CHRONIC PAIN, END OF LIFE

This August has been quite a month.  Two weeks ago, Renee and I drove to northern Virginia to celebrate my niece’s daughter’s Bat Mitzvah.  On the way there, we stopped in Richmond to see old friends.  On the way back, we stopped in Norfolk to see my 95- and 98-year-old uncles and my sister -in-law.  My sister-in-law did not look good and I suspected that her death was imminent. She was miserable, living with chronic, unrelenting pain. I hate when I’m right!  I also hate to see anyone suffer like Chrissy was suffering.

Shortly after returning to our home in North Carolina, we received the call.  Chrissy had died soon after being admitted to hospice.  So, we packed up our loaner car (mine is in the body shop since Renee was rear-ended) and headed back to Virginia Beach.

So, why was Chrissy suffering with intractable pain?  The diagnosis of intractable pain is easy.  Finding the cause is not so easy.  There are many causes of pain.  Unfortunately, if there is no apparent cause, doctors and family members are quick to assume that the pain is either not real or that the person suffering with the pain is just being dramatic. 

Doctors often take a cynical approach to pain patients, having dealt with drug seekers throughout their careers.  Personally, despite the fact that I had seen a large number of drug seekers throughout my career, I always chose to believe my patients and treat their pain until either the drug seeker slipped up and revealed themselves or I found the underlying cause of the pain.  First, let me explain, psychological pain is just as real as physical pain.  That being said, if you pay careful attention to your patient, the drug seeker will always have a tell.

Patient “X” is a 45-year-old male supposedly hurt on his job.  He walks painfully and slowly to the exam room.  He has pain on all movements of his body, especially worse on taking off his shoes, socks and pants.  Every place I touch him and every time I move his legs and back, he winces in pain.  His reflexes are exaggerated.  I validate his pain and ask him to dress.  I watch as I write my note.  He dresses swiftly without any signs of pain.  He sits with ease and waits for his prescription.  When I tell him to take Tylenol and schedule a plain x-ray of his back, he gets angry and leaves.  I follow him to the front and watch him slide into the driver’s seat of his Camaro.

He is the fourth back pain that week. I look for and find the chalk mark on the front of my office.  While I found four drug seekers, I missed one.  The one I missed marked the wall with chalk alerting his/her friends to the fact that I prescribed a potent pain pill for his/her bogus pain.  Yep, they literally “marked” me if I let one slip through my defenses.

In addition to the curse of drug seekers who fake injury to get narcotics, there is currently a government driven war on docs who prescribed pain pills.  The poor patient with real pain suffers as docs are threatened by their government and challenged by fakers.  Most docs I know refer patients with chronic pain to pain specialist who are often inundated with referrals and take months to get seen.

So, what do you do when you are at the end of your rope, the pain is truly debilitating, and life is slipping away?  One of the tools I used was hospice.  Patients and docs alike often believe that hospice is only for patients dying from cancer and that death is imminent.  I found that hospice was available to anyone with a terminal diagnosis and who was expected to die within 6 months of starting hospice.  Hospice helps make patients comfortable and improves quality of life by offering services not routinely covered by Medicare.  I have had patients on hospice for as long as 2 years. 

Here’s your joke for the day:

A married couple is lying in bed.

The wife leans over and says, “I want you to say dirty things before we start”. So, the man starts to caress her neck and whispers to her, “Living room, Bathroom, Kitchen”.

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