Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

You just don’t understand my chronic pain!

Nurse K at Crass-Pollination (in her sidebar, read the definition) writes Saturday morning CRAYZEE!!!!!!!!!!!!!! about a response to an old post of hers What do you do when you start to feel like a drug dealer at work?

First, Nurse K works in the ED (Emergency Department).

Let’s think about that. Chronic pain is something that is long term, so it should not generally result in a trip to the ED. Emergencies are the kind of injuries or illnesses that lead to acute pain. There should be a method, for the patient with chronic pain, to deal with break-through pain. The method should not be to go to the ED. The method should not be to procrastinate on refilling a prescription, until the weekend, so that your doctor is not available. This is manipulative and self-destructive.

The problem patients Nurse K describes are patients who are abusing the system. Legitimate chronic pain patients should be just as upset with these patients as Nurse K is.

The abusers of the system only make it more difficult for those with legitimate chronic pain to receive appropriate pain management.

Legitimate chronic pain patients should hate these people who make a mockery of genuine chronic pain. Those who put on an act to receive their pain medications.

How we deal with pain tells a lot about who we are.

I’ve had patients with extremely bad injuries. Injuries so bad that I feel very uncomfortable not giving them something for pain.

When the patient says, “I’ve had worse,” and I doubt that I have; or “I’ll wait until I really need something,” and I’m hoping that will be sometime before the surgeon starts cutting; or “I used to abuse drugs and nothing is worth living like that again;” or is lying in bed with a heart rate of 150, pale and sweaty, but discouraging large enough doses to make a significant dent in the level of pain; with that perspective, we are able to see the range of response to pain.

What is 10/10 pain?

For most people, burns seem to be the worst kind of pain. Imagine a red hot frying pan.

Now, reach out and touch the tip of your finger to the frying pan for half a second. What would happen if this were done for real? You have a burn. It hurts. Few people would repeat that experiment any time soon.

Now, imagine having your hand being held against the red hot frying pan, the entire palm of your hand, it doesn’t matter which one.

Think about that pain for a while.

If you have any kind of imagination, and you do not have a psychological illness that isolates you from this kind of empathy, then this should make you uncomfortable, at least.

The pain scale is not from This Is Spinal Tap. It does not go to 11.

Work on a burn unit. These patients have experienced this kind of pain, but now are experiencing severe chronic pain similar to the acute pain they experienced with the initial burn. This is not the only kind of acute or chronic pain worth treating. That is not what I am stating.

I am trying to give an idea of what debilitating pain is.

Fibromyalgia is a way to give a name to a much lower level of pain. If it has a name and a diagnosis, well then the drug companies can sell you a treatment for it. Pregabalin (Lyrica) an anti-seizure, neuropathic pain medication is approved for treatment of fibromyalgia. Here is an interesting view of the effect of pregabalin.

In a study of recreational users (N=15) of sedative/hypnotic drugs, including
alcohol, LYRICA (450mg, single dose) received subjective ratings of “good drug
effect,” “high” and “liking” to a degree that was similar to diazepam (30mg,
single dose).

Pregabalin does not have any studies that show addiction to it. It is interesting that recreational users of drugs would rate it as similar to benzodiazepines (part of the class of drugs these drug users desired). Pregabalin, the only drug approved for the treatment of fibromyalgia, is not an opioid (a natural or synthetic derivative of the opium poppy, related to morphine). The idea of using opioids to treat fibromyalgia is not one the FDA appears to be endorsing.

I am very liberal with pain medicine (when OLMC allows it) and I do not take pain lightly.

Encouraging people to lie there, and to give in to the pain, is just the wrong approach. The more you give in to the pain, the more pain medicine you need, the more you become dependent on pain medication, the less you are able to take care of yourself, the more you become a victim of your own response to the pain.

You become your own victim – not a victim of the chronic pain.

This is tragic. The epitome of tragedy, Hamlet, said –

there is nothing
either good or bad, but thinking makes it so: to me
it is a prison.


O God, I could be bounded in a nut shell and count
myself a king of infinite space, were it not that I
have bad dreams.


That last line confuses many people, not having the ability to understand Hamlet’s “bad dreams,” but it would never work if he were to say, were it not that I have fibromyalgia.”

Hamlet’s dead father would come to him in his dreams and tell him that he was murdered by Hamlet’s uncle, who is now also Hamlet’s step father and the new King. Very unhappy times for Hamlet and this is just the beginning!

Hamlet may have been the prince of despair, the Shakespearean character most likely to whine, but fibromyalgia would never have worked for him.

Maybe it was King Lear with his prove to me that you love me, or Othello with his willingness to let Iago convince him that his wife was fooling around, but Shakespeare knew how to write tragedy. All of these responses to adversity prove to be tragic. And fatal. And whiny.

Was Nurse K being inappropriate?

Not at all. Chronic pain patients would be better off listening to her, than those who say just lie there and suffer, but do it dramatically.

.

Comments

  1. In my jaded world I used to think that if you were making a lot of noise you couldn’t be in that much pain (you know–the dying swan types). I was put in my place though once by a 21 y.o woman with intussusception who we all assumed was putting on a show. Well after they took her to the OR we all sheepishly tapped our feet against the sides of the nursing desk and stared at interesting things on the floor for a while. It was a good lesson. Emotional pain emerges from the same place in the brain that physical pain does. Knowing that has helped me have a bit more compassion to the drug seekers. So no, I don’t think any of us can profess to understand the pain someone else is suffering, whether it be real or imagined, or fabricated–it is “real” for the person suffering. I’m not saying I don’t want to strangle the back pains and the migraines with O2 tubing most of the time…but I try and keep some perspective on where that anger and frustration comes from.We all seek our highs in different ways. Nothing is more dangerous (and cruel) than a judgmental health care worker. Great post Rogue. Well presented.

  2. ABB,Thank you. It is sometimes difficult to tell the difference between patients who have legitimate pain and those who are exaggerating, drug seeking, or attention seeking. I would rather treat, with opioids, a bunch of people for whom opioids may not be indicated, than not treat someone who is in legitimate pain. So, I get called the candy man. I think part of it comes from the realization that I do not know what someone else is experiencing. A good assessment, continual reassessment, and accepting that we will occasionally be fooled can make a big difference.

  3. “I would rather treat, with opioids, a bunch of people for whom opioids may not be indicated, than not treat someone who is in legitimate pain. So, I get called the candy man.” Couldn’t agree more. Hence my “How about a cup of chamomile tea instead?” response to lame pain management plans. 😉 Oops! Another “inside voice” thought is spoken!

  4. Sometimes I can’t even get orders to give the patient some tea, never mind a particular flavor. :-)Some doctors never will understand pain management, some don’t yet understand it, and some do understand. The progression is almost never in the opposite direction. Feel free to let out all sorts of “inside voices” here. I sure do. 🙂

  5. I’ve got to disagree with you on this one. I have chronic pain. Not low grade. I have degenerative spine disease in addition to arthritis. I have not given up and have tried everything: yoga, meditation, vitamin therapy, diet alteration, swimming, dissassociation and yes, medication. As a last resort, I am on p.o. time-released morphine as well as a prn for percocet. I have to tell you, having chronic pain has changed my perception.

    When a chronic pain patient goes to the ED for treatment of the pain, it’s because they’re having an exacerbation of their pain process or their condition is worsening. (Yes, there are abusers.) I’ve had to go to the Ed and have felt embarassed about it because of how I’ll be perceived. The ED nurses as well as the docs explained to me that exacerbations do occur. My pain management doc confirmed that explaining that how our receptor site perceive medication sometimes changes.

    Oh, did I mention I’ve also had 2 surgeries and an epidural as a last resort to resolve this pain. Each medication works differently on people. Neurontin makes some people suicidal–I know, been there done that. And not all people get high on opiates. I’m one of them as are other family members of mine. Patients whom I’ve spoken to say that when they’ve had the surgery to block the pain via electrical stimulation actually makes the pain worse yet they endure it because the “experts” say it’s supposed to work.

    Please don’t judge those of us with chronic pain who’ve had to go to the ED. As a matter of fact, unless you’re a chronic pain patient, don’t judge us at all or proclaim yourself an expert. It’s like the person who has all the book knowledge and no clinical experience who tries to teach a class of seasoned medics–bull crap.

    • Valerie Schoen,

      I don’t see anything that you have written that disagrees with what I wrote.

      • Then re-read your original issue and my reply. You come across as someone who doesn’t believe that chronic pain patients have exacerbations and as a result of the intensity–the crippling pain that occurs, the pain that makes you wish you were dead–need to go to the ED. It’s not a matter of misuse of medication. Most pain patients do not misuse their meds that they need a hold-over until their refill. If they’re taking their meds as prescribed they realize that liver damage would be immediate.

        A couple months ago I had laid out my meds for the week and had to wait for my long-acting pain med to come it. It came in, however since I didn’t leave myself a note to place it in with the others I went 3 days without that med. I swore I had another herniation. My husband tried to convince me to go to the ED however I refused. Then on day 4 I noticed the pill was missing. Do you know what that taught me? My pain was real. It was not in my head. I had looked down on myself for this disease process to the point I wouldn’t have gotten help.

        You seem to disagree that this is a disease with exacerbations that cannot be treated at home. It’s been a long time since i had an ED visit, but when I go I not only get pain meds, I receive IV steroids to decrease the inflammation which causes the pain also. Someone like myself is not in the ED to get high no more than the CHF patient is who receives morphine.

        In 3 hours I will begin yet another round of physical therapy. The practice I go to often has police, fire and EMS as clients. We all express frustration at the attitudes we face from people like you. The fact is, you don’t understand the concept anf refuse to humble yourself to learn something. Again,as I said, the newbie who rises too quickly and tries to replace book knowledge with experience.

        I bid you peace and an open mind.

        • Valerie Schoen,

          Please show where I stated that chronic pain patients do not have exacerbations or that it is never appropriate to go to the ED for exacerbations or that it is a matter of misuse of medications.

          I wrote –

          There should be a method, for the patient with chronic pain, to deal with break-through pain. The method should not be to go to the ED.

          The pain management physician should have prescribed medicine for breakthrough pain, rather than expect the patient to go to the ED for exacerbations.

          It’s been a long time since i had an ED visit, but when I go I not only get pain meds, I receive IV steroids to decrease the inflammation which causes the pain also.

          It seems that you agree that ED visits for exacerbations of chronic pain should not be common.

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