Happy Mortal

This life, well-lived.

Pain & Punishment

Pain

My Wednesday reflection on service and my recent experience in the ER (from both sides of the curtain) got me thinking about pain.

Simply put my job as a physician can be boiled down to two primary objectives – 1. To treat treat/cure disease, and 2. To alleviate suffering. And, of course, in the application of each of these there is the ever present imperative to “benefit and yet not to harm.” Based on my observations thus far, there are three primary reasons people come to the ER – 1. They come for treatment, 2. They come for reassurance, 3. They come for pain pills.

PAIN PILLS: THE BANE OF AN ER PHYSICIAN’S EXISTENCE

It sucks to feel used, it is no fun to be lied to. It sucks to be in pain, it is no fun to be ignored. And thus the conflict that gets played out hundreds, nay thousands of times in American emergency rooms each day. The classic dilemma of distinguishing between those who are “drug seeking” and those who are in “real pain,” begs any number of questions. Who is to say they are different people? Whose right is it to determine or judge the level of pain another individual is experiencing? Is all pain bad? Does pain always need to be treated? Are narcotics over-used? Are narcotics under-used? Is it a doctor’s job to relieve patients of all pain and at what cost?

These questions and more have led me to a broader reflection on the meaning of pain in our culture. What follows is a collection of scenarios, quotes, and common sayings related to or inspired by pain. I am curious to hear what the topic brings up for you.

  • “No pain, no gain.”
  • Narcotics: Illegal, Prescribed, Controlled, Addictive, Pain-alleviating, Sleep-inducing, Potentially-lethal, Expected.
  • The brand name of prescription narcotics and muscle relaxants are also household names: Vicodin, Percocet, Flexeril.
  • Most people I know have been prescribed a narcotic for one reason or another at one point on their life.
  • The juxtaposition of a sweating writhing man passing a kidney stone rating his pain at a 6-7/10 and a young woman with a sprained ankle resting comfortably in bed rating it at a 10/10 and demanding narcotics.
  • “A lot of people run a race to see who is fastest. I run to see who has the most guts, who can punish himself into an exhausting pace, and then at the end, punish himself even more.” -Prefontaine
  • An elderly woman is dying. Her disease causes her severe pain even at rest and makes her feel as though she is suffocating. Morphine could help alleviate both, but she refusing saying, “I don’t want to get addicted.”
  • The husband of a young woman with chronic headaches threatens to kill an ER physician for not giving his wife more Dilaudid stating,”You are obligated to treat her pain.”
  • “Cutters” – inflicting physical pain on themselves to relieve existential, emotional, psychological distress.
Pain:

Merely the body’s messenger of injury and imbalance?

Perhaps a villian to be slayed at all costs?

Or is it a virtue to be endured and even relished?

Discuss.


4 Comments

  1. Wow. Nice post. The collage of pain related issues that you raise makes me want to sit and think for a while. While I do that, I have a couple of questions for you as someone who has been on both sides of the ER curtain:

    1. In the case of the man threatening to kill the physician, how much is the doc required by law to alleviate pain?

    2. Is there some kind of protocol for determining whether or not a patient is “drug seeking”, or is it strictly up to personal discrimination?

  2. I hear ya. The very fact that I presented the issue in collage form represents the scattered nature of my own thoughts. The truth is it is a difficult topic and every doc I’ve met handles it differently.

    To answer your questions …

    1. I am not aware of any laws regarding pain management requirements.

    2. There is a lot of variation in how docs deal with this issue. There are clues that a patient is abusing pain medication. One clue is frequent use of the ER for vague pain complaints. Some ERs have lists of patients who have been known to abuse meds in the past. Patients who struggle with chronic pain will often have “pain contracts” – agreements with their primary physicians that they will be given X-amount of medication with refill so frequently and that they will not be given additional meds and the prescriptions will not be filled early for any reason. There are other signs of possible abuse, such as over familiarity with the hospital system, asking for drugs by name, having “allergies” to anything but X-narcotic. There are also some physical exam techniques that can be used if there appear to be inconsistencies regarding the reported injury and the level of pain. As a general rule, ER docs don’t really like prescribing pain meds for chronic sources of pain. That is best taken care of by a primary care physician who can develop a relationship with a patient and manage medication use and adequate pain management over time.

  3. Makes sense. I hadn’t thought of the primary care/ER doc difference. Not to be too simplistic, but it seems we have a bit of a pill-popping culture going in general. I think that many people view technology in a pill-popping way–technology is the magic that is supposed to make life easy/great/bearable/escapable.

  4. I have mixed feelings on the subject as well. I agree with you willwindow that we live in a pill-popping culture. And with as readily as doctors (in my experience and the stories I hear) are willing to give out blood pressure medicine, antibiotics, viagra etc, it seems silly that people’s problems with pain shouldn’t be addressed in the same way.

    What constitutes addiction? Are men who always have to take viagra to have sex addicted? Are people who take blood pressure meds daily (possibly due to bad lifestyle choices) addicted to a quick fix?

    These questions aren’t to say that being “addicted” or reliant on/to pills of any kind is good or bad.

    But why do we as a culture have an issue with substances that calm us down or subdue our pain? Pot is illegal, but caffeine not. Taking pain killers regularly bad, but taking sex enhancers regularly is great. I wonder if it has anything to do with our “achievement” based society?