Awoken by Pain

I am awoken by pain this morning. My pain is like a ball crammed into my right lower back muscles, a most unwelcome visitor. My pain is like a parasite that distracts my attention, sometimes limiting my ability to be present, or worse, shortening my fuse.

I try to not allow my pain to limit what I do, but I have to admit that it already has. Cross-country skiing? Forget it. Sitting comfortably for more than an hour? Generally not possible. Waking from sleep without discomfort? A rare occurrence. And even swimming, that form of exercise that seems the most low-impact? Aches nonetheless.

So what does one do with pain which seems to want to stick around and be a constant companion? I've tried ignoring it. I've tried catering to it. I've talked to it and rejected it. For now, it seems that I'll simply continue to try to live my life as if it weren't there.

The Narcotic Merry-Go-Round

The number of patients that I see who are prescribed chronic narcotic medications is astronomically high. Of course, there are many people who have pain worthy of taking narcotics on a daily basis---for cancer-related pain, post-surgical pain, etc---yet so many people abdicate their pain management all too easily to the drugs that will cause them physical dependence, constipation, and somnolence with no end in sight. As a person with chronic pain with an unknown etiology, I fully understand that strong drive to eradicate pain from one's life. Pain overtakes one's psyche, pushes other concerns out of the way, and leaves one desperate for relief.

While it is well-documented that pain is woefully and poorly managed throughout the United States, leaving countless patients suffering unnecessarily, I still find myself having mixed feelings about the ease with which so many providers seem to write those scripts for Oxycontin, morphine, and Percocet. At our local ER, it seems like there's a gum-ball machine near the revolving door, and patients simply have to say they're in pain and a prescription is produced in a knee-jerk reaction of instant gratification.

One of the questions we ask ourselves and each other about these patients on chronic narcotics is how long they will be on these meds? For the patients with failed back surgeries and other serious conditions, we consider that they may very well be on narcotics for life, and that is often the lesser of many evils. For others whose pain has no visible or discernible cause, we often question the intelligence of long-term narcotic use, understanding that tolerance will increase with time, and dependence only continue to deepen, both physically and psychologically. Now, often that dependence (which is different than addiction, mind you) is wholly warranted and acceptable, yet I feel that there is sometimes a lack of judiciousness on the part of the prescribers as they acquiesce to the pressure to write those scripts for controlled substances.

I do not question that narcotics are often needed for patients whose pain is not touched by non-steroidal anti-inflammatories and other non-pharmacological interventions, but sometimes I feel that those prescriptions move just a little too freely, especially when one considers that diversion (the selling of such medications to others for profit) happens on downtown street corners on a daily basis. Word has it, I hear, that our clinic is considered a great place to score some narcotics to sell at the bus station. A nice reputation to have.

Perhaps I feel uncomfortable with the amount of narcotics that fly off the shelves these days because a significant portion of my job these last few years has been fielding calls from my patients who are on chronic narcotics as they seek a new refill of their meds. Since many of my patients are former substance abusers and our level of trust in them is relatively low, some of them need to come to the office every seven days for a one-week supply of morphine or Percocet. While having to come in to see me weekly is inconvenient for them, it is equally a hassle for me in terms of printing up scripts, hunting down docs for signatures, and having all of this ready in a timely manner for frequently impatient patients. As I ready to leave my job of seven years, I quietly revel in the notion that I will soon enough finally escape from this narcotic merry-go-round.

Percocet, anyone?

Time (and Urine) Will Tell

"So," I say into the phone. "You were in the ER last night."

"Yeah," he replies. "I felt so sick. They sent me home after a while, though."

"Do you know that your urine came out positive for cocaine and alcohol?"

"Well, yeah. Let me be truthful," he replied. "I was in New York with my cousin, I was stressed out, and I did some cocaine. No lies, OK? Urine tests don't lie, and if I lie to you, I'm really just lying to myself, right?"

I took a deep breath. "Yes, that's right. Now, the other problem is that your urine came back negative for opiates. We've been prescribing you morphine for pain, and your urine should be positive for morphine. What happened there?"

"OK, OK. Like I said, I was in New York and forgot to bring my morphine. That led to me stressing out and doing the coke and alcohol. I know you're not gonna trust me now. I'll do any urine test you want, any day you want. I want to earn your trust back." He was pleading now.

"You just have to understand," I explained. "When we prescribe you morphine, we expect to see it in your urine. When your urine comes back negative for morphine and positive for cocaine, what do you think we suspect that you're doing with the morphine?"

"Selling it on the street to buy cocaine?" he answered faintly.

"Exactly! And that's a big no-no in our book, I'm afraid." I pause for effect. "The last thing a doctor wants is the medication he prescribes to end up being sold at the bus station, and believe me, alot of what we prescribe IS sold at the bus station."

He was worried now. "Look, I'm so sorry. I'll do whatever you want, but you can't cut my morphine off. My pain is still so bad. Tell Dr. ___________ that he can order any tests he wants. Please."

"Don't worry, we're not cutting you off yet. That would be cruel. But you've got work to do." I continued my diatribe. "There will certainly be urine tests, but they'll be random. And you can't say you can't make it when we call you to come down to the clinic. You signed a pain contract, so now you have to honor it."

"OK, OK. I'll do it. Tell the doctor I'll do it. I'll show you that this was a one-time thing."

"OK, just relax, and we'll talk to you soon. And stay out of trouble, y'hear?"

"Yeah. I'll talk to you soon." He hung up first.

I hung up the phone and took a deep breath. I hate these conversations. I also hate dealing with narcotics. I hate the whole system. Pain management is a total drag for the tired Nurse Care Manager, and narcotic diversion onto the streets haunts us daily. These are the times I play Good Cop/Bad Cop, and it's no fun for anyone, including me.

Was he telling the truth? Can I trust him? Will his subsequent toxicology screens be negative? My sense of hope and faith say yes, but only time (and urine) will tell.