My love/hate relationship with pain medicine.

(Yes, another medical post. Just one more day of working then I'm off for a few more weeks.)

I have a love/hate relationship with pain medicine. Actually, it's mostly a hate/hate relationship. Modern medicine has given us lots of very strong pain medicines, which on the surface sounds like a great thing. Honestly, for many people, it is a great thing. People recovering from surgeries don't have to be miserable anymore. People with debilitatingly painful conditions can find some relief and live a normal life. Those who are near the end of their life dying from cancer can find rest easier.

The problem that arises, though, is that most of these medicines are also incredibly addicting. They can make people feel too good. Working in the ER and hospital I am constantly confronted with people who are flat out addicts. They beg and plead, moaning and groaning and it is always difficult to tell what is true pain and what is them just acting out for my benefit.

The tricky issue is that frequently these patients have actual medical problems that could be painful. As an example, we take care of lots of patients with sickle cell disease, a blood disorder that can be incredibly painful. They come in complaining of pain, and so we give them pain medicines. Pretty soon, they need more and more pain medicine because they have gotten used to it. Eventually, they get to the point where they can't function unless they are taking really strong doses of pain medicine, and usually they aren't functioning well no matter what. There are often similar situations for those with chronic back or neck pain. I don't want anyone to suffer. I got into to medicine to help people, to try to heal and comfort. At some point, though, my giving in and writing a prescription for a narcotic becomes harmful. I often have a hard time know at where that point is.

I sometimes feel like I can't blame these patients because the medical field is part of what has created their problem - we get tired of hearing them complain and complain, and so we give them what they want because sometimes that's easier than continuing to refuse. Just today I had to deal with two incredibly frustrating patients, both of whom have real issues that I'm sure are painful, but who are both incredibly manipulative and addicted. One is younger and every day that I've seen him he asks me for more frequent or higher doses of pain medicines. He is a connoisseur, preferring the flavor of one narcotic over the other, demanding that I give him this one instead of that one. He has a significant infection in his arm and has been to the OR to try to clean it out, and so I know he's hurting. But he also is going to be arrested when he leaves for stealing prescription pads and selling fake prescriptions. I know that addictive substances have already wrecked his life, and so ratcheting up the dose will only make it harder to get off. Additionally, he's incredibly rude and demanding, which makes him much more difficult to help. I talk with a doctor who is sort of a pain medicine expert and he gives me some ideas. They seem to be working, but then my patient got mad at the end of the day today because the surgeon told him he can't go outside to smoke anymore and so he signed out of the hospital against medical advice. Sigh.

The second is older, a little more polite, but still cannot focus on anything except the pain he is in and the pain medicine he wants. He lies to the nurses, saying I said he could have more pain medicine. He lies to me, telling me the ER doctor promised him another dose of pain medicine. I want to help him, but he is another one whose life is consumed by his search for narcotics. I gently but firmly tell him I will not give him anything besides what he is already on. I am discharging him, though, and so I write for a few days worth of pain medicine to take home with him. I'm not sure I should have.

Most days, I just wish I didn't have to deal with them, that I didn't have to feel like patients were manipulating me into giving them more. But then I go into the room of the very sweet 70 year old I saw today. A few days ago, she fell and broke her hip. Xrays revealed an unusual spot on her bone. More xrays and cat scans found lung cancer, so far gone it's already spread everywhere. Her back is being eaten away by it, just like her ribs and her hips. She had been having back pain for weeks. And now, because I'm giving her pain medicine, she's not.

Therein is the dilemma. I like making people feel better. I do not like it when I feel like a well-paid drug dealer.

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