Wednesday, September 27, 2006

Chronic Pain - Your Baggage, My Baggage

Before we get started, just wanted to say that most people living in chronic pain are true survivors. I'm met people in chronic pain who are well-adjusted and really stellar examples of the adaptability of the human spirit. Many who have enviable personality traits that we should all work towards. This is NOT about them.
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Chronic pain. These are words that many physicians dread to see on a new patient's chart. It's not the pain that's hard to deal with. It's that pain often brings along a lot of unpleasant companions that can make it an emotionally draining encounter. It's hard to tease out all the different reasons, but here are some of them:

1) people in chronic pain have spent a lot of time trying to navigate the medical system, jumping through hoops, looking for answers, and so bring a lot of baggage with them. Some of them get stuck in a negative feedback cycle with the medical establishment and come to you with past experiences of resentment, anger, and misunderstandings that they bring to the table. It's not really their fault that they are they way they are, but it does make the interaction difficult. A good analogy would be a significant other with a lot of prior emotional baggage. You may want to work through issues, but every step you make has the potential to set off a long hidden landmine...

2) some people in chronic pain, just like some people without pain, have personality disorders that make them difficult to get along with. And others may have developed problems like depression and anxiety due to the chronic pain and its profound impact on daily life. Nothing against people with personality disorders, but for those of you who are on the more sensitive side, you've probably had the experience where, after talking to someone who is depressed, you leave the room or leave the interaction with your shoulders hunched and your head hung low. The sky no longer seems as blue, nor the grass as green. These personality disorders and resultant emotional issues need to be addressed, but unfortunately, it's not something that can be easily done by you (unless you're a shrink) or done in one visit.

3) A very small number of the patients are actual drug seekers, which means that we as physicians may fall into the trap and plop our own overweight baggage onto the table. Whether they are or are not should not be an issue when we're taking care of patients - ideally, we should be able to treat pain regardless of why they have pain, but it just takes one bad experience to really shake you up and make you think twice.

I still remember a young woman who came in with a large deep venous thrombosis (DVT), who gave a really good history as to how she got the DVT. She was admitted for pain control because of excruitiating pain in the affected leg. Although the pain seemed out of proportion to the problem, given that she did have a clot in her leg, we set out to treat the pain. Every time we walked in the room, she would be writhing on the bed in pain, complaining that we were completely ineffective at treated her, and yet, when we were nowhere to be seen, said patient would be strolling the hallways with her Dilaudid PCA pump, waving at the hospital staff. When we tried to switch her over to an oral pain regimen, she all of a sudden developed complaints suggestive of meningitis, accompanied with an excruitiating headache that required Dilaudid and only Dilaudid to treat. We were somewhat puzzled by how this would happen as she had no known risk factors, but again, she was very convincing and her symptoms were concerning. So to rule out meningitis, we discussed a lumbar puncture with the patient. She was extremely reluctant to get the LP, coming up with one reason or another why she shouldn't get it. Finally, the morning of the said procedure, her headache miraculously resolved.

This whole time, although we thought she was a tad melodramatic, and the whole clinical picture didn't quite make sense, no one suspected anything. The patient was extremely convincing, and even gave us a sob story of having two children at home that she had when she was very young, and told us that she was trying to get off pain medications because she wanted to be a good mother and role model for her children.

Meanwhile, the nursing staff stated that they believed the patient was "milking" the PCA pump. This was the first time I had ever heard of such a thing, but apparently, there's a way of milking the tubing attached to the PCA so that one can get more of a bolus than the machine delivers. The first time this happened, the nursing staff thought they had miscalculated the amount of opiate in the bottle. The second time, they got suspicious. The third time, they caught her doing it. We asked her about it, at which time she started crying and furiously accused us of not trusting her, stating that she didn't want to have the pump if we were going to accuse her of abusing the medication. By this time, this was three weeks into a hospitalization that should have taken a few days, and the attending physician decided to stop the pump and convert her to an equivalent amount of oral medication. Apparently you can't get as much of a high from the long-acting oral medication, because as soon as the pump was discontinued, she decided she was all better and was ready to go home.

Two weeks later, my co-worker, then on a rotation at a different hospital, admitted the same patient, who was now using A DIFFERENT NAME, from the emergency room with the same exact complaints. Because he recognized her from morning rounds at our hospital (but not the other way around), the medical team there did the necessary medical workup, but were aware of what she was trying to pull. She got oral medications but no PCA pump, so left the hospital very soon after admission. A week after that, I received a frantic email from yet another hospital emergency room, for the same patient, with yet another variation to her name. The patient had given a sob story and said that she had an extensive workup at our hospital, and we had given her this and that pain medication, and she was asking for the same from this third hospital.

On some level, we should feel sorry for someone who is so addicted that they need to do whatever they can to get the next dose of their drug. And in a way, it might be easier to just give the patient what they want. But that can't be the right thing to do by the patient - you just make it easier for them to abuse the system and abuse their bodies. And besides the ethics of the situation, when you're the one that was duped by that innocent face, that sob story, there is definitely frustration with the patient and anger at yourself that you were dumb enough to fall for it all. And the next time a similar patient comes along, the prior experience is there, reminding you to be on your guard. Our baggage, I guess, of sorts.

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