"Some Discomfort" or Why can't doctors tell the truth about pain?

In My Humble Opinion
61

Oy. Where to start.

I am sooo tired of the “you must be drug seeking to want more pain relief” myth in this country. I had an ER nurse tell me that the ER docs usually don’t medicate pre-teens for “this type of injury” when I insisted that my 13 year old daughter get some Tylenol #3 for an injured knee tendon due to a fall in figure skating. She had to wear a knee brace for 3 weeks. Sometimes I wonder how many clueless people are out there.

Hear this: NOONE is going to get addicted to painkillers in the short time it takes to recover from surgery/tooth extraction/injury. If the pain becomes chronic, a tolerance for the painkiller may develop. That is NOT the same as addiction.

I am on both sides of the fence on this issue. As a nurse, I see plenty of people who are laying in bed, watching TV and yet insisting their pain is “off the scale”. But see, I am accustomed to dealing with acute pain, not chronic pain–and those two categories present with very different symptoms.

But-and hear this-especially the nursing student here (sorry forgot your name)–I medicate everyone. No, I don’t dope 'em up, but I advocate for analgesia on all my pts who ask (and some older folks who don’t ask-a whole 'nother thread).

I do this BECAUSE I cannot judge who is in pain or not. Pain is a subjective experience–who am I to say, “nah-it’s not that bad.” for anyone else?

That is part of my job and duty as a nurse. And ya wanna know what else? Even IF Joe Patient IS addicted to Demerol, my “moral high ground” in refusing to “feed his habit” is not likely to do much for his addiction, or his need for pain control. So, I tend to medicate these types as well.

As a patient, all I can say is that the doctor MUST tell me that it is going to hurt–HURT. I had an endometrial ablation this summer. Gyne told me that I could work the next day (I did not schedule myself for work, because often I do not sit down for 12 straight hours-no way was I having surgery and then going to work next day). “Mild discomfort, easily handled by Tylenol” was the statement used.

Bullshit and then some. I had LMA (laryngeal mask anesthesia)–my neck and throat hurt–hurt as in I had trouble moving my neck and swallowing --for 2 days post-op. I woke up in recovery, asking for codeine. And the nurses advocated for me–told Gyne that I was a nurse (which she knew), that they wanted to give me Vicodan. She gave me a disgusted look (one I will remember) and said, “Tylenol #3 and that’s pushing it.” I didn’t get an Rx-I got one tab of #3 and in an hour, I got the other one. Well, screw her. It did nothing.

Pain was so bad and I was concerned, so I called the office-same day, 8 hours post-op. Talked to the receptionist (warning: when you call a doc’s private office, you most likely will NOT be talking to an RN or even an LPN–you are talking to a layperson who thinks they know stuff. They don’t). I asked to speak to the doc. Was told she was doing a C-secxn and what was the problem? Told her I was in alot of pain. She said, and I do not kid–“I would go take 4 Tylenol extra strength and take some more tonight.”

I told her I had already had 2 Tyl#3’s w/o relief and that 4 Tyle ES was too high a dose. She just said, “well, it works for me.”

At that point I gave up and took Flexeril to knock me out. :rolleyes:

I told Gyne at my follow up appt that my neck and shoulder muscles were killing me for 2 days-so badly that I took some Flexeril that I have on hand in order to sleep. I said that I really could have used that Vicodan. She said that I wasn’t supposed to have any of that.

So, therefore, it doesn’t exist? WTF? She was good to me in labor, so I am left with :confused: Maybe she only empathizes with labor pain?
Bottom line: we undermedicate pain in this country. For all sorts of reasons-we’re “afraid” of addiction, we don’t want to “depress someeone’s breathing”, we don’t want to “make the baby sleepy”, we don’t want to deal with other people’s suffering is what it comes down to. So we minimize, dismiss and marginalize patients.

Patients are not completely without responsibility here, though. Be open with your health care practitioners–tell them you have a low pain tolerance or a high one. Insist on more, if needed. If you are too weak or sick, make sure there is someone who will advocate for you with you (and that may or may not be a family member–some “loved” ones won’t advocate-again, another thread). And IF doc or nurse doesn’t help make the pain manageable (NOT gone-that may not be possible)–give feedback. Lots of feedback–via letters, phone calls, stop using that doc and tell him/her the reason–help to change the system.
[/off soapbox]

62

Because low dose codeine preparations (codeine+paracetamol/acetominophen and codeine+ibuprofen) are available OTC here, I think it makes a difference.

  1. People know to work up from a basic painkillers to a stronger one, and will only seek help for acute pain if the stronger OTC preparations don’t work. We may well get people presenting later, but we also get less people in the emergency department looking for simple pain relief because the OTC stuff doesn’t work and their doctor can’t fit them in.

  2. Doctors are happier to prescribe stronger analgaesia, because everyone uses the OTC opiates, and if the patient says they need more drugs, they’re assumed to be in enough pain to need more drugs. Generally speaking patients have realistic expectations of how well low-dose opiate painkillers should work, as they’re more used to them. The only exception is the post C-section ladies who intend to breastfeed- they go through the third degree to get anything stronger than a cup of tea and an aspirin, poor things.

  3. We may well have a whole bunch of recreational codeine addicts about the place, but they don’t cause the health service enough problems to make a policy change worthwhile. Essentially, if they’re buying OTC codeine in vast amounts, that’s their business, as long as they don’t try and scam harder drugs off their doctor.

  4. People with chronic pain can treat themselves OTC, and only go to a doctor if the pain is unmanagable, once there they are usually assumed to be telling the truth and are referred to a pain team (which consists of neurologists, anaethetists and psychologists to try and cover all the bases).

63

Another reason I would like to live in the UK. Or even Ireland (but I’m orange, sorry).
I think our hysteria about addiction etc stems from Victorian times (and Puritan ones, too)–the whole “demon rum” crappola.
But one would think in this day and age that some complexities would be allowed and that suffering physically would not be tied to moral anything, but… :rolleyes:

64

Some discomfort?

The bottom line is that they don’t know what you’ll feel because it’s entirely subjective. Some people are really wimpy or have low tolerances or both. Other people are tough.

Still, other people think about pain differently.

I’ve been doing some long distance running and some ultramarathoning, and I’ve become conditioned to some pretty severe suffering. My hands were burned as a kid, and I suffered pretty hard through that, but, I got used to the pain.

So, in the respect of overt physical suffering, I think I’m pretty tough.

But, it’s not about overt physical suffering. You can handle whatever you can get your brain around. The human body can only suffer so much. There are limits to what your body will allow you to feel in terms of pain before it hits the reset switch… so to speak.

Last week on the ultramarathon, it was pure agony for a while. Then, apparently my body decided me it had sent all the intense pain signals I was owed and while the pain was still there, it got dialed back several notches.

What is difficult about pain though is how you handle it. I got stitches once without novocaine (when I seventeen and foolish) to see if I could handle it. I could, it wasn’t really all that bad.

However, put me in a dentist chair and give me even mild tooth pain as the dentist drills and I can barely keep myself together. I get tons of novocaine and it’s still horrible and it still hurts with unbearable agony.

I had a bad dentist as a kid and I never got over it, and I start to fall apart when my teeth are worked on.

The actual pain isn’t all that bad, it’s the way I handle it that makes it horrible. I try to use my toughness in other areas to overcome it, but typically it doesn’t work.

Other ideas of pain are intolerable, such as testicular pain. The idea is so horrible that it almost wouldn’t matter what the trauma or pain was objectively. It would be horrible.

On the other side of the coin, patients subject themselves to excruciating pain willingly in order to conquer things like cancer, or for rehab. If the pain is serving a purpose than it’s amazing what a person can tolerate.

As a former burn victim, I used to visit a burn center with children in it as an example. I would show my hands which I regained dexterity by doing magic tricks, and show the magic tricks. The basic message was that I was an example of the pain getting better and healing, which was important for these children to see.

The truth though was that in the scheme of things my burns were relatively minor with only little nerve damage. I have seen some kids who had truly horrific injuries, things that would be years, decades, or lifetimes of suffering. There, suffering pain at the limits of what the body can actually give you, for extended periods of time… they were still kids. They would still laugh and play and want to do things.

It comes in waves, with, or without medication. The wave peaks when your brain just can’t give you any more pain, and while the suffering never goes away, it always drops to what you can handle… if you let it.

I’ve never really articulated it to a Doctor, so I may be talking out of my ass, but I think that pain medication may not really help all that much. It covers and masks the pain, but it leaves you vulnerable to it when it returns… and it will. Your body generally does a pretty good job of managing what you can take, and you tamper with that mechanism at your peril. You may be making charges on a credit card that will have to be paid back with interest. So, I try to avoid it.

So, pain is entirely subjective. If you think it’s mild and no big deal, than it is mild and no big deal.

If you think it’s a big deal and horrible, than it is.
Unfortunately, you can’t… or it’s very difficult… to actually decide for yourself about these things. Your subconscious lets you know which it is, and that’s basically it.

Being entirely subjective, the Doctor has no idea what you’ll feel or more importantly how you’ll react to what you feel.

65

Great post, eleanorigby. I get too upset with people like Doctor J and his “I know how much pain you are in better than you” attitide that I can’t see clearly enough to write posts that can stay here in IMHO. You are right to call the fear of drug-seeking a myth and hysteria. Very, very few people are addicted to pain medications–far more are tolerant, as you pointed out, and even more are undermedicated and desperate. You are also absolutely right about people with acute and chronic pain presenting differently. Add on top of that having had to deal with bullshit doctors who don’t believe them, and you get some weird behaviors.

I hope Doctor J comes back and responds to these ideas. Fighting ignorance, even with just one doctor, would make a huge difference to his patients.

66

So, now that I’ve had my first good nights sleep in a week (Percodan is, in fact, my friend. As is the yucky tasting stuff packed in my socket.), I’ve been thinking about it, and I think that, in this particular case, alice_in_wonderland was originaly right about why I got the “some discomfort”. You see, novacaine doesn’t work well on me, and I’d been so poorly treated by dentists in the past that it had been 6 years since I’d been to one when I presented myself to this guy, with my seriously rotten molars. Because I didn’t actually explain to him the way that I face pain (I want the “worst case scenario”), and he is used to dealing with dental phobics long past the point of reasonable or logical, I’m thinking he honestly thought that if he said, “yeah, this is going to kill” I’d have walked out and never come back, in defiance of all sanity. Given my teeth were so bad I was at that point at risk for a life-threatening infection-- if I were him, I’d have probably said anything to keep me in the chair, too.

When I went back yesterday, I said point blank that I wanted full, graphic honestly about pain, as this was my best way of handling things. So when they cleaned out my socket, the lady said, “Get ready, this is really going to sting.” And it wasn’t that bad-- I was expecting worse, so I was happy. She asked if I wanted stronger painkillers, I expressed surprise that they offered them, and percodan script I got.

This does not excuse my friends gyno or that ER doc with my back.

We’ve always had a policy in my house (like someone said above) that if you get a script, fill it. Even if in this case you don’t need it. There WILL be a time, down the road, where you or a loved one will have a doctor who’s stingy about pain meds when you’re really in pain.

67

Working in an emergency department in a small town, I see drug seekers all the time. Plenty of people are addicted to OxyContin and Percocet or sell them on the street for big bucks. I know people who get hundreds of tablets from their GP, have NONE in their system if they present to the ER in crisis, and who can be seen around town doing demanding physical jobs but take thirty minutes to walk ten feet in the ER while moaning like a George Romero extra. Doctors can get into serious problems prescribing these people opiate medication. And these people do tend to be the ones who claim to be in 10-12/10 pain. I can’t tell how much pain someone is in, and don’t think other doctors can. But you can sometimes tell when someone is acting, lying, comfortable or holding long conversations with the person in the other bed but moans ONLY WHEN THE DOCTOR ENTERS THE ROOM. Some people, I’m sure, do have genuine allergies to Toradol and sensitivity to codeine and forget the name of the medicine they want. (Why do seekers do this? “There’s a medicine that starts with O. Oxy something, Oxycotton?”).

So I agree with DoctorJ, to some degree. The flipside is some doctors do not want to give ANY opiates for any pain. Treating pain is an integral part of the profession. I spent some time working in a downtown specialty clinic for patients with chronic pain addicted to opiates, which is a substantial group – that still needs their pain needs addressed. I know a lot about pain – and I can’t tell how much pain you are in. I give almost all my patients analgesia in some form if their condition is painful, even a script in case the pain gets worse. But I won’t give you a script for PO Demerol or, except in rare cases, Dilaudid. I use NSAIDs even when I prescribe narcotics. OTC Tylenol #1s are available in Canada, but this is not publicized, and most people do not get them even though this would do them a world of good.

Seeking is a serious problem, not one of myth or hysteria. The good doctor gives the patient full benefit of the doubt. People with addictions also have pain and I tend to give smaller quantities of opiates to people whom I think are lying, or simply seeking drugs. But I could certainly be wrong, so I tend to give even possible seekers good pain medicines, although no prescription for 100 Percocets. People seeking medicines do often present in a very similar way, are often fairly easy to identify (especially in a small place), and deserve to haver their pains treated. I am under no obligation to treat this pain with the medicine they demand, or with narcotics at all (although I often do). There are plenty of other ways of treating pain in addition to narcotics.

68

I don’t have too much to contribute to this thread as the worst pain I’ve ever dealt with was a back spasm, spacers for braces, and a case of through the skin to the fat road-rash, but I am hoping to enter medical school someday soon. Thank you **Obsiddian, Quagop, Paprika, et al., ** I think that I’ve learned a great deal about pain and pain mangement from “both sides” of the healthcare relationship.

–threemae

69

Ok, Dr. Paprika, don’t get all reasonable with me. :slight_smile: I was overstating to say that drug seeking is a myth, but I still strongly believe that many doctors overestimate its prevalence and “see” it when it that is not what is going on. Many, many patients are undertreated for pain, and that leads them to act in ways that are not always logical. I would like to see more doctors understand that not everyone acts the same when they are in pain. Being able to carry on a conversation is not necessarily proof positive that the person is not in pain, nor is being more obvious about the pain when a doctor walks in the room. I can’t tell you the number of times I have seen patients do that, but I have also seen lots of patients do the opposite–complain to me, then pin on a “good patient” face when the doctor is there. Let’s face it, many of us have weird relationships with doctors. We want you to fix us, we fear your judgment, and you are the keeper of what we want and can’t get without you–something to make us feel better.

I am glad that some of the doctors here are so reasonable (you included, of course) about pain medications. I just wish more of your colleagues both here and IRL were. I don’t understand why the hard ass persona is so popular in medicine.

70

I question why Percocet or whatever needs to be prescribed in 100# lots. Why would you do such a thing, Paprika? If someone is asking for that many pills, that is a huge red flag that needs to be addressed. The most opiates I have ever been prescribed is a count of 30–and that was from an old friend and doc of mine. I, of course, went out and tried to score more Tylenol #3s… :rolleyes:
Sorry to sound snarky, but the vast majority of pts are NOT drug seeking.

NSAIDs are not the answer to all pain and alot of pts cannot take them d/t liver issues or stomach problems etc.

I am not saying that narcs are the only way to go–I just wish the attitude of “you can’t be having this pain, because it is not supposed to hurt all that much” would die a quick and painful death.
Chronic pain is so badly handled in our system as to be a whole nother thread.
I won’t go so far as to say that everyone asking for painkillers is a victim of pain that can be appropriately treated with opiates, but I will say that all pts seeking pain relief need something-whether it’s Vicodan or psychotherapy or a 12 step program for Narc addiction is up to the situation and the pt.

I cannot come here and defend the health care system’s treatment of complaints of pain. I still have docs at my hospital who insist on Demerol, for instance–even for acute pancreatitis. Medicine may well be an art, but there is science attached to it in a rather big way. It can be quite frustrating for the nurses–guess who stays at the bedside and has to tell the pt that the doctor won’t prescribe anything stronger? Not the doc, that’s for sure. I have been known to hand my wireless phone to the pt (with the doc on the other end) to let the pt hear it from the doc himself. Funny, but the pt usually ends up with something that way…

71

Chronic pain is another topic – this pain often does not respond well to opiates at all. We’ve been down this road before.

With all due respect, EleanorRigby you do not have a better idea than I do what percentage of patients in my specific small town emergency department are probable drug seekers. In a small town, we do see the same population repeatedly. There is a difference between a drug seeker, an addict in pain, and a “reliefaholic”. The possibilty exists that I may even know more about “red flags” than you do.

I have never written a prescription for 100# Percocets, nor did I say so in my post. I tend to give patients one to two dozen Percocets. Family doctors with patients they have known for years on stable doses of narcotics often do write larger scripts, rather than see a patient needlessly every few days. For some patients with genuine pain, 30 Percocets might last four days. The Contin preparations are great when used properly. They are worth a lot on the street, though. Methadone is a great medicine for some things, too. The problem in Canada is many people have pain but no family doctor.
I don’t follow EleanorRigby’s logic with problems using Demerol to treat acute pancreatitis. My understanding was the sphincter of Oddi thing was over-hyped. I do think the “hard ass” attitudes are probnlematic, but I see them inthe nurses as often as the doctors.

72

Yes. Unfortunately, not as many as I would like. My GP seems to be a bit more honest with me than any specialists I have seen.

73

Paprika --what are you on about?

I did not say you had prescribed 100 count of Percocet–I said that someone asking for that would rasie a huge red flag and why would you do such a thing? By that, I meant what kind of practitioner would go ahead and just write that script? I apologize that that was not clear-I should have left that a general remark and not tied your name to it.

But I don’t understand at all the “hard ass” remark. I advocate for my pts pain relief, as all nurses should. I also advocate for them to enter AA/NA or similiar-and I discuss it with the attending MD beforehand, as I should.

Where is your thinking on Demerol? With other options to use, why would Demerol be prescribed? Many hospitals don’t even dispense Demerol to their inpts any more. Surely you know this. I have yet to have a pt with acute pancreatitis obtain relief on Demerol, but perhaps you have. I do know you are not at the bedside, watching that pt writhe in pain 45 minutes after that dose of Demerol has been given.

No doubt you do have a better handle on the percentage of the population you serve that is drug seeking. How is that relevant? We are talking here about requests for pain relief dismissed and projected pain underestimated. The drug seeking came up because that is used as a rationale for NOT prescribing adequate analgesia. As you know, the majority of pts in pain are NOT drug seeking–that was my whole point.

Perhaps the majority of the pts you see are indeed drug seeking–how would I know?

Drug seeking, addicted, suffering from chronic pain–all of these pts need attention, whether psychotherapeutic, pyschospiritual or medical (usually a combo of all of the above)–I dont’ understand why you have an issue with that.

74

Re my acute pancreatitis bit above. Let me clarify and say that I do not mean** Paprika** personally. I mean that any DOCTOR who gives an order for Demerol does not stay at the bedside and watch the pt writhe in pain 45 minutes after a dose of Demerol is given. Usually Demerol is ordered every 4 to 6 hours–which is too long between doses. Sorry, another thread.

75

Well, you DID tie my name to both “giving out 100# Percocets”. I do have an issue with this. It is clear from my previous posts I feel everyone in pain deserves analgesia.

I tend to give even probable seekers good analgesics and take much flak from the nurses for doing this – they also have the unfortunate “hard ass” mentality. Many nurses do. I’m sure if more nurses had chronic pain, they would be more sympathetic.

Demerol is a good pain medicine – I use it fairly often, and give it q3h PRN. If a patient comes in with abdominal pain caused by (perhaps) acute pancreatitis, the differential diagnosis may still be quite lengthy. I treat their pain long before I get the amylase back from the lab (and our lab is too small to even do a “lipase” which might take us days to get). Unfortunately, any pain medicine will take some time to work. For that reason, I would probably also use IV Toradol if confident there was no internal bleeding.

The debate between morphine and Demerol in acute pancreatitis has been played out in the AAFP journal. Morphine has never been proved to cause contraction of the sphincter of Oddi, originally the rationale for using Demerol over morphine. Demerol has the beneficial effect of lowering biliary pressure, however. There is a small increased risk of myoclonus and seizure particularly in alcoholics. I have seen many people with pancreatits get relief from Demerol. but toradol works at least as well for this inflammatory pain. Here are articles advocating Demerol:

http://www.aafp.org/afp/20000701/164.html
http://www.emedicine.com/EMERG/topic354.htm

Some institutions think Demerol is over-rated, but this is a minority view in Canada.
http://www.aafp.org/afp/20010715/letters.html

76

I totally agree with you about some nurses being hard asses about pain relief, too, as well as doctors. My question is why that is the case. I have never heard either doctors or nurses talk the way Dr. P and QtM have in this thread. What I have heard is lots and lots of “oh, the pain isn’t that bad, the patient is drug-seeking, exaggerating, etc” BS. Doctors seem proud of being hard asses. I just don’t get it.

77

Well, there are times when one must be a hardass, and times to not be a hardass. Or more pointedly, we need to look at the patient and make an appropriate decision.

I’ve got patients in prison for drug offenses who come to me telling of their 12/10 level pain, and how they just can’t get by without their oxycontin, and how they’re contacting their lawyer if I don’t give it to them. Yet the officers report the patient seems comfortable, sleeps ok, goes to recreation and plays basketball, and laughs and jokes with his peers. Only in my office does he start dragging his leg and trembling pitiously. Objective exam does not correlate with subjective complaints. He gets no opiates from me. I tell him how I feel his pain should be treated. He talks about his lawyer again; I request that the lawyer make sure to spell my name right. The last lawsuit was addressed to Dr. Mere Cotton. I hate when that happens.

Another guy comes in with a complaint that his longstanding back pain has gotten worse, and is running down his leg now. He says it used to be tolerable, but now it’s recently just too much to bear. He seems mildly uncomfortable, but not dramatic. Officers report he’s less active on his unit than formerly, and has mentioned pain in passing. Exam shows absent reflexes and muscle weakness along with a little atrophy in the affected leg. Hmmm, a radiculopathy. And a progressive one at that. Haul out the opiates, get therapy set up, plan for an MRI.

We doctors need to assess and treat the patient adequately. That often means that no opiates will be forthcoming, because they’re not appropriate. Not because we’re hard-asses. (Ideally, anyway. Not all my colleagues seem to agree with this model)

78

I dealt with a doctor in Hawaii who flat-out told me: “I don’t prescribe narcotics.” Not “You don’t need narcotics.” He didn’t prescribe them at all, for any reason. When he discovered I am allergic to non-steriodal anti-inflamitory drugs, he gave me nothing at all for pain.

79

Sometimes, for a variety of reasons, physicians will not have a valid DEA number allowing them to prescribe narcotics. If they’re in primary care specialties, or in any area of medicine where occasionally there is a need to prescribe opiate painkillers or other controlled substances, these doctors really should have a backup arrangement with a colleague who can review the case and prescribe narcotics when appropriate.

I can see making a statement like “I don’t prescribe narcotics for chronic pain”. That’s a practice choice, and the doctor ought then point the patient to the local pain center. Narcotics are almost never the first choice therapy for chronic pain.

But for severe acute pain, narcotics are frequently not only the first, but also the best treatment choice. As such, I consider such a declaration as made to you to be asinine.

80

Reminds me of my mom once having an urgent care doc (she broke her ankle) who felt this way. He simply didn’t believe they were ever appropriate. Or maybe he’d been scared by the DEA, who knows. Mom had a circular conversation with him which went something like this:

“Okay, I understand. However, NSAIDs aren’t even touching my pain, and I’m unable to sleep. What else can we do?”

“I don’t feel opiates are appropriate in this case.”

“I’m not disputing that, but my foot still hurts, what can we do about that?”

rinse, repeat. It was like he couldn’t grasp that while drug seekers are looking for a med that makes them high, people in pain just want pain relief. If stuffing my mouth with green paste makes it better (and right now, it does), fabulous! I can go to work without being drowsy. I don’t NEED opiates. I NEED pain management. I swear, even just a “Wow, I know that kills-- I just can’t help,” would go a long way.

Mom just got up and walked (hobbled) out, and now she has a tendancy to make that the first question she asks of any doctor. “What are your policies on pain control?” She could get away with this as a respectable, grey haired little lady. Me? At 26? How many doctors would look at me funny and be skeptical about my pain? Whether you suffer or thrive after illness or injury is entirely based on your doctors individual morality and paranoia-- it’s a total crap shoot. And then you’re stuck with this dude. Because nothing labels you as drug-seeking faster than doctor shopping right?