Posts Tagged 'pain management'

The Jig Is Up

Jeremy Jones’ back surgery didn’t seem to have done much for his pain. He came to me on long-acting narcotics and generous doses of short-acting painkillers to take as needed.

His spine surgeon had nothing more to offer, and it was up to me to prescribe and monitor his medications.

Last month he produced the right number of pills for his random pill count. He didn’t seem surprised when Autumn, my nurse, called him in for a pill count; it is part of the narcotic contract he signed when he first came to our office.

Some doctors don’t accept new patients with pain issues, even if they are in dire need of care for diabetes and other medical problems. Our office doesn’t discriminate like that, but we try to be firm and fair in our enforcement of the office’s narcotics policy.

The random urine drug screens sometimes reveal that a patient isn’t taking the pain medicines we prescribe. The “street value” of these drugs is ten dollars per pill and up.

Other times we find medications not prescribed by us or illegal substances like cocaine – all reasons to stop prescribing pain medications or to discharge the patient from our practice.

Jeremy’s first random urine drug screen didn’t happen.

“I just went before I left the house”, he explained. Several cups of water and an hour later it was almost closing time.

“We’ll catch you another time”, I said casually, not realizing how prophetic that sounded until after I had said it.

Several weeks went by. Then, last week, Jeremy had a morning appointment.

“Let’s have you do that urine drug screen today”, I insisted.

“Oh, I just went while I was waiting to see you. I couldn’t hold it”, Jeremy explained.

“No problem”, I reassured him. “We’ve got all day.”

“But I have an appointment with Dr. Anderson over at the hospital in an hour.”

A quick call confirmed this was true.

“No problem”, I told Jeremy. “I’ll write you a lab order and you can just go to the hospital lab after your appointment with Dr. Anderson. After all, that’s where your sample would be going anyway.”

“Great, I’ll just stop in there, then”, Jeremy smiled nervously.

“Fine”, I said.

I got busy and a couple of days went by. Then Dr. Anderson’s report from Jeremy’s appointment arrived. That reminded me – I had not seen Jeremy’s urine drug screen yet.

Two minutes later I knew that there was no record of a urine sample on Jeremy Jones at the hospital.

I reached over to the keyboard and started typing: 

Dear Jeremy…

A Hero’s Pain

“I don’t know if you understand, Doc, what kind of man this is.”

The man who spoke appeared to be a few years my junior. He was speaking of his father, who is one of my patients at the local Veteran’s Home, where I am a relative newcomer.

“This man fought in two wars and earned two Medals of Honor. He is not going to tell you how much pain he is in, even when you ask him, because he isn’t even going to admit to himself how much he hurts.”

He made a point I actually hadn’t considered before during my tenure at the Veteran’s Home. My patient has metastatic cancer, and the nursing staff asks him every day to rate his pain. His answer is always 2 on a scale from 0 to 10.

As doctors and nurses we estimate our patients’ discomfort through their words and also through their vital signs, facial expressions, posture and other nonverbal clues. But when it comes to treating war heroes, do our usual instruments fall short?

I remember thinking when I admitted the ailing veteran that he seemed so humble and plain spoken. The words “true hero” came across my mind then. I didn’t consider that I might not be able to accurately assess his cancer pain or his level of distress over his terminal diagnosis.

There is a lot of talk about cultural competency in this country. Today I even read in one of the publications of the American Medical Association that several states are mandating that physicians take courses to improve their skills in dealing with patients from cultural and ethnic minorities.

Somehow I think we oversimplify the issue of cultural competency if we focus on only those we think of as minority groups. Our challenge in caring for all our patients is to meet them where they are, to step out of our own world long enough to at least get a glimpse of theirs. We must first meet as human beings before we can begin our medical assessment.

War heroes are a minority, too.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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