When to give pills to a drug seeker

I saw a 31 year-old in the ED last week who came in complaining of wrist pain after falling from his skateboard. The triage nurse did not find his story compelling (acute) enough for immediate transfer back to the ED. He was upset then told the nurse that he also had abdominal pain as well.

Once in a room back in the ED I looked at his hand. There was not the least sign of a fall: no abrasion, no redness, no swelling, no deformities, no numbness, no cold hand, no painful movement. When I pressed on his hand bones he vaguely retracted his arm as if to show me that he was in pain. He made no facial grimace when I asked him to gasp my fingers as hard as he could. It was pathetic acting. People really in pain wince when you push in a tender place or ask them to use a part that hurts. They do not look at you stone-faced. They do not invite you mash around on a sore body part, as this guy seemed to do, with "push there, it really hurts, yeah, right there, and it hurts here too, push there."

As part of a routine exam I asked him if he had any underlying medical conditions. He leaned forward and said in a suspicious voice, "this is just between me and you - you can't tell anyone - but I have 4 herniated disks in my back and so I take a lot of Percosets. You see, I need a lot more pills than usual to help my pain." Percoset is one of the many prescription pain pills. It is a narcotic, a relative of morphine, opium, and herion. He gave me some bogus excuse for this secrecy as needing to protect his health information from his insurance company, which would drop him if it discovered he had an expensive medical condition like 4 herniated disks. The story was absurd, obviously. Having such a debilitating back condition like that at such a young age would be a perfectly good reason to have insurance. And why the hell was he riding a skateboard anyway? And why was he telling me medically relevant information if he didn't want it in his medical record?

As I stood up to leave the room I excused myself by saying that I would discuss the case with my supervising physician, as I always say to every patient. He jumped up from the exam table and closed the door in front of me. "You promised you would not tell anyone, who are you going to tell now?" he exclaimed somewhat desperately. I brushed him aside and immediately left the room. This was clearly a sign of aggression.

If there was ever a "slam-dunk" case of a drug-seeking patient, this was him. I have no doubt that this guy made up story of falling on to his wrist as an excuse to get narcotics from the ED. Every ED doc in a urban center will see someone like this on every shift. It is aggravatingly common. I offered ibuprofen and ice, which is exactly what I would have given my own friend or child, but he insisted that his pain was just too bad that he needed something more.

What makes treating pain so tough is that one can never know how much pain a patient is in. Sure, clinical experience gets you a long way, but ultimately it is based on the patient's report, and even then one and the same type of condition may very well be more painful to one person than another. However this case was straight-forward, and it I admit I content to know confidently that his claim of pain was false and his visit to the ED was a ploy to get drugs. A young healthy guy falling off his skateboard with absolutely no evidence of injury (wrist x ray was negative) will not be the sort of pain that warrants narcotics.

There are many ED docs who would have just given him a few days of pills and sent him home. That's the easy way. You get the patient out of your ED and free up your bed for someone else. No arguing with the patient, no explaining why you are "so mean and heartless" for not understanding what the patient says they are going through.

In reality, most cases of pain management in the ED are not so black and white. Many involve people with chronic pain conditions (back pain is classic), who really do have pain and really do need pain relief, but have become dependent on narcotics. And the dependence is not only physical. Actually the psychological dependence is perhaps more common and destructive. So many people I see on chronic narcotics have come to refashion their identity around their disability and see narcotic use as the one way they can be functional. It is a rationalization, just as with any drug abuse behavior. Ironically people on long-term narcotics are notoriously non-functional. The pills dumb you down, they're sedating. Sure, they make you don't care about your pain, but they also make it less likely for you address that pain in a positive way. Motivated people with chronic back pain are usually able to manage it with changes to their lifestyle, such as loosing weight and exercise. But pills, as our culture has increasingly come to believe, are the easy answer.

It behooves me to develop my own personal policy about narcotics since I will be working in the ED. I think the Japanese have a great approach. In Japan prescriptions for narcotics are illegal except in a few cases or known, documented chronic pain, such as cancer. This makes a hell of a lot of sense. In the hospital or clinic the patient is there under your supervision. They are not going to over dose or abuse the medication. They are not going to sell it on the street. I think liberal use of narcotics when indicated while in the ED is totally justified. But sending home people with narcotics who do not have a convincing reason for needing them, I think, is bordering on unethical. Sending this guy home with just 3 days worth of pain pills - say 20 - can fetch $200 on the street. That's not bad money from sitting in the ED for 3 hours.

There are now more deaths from prescription narcotics (Vicodin, oxycodone, codeine, Percoset, Dilaudid) that from street narcotics (heroin, opium). By following our Hippocratic oath to do everything in our power for the "good of the patient" we have inadvertently created a epidemic of physician-mediated narcotic abuse. Getting these millions of people of these meds will be a huge challenge to come. Especially since the association of chronic narcotic use and mental illness, such as depression, is alarmingly, if not surprisingly, strong.

An even larger challenge will be reversing the cultural attitude in this country that one is entitled to live free of pain. We need to look to other cultures and to our own ancestors who suffer and suffered from just as much pain as we do and yet did not dependend on narcotics. Pain is very much moderated by emotion and context and how much significance one bestows on it. It is a fact of life, of aging, of disease. It hurts and it's inconvenient, but perhaps in the greater scheme of things there's a reason for that: pain forces us to be aware of our bodies' frailty and vulnerability.