Chronic Pain Patients and Drug Seekers

I'm currently on my Internal Medicine rotation, and there is something I have been pondering recently:

Among the things you deal with when you work in a hospital are patients who are admitted for chronic conditions who are treated with opiates. Unfortunately, there are plenty of people out there who know how to manipulate the system - they know exactly what to say so they can get admitted and get their narcotics. There are also plenty of patients who have legitimate pain and really do need that help to control their pain but are quickly dismissed by most doctors as yet another drug seeker.

I admit that I am myself guilty of joking around with the medicine team about how a patient happens to be allergic to all analgesics except Dilaudid, or how a patient previously writhing in constant "10/10 pain" seems to be astonishingly well-recovered when he thinks no one is looking. I can understand the frustration of wasted time and resources when there are patients with serious diseases (that have actual treatments) around who need help.

However, a recent patient I had really got to me because of the way the doctors on our team treated her. Names and details have been changed for the sake of patient privacy.

I was supposed to pick up two new patients that morning off of our patient list, and "Helen" was the second one I selected. Her chief complaint listed was new onset upper extremity weakness, and since I hadn't had any neurology patients as of yet, I thought it would be an interesting case. I got to her room just as the neurology team was finishing up with her. I struck me that they seemed dismissive and in an awful hurry to get out of her room. Looking at her, she was extremely upset, looked like someone who hadn't slept in days (in fact she hadn't gotten any sleep in 5 days) and seemed desperate for someone to listen to her. So I did. She gave me her whole story of her illness - of how before this all started, she was moving up in a male-dominated industry and kicking ass at it, a loving husband and three young children. She loved her life and career, and then it all hit a brick wall. She started getting sharp, searing pains in her legs, and a multitude of neurological symptoms that came and went. She saw doctor after doctor, and as her condition progressed, she had to quit her job and wound up confined to her bed most days and requiring high doses of opiates to control her pain.

Eventually after nearly 10 years of searching, she managed to be directed to a doctor who recognized what she had, and was able to send her to a specialist who is world-renowned for treating her disorder. relieved to at least have a name for it and that she wasn't going to continue to be told that she was crazy or that her symptoms were caused by depression, she still faced the problem that her disease had no cure and that she still needed narcotics for her pain.

She presented to the emergency department in a flare-up of her pain in addition to the new loss of strength in her right arm, and was admitted to our service because neurology had refused to take her. She was in a lot of pain on admission and refused the arm MRI that neurology wanted to do because of the discomfort she was in. What astonished me was how quickly the residents (and even the attending) on my service started making fun of her - that she didn't want the MRI because she "knew" that they wouldn't find anything, that she "clearly" was faking it, and refusing to up the dose of her pain meds as asked us tearfully to do just so she could sleep. The junior resident on our team seemed to particularly fond of purposely antagonizing her.

It really pissed me off when the junior resident offhandedly remarked, as we readied to discharge her, that we should "just let her enjoy her new diagnosis". SERIOUSLY? This woman clearly wasn't "enjoying" anything, and even if she wasn't in as much pain as she said she was, she still deserves at least a modicum of respect.

She came to us for help and she was treated like crap. Perhaps I was taken in, and the fact that she reminded me so much of myself made me oversympathize with her. But I still feel that the way her case was managed did nothing to help her and was bad for us as clinicians. When someone has pain, you can't see or measure it, but that doesn't make it any less problematic than a symptom you CAN see and measure. Helen has watched her life completely fall apart, and my team took part in making her more miserable instead of less. Whether or not you feel she belongs in the hospital, the least we could have done is express some empathy, instead of just telling her we had no justification for keeping her and kicking her out.

Having been on the receiving end of a cold dismissal by a physician (even without the "drug seeker" label, I can imagine what Helen is feeling right now - hurt, rejected, alone. I can only hope that she continues to look for something, anything that will help and that physicians she encounters in the future care more than my team gave her.