’s lifetime.
I look forward to a world where opioid medications can be used for extended periods of time without losing their effectiveness; where a low dose of hydrocodone works indefinitely in a patient with a pain disorder. On the other hand, I wonder about a world with euphoria-inducing molecules that have been freed from the consequences of tolerance and withdrawal. Many people would be relieved of so much suffering… but the law of unintended consequences makes the discovery of such substances a bit frightening.
Junig, J. (2010). Pain and Judgment in the ER. Psych Central. Retrieved on April 22, 2018, from https://blogs.psychcentral.com/epidemic-addiction/2010/09/pain-and-judgment-in-the-er/