Perspective
Don’t Assume the Worst
What do you think when a patient comes to the ER seeking relief from chronic pain?
By Bradley S. Hernandez, M.D.
There are many aspects of my job as an emergency physician that I love. I love to care for the critically injured. I love knowing that when people have no one else to help, heal, or shelter them, they can come to my emergency department. Being part of the safety net for the community is an honor that I cherish and wear proudly, like a firefighter wears his badge. I also love having the opportunity to save a life occasionally, although I know that saving lives is really not what keeps me and other emergency physicians coming back for the next shift. What sustains us is our ability to reduce suffering, and we accomplish this in many ways. We do it by making a diagnosis that the patient’s primary physician could not, by admitting an elderly parent who is too frail to stay at home, and by relieving the pain of the woman with the fractured wrist or the man with renal colic.
But there’s a troubling paradox about our work: The very narcotics that we use to alleviate acute suffering can cause another kind of suffering. As a result, we face a very difficult population of patients—those who perpetually seek narcotics for their chronic pain.
I admit I would prefer to see almost anyone else. Bring me a non-English-speaking patient and I will readily dial the interpreter. Give me an elderly nursing home patient with dementia, and I will gladly review her medication list and do a thorough evaluation. Show me a patient who is angry because he feels he did not get good care and I am happy to defuse the tension by explaining what we did, why we did it, and where he should go from here.
But the patient who comes to the emergency department seeking narcotics is my greatest challenge. Nothing makes me more anxious than seeing the name of a familiar patient yet again seeking treatment for chronic pain. And when I learn that this is her eighth visit in three months, I panic. Am I going to have to confront her? If I do, will she ask to see another provider? Will she complain to the patient representative? No provider wants to think he is being manipulated, so I am cautious, sometimes overly cautious.
But why is that? If the thing that puts a bounce in my step is relieving suffering, then shouldn’t I have the most sympathy for the patient with the most pain? Unfortunately, it’s not that simple. The medications used to treat pain can be sold illegally on the street. If I prescribe narcotics to a chemically dependent patient, I contribute to their addiction. Yet if I withhold medications from a patient with legitimate pain, I am cruel. Trying to understand a patient’s true motivation in the 10 minutes I am allotted for a visit is daunting, if not impossible.
Much of my frustration stems from the fact that the patients who are seeking narcotics are a product of our own creation. At some point, we prescribed narcotic medications believing they were justified, and somewhere along the way, the patient’s best interests got lost. Most do have some component of real disease, and we cannot forget that. These patients deserve our patience and attention, yet they also need our highest index of suspicion. What makes matters worse is at the end of the day we have no way of knowing whether we have relieved suffering or contributed to it. So what is a physician to do?
In the end, all you can do is give these patients the benefit of the doubt. If they tell you they are visiting from out of town and forgot their medicine, believe them. If they have a complicated history, listen to them. If they are angry, empathize with them. And if they admit to chemical dependency, ask them about it, listen to them, and offer resources that can help them. Doing so may relieve their suffering more than you know. MM
Bradley Hernandez is an emergency physician at Regions Hospital in St. Paul and an assistant professor of emergency medicine at the University of Minnesota Medical School.