Are you feeding the monkey or the pain?

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All primary care providers face the challenge of assisting patients with chronic pain. With the upswing in prescription drug abuse, diversion and overdoses of controlled substances we also face the difficulty of deciding if we can trust what our patients are telling us. It is clear to me that pain scales don’t work in adults. When asked to rate their pain from one to ten, how many patients rate it ten out of ten. Even while sitting quietly in their chair, easily bending over to tie their shoes, and conversing in a calm manner. It makes sense to me that in an acute pain or chronic pain situation that a patient would elevate their numbers. If they say a two, are you going to take them seriously? No test exist to accurately rate pain levels, therefore the sufferers account is taken at face value.
In a perfect world there would be no need for health care providers. There would be no dishonesty and mutual trust would be a given. Unfortunately, we do not live in a perfect world. With all my heart I desire to trust what others tell me to be fact. In 47 years of life, my extension of trust resulted in bruises, heartaches and at times potential patient harm. Let me explain. Twenty years ago, as a budding enthusiastic Physician Assistant I had a pleasant, but odd, noncompliant, uncontrolled diabetic patient. Armed with the latest and greatest medical knowledge and best intentions I treated her with the standard of care. The first time I saw her I performed a monofiliament test. I asked her to close her eyes. I even blocked her view using a piece of paper. No neuropathy identified. I adjusted her diabetic and blood pressure medications and ordered labs and a follow up exam in 4 months. One month later she returned to the clinic. Her complaint, redness and swelling of her right foot, ankle and lower leg. Further exam revealed a fever and advanced cellulitis. I also found a push pin in the bottom of her foot. She faked me out. After we cleared her cellulitis and osteomyelitis I asked her why she cheated on the test. “I didn’t want you to know that my diabetes was that bad.”
So, do patients tell us untruths? Yes. Do they omit things? Yes. Pain management and controlled substance issues open universe of concerns. Some reasons untruths may be told.
1. History of undertreated pain. So called pseudo-addiction.
2. Untreated psychiatric disorders improved with the medication being prescribed.
3. Diversion- The street price for oxycodone can exceed $5.00 per milligram. At this cost, if 120 tablets of 5 mg oxycodone are prescribed a month, the potential income from that prescription is $3000 per month or $36000 per year. It is also not uncommon for people to trade prescription medications for heroin or other illicit drugs.
4. Addiction.
The question we must ask ourselves. Are we responsibly prescribing controlled substances to our patients? Are we treating pain, anxiety, or are we feeding the monkey on the patient’s back. In my next blog I will discuss universal precautions in prescribing controlled substances.

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