I got up and walked OUT on a patient today.

[Aristus]

Ugh! Hold me... :hangover:

Drug-seeker. She had a pretty good cover, too. She was slightly scoliotic, so I could believe she was in some pain. But she declined my non-narcotic treatment plan, and demanded tramadol. When I reiterated that my clinic does not prescribe narcotics, she got a little abusive.

I stood up and walked out. Last patient of the day, thank God, so I went into my office to chart the visit and cool off a bit.

She is scheduled to come in next week for some screening lab tests, but I think I've seen the last of her.

She'll go somewhere else to get her fix...

Other than that, mostly a good day today. B-)

[freshwest]

1. Just curious. What did your 'non-narcotic treatment plan' entail?

[Aristus]

3. Non-steroidal anti-inflammatories or anti-pyritics (like Tylenol), plus

plus, regular applied ice/heat treatments, stretching, and ice massage. That would hold her until I reviewed her past records and determined where to send her next: physical therapy, or an orthopedist. She was very (maybe deliberately) vague in her past medical history (she was a new patient), and wasn't making a lot of sense. Anyway, a demand for tramadol was her first move, and that always raises red flags with me.

There are still places out there that treat chronic pain with narcotics, but there are fewer and fewer all the time. I'm a firm believer in treating the condition, not the symptom.

[Name removed]

17. Deleted message

Message removed by moderator. Click here to review the message board rules.

[Aristus]

19. It sounds like you're in a different state altogether.

First of all, it was not your mother I was evaluating. In school, they gave us training in how to recognize, diagnose, and treat serious debilitating diseases. We take those seriously, and prescribe the recommended treatment for them.

"You automatically assume that any one who needs these pain pills is a junkie..."

I have never had a true chronic pain patient decline my treatment plan, or the oral analgesia I am permitted to prescribe. When someone is in pain, they'll take anything in order to obtain relief. It's the people who walk in, in no acute distress, demand narcotics, and get abusive when I don't hand them over, that I'm talking about. I got a death threat once. My actual chronic pain patients never do that.

I'm sorry your mother is in pain. Her pain is not my fault. And wishing others could suffer the pain your mother suffers seems a little......inappropriate.

[Boudica the Lyoness]

23. I would decline your treatment plan.

Like I said down thread, I have tried everything and now have found relief in narcotics and short treatments of prednisone. If prednisone wasn't so damaging I would love to stay on 20 to 30 mgs for the rest of my life and then I wouldn't need the narcotics.

I never went looking for pain meds..I honestly thought once I got a diagnoses for my symptoms I would be given some treatment that would cure me. I really believed that. Imagine my surprise that there was no cure and I was going to get worse.

I wouldn't threaten you with death if you refused to give me hydrocodone... because you apparently can't prescribe it there. lol. Thank goodness I have two compassionate doctors who understand their limitations and help me anyway they can.

Since becoming ill, I have met others who take narcotics and have done so for many years with no ill effects. When we take steroids we stop the narcotics because we don't need them...in other words..we are not addicted to them at all. I actually have forgotten all about them while doing a course of prednisone. Not everyone becomes an addict...even after three + years like me.

Like I said I would decline your Tylenol & ice treatment plan and so according to you, I'm not a true chronic pain sufferer!

[Tuesday Afternoon]

85. not only would I decline his treatment plan but, I would also call

and report his unethical and callous disreagard to whom ever might be his superiors.

I hope they don't try to to bill her for this crap.

[LeftyMom]

73. If I were in pain I would decline that "treatment plan."

I know all about nsaids and ice and the one time I showed up at a doctor's office needing something stronger- for eyewatering pain in my neck- I'd already tried them (along with all the other usual home rememdies) with no relief. I assume most people old enough to cross the street without holding a grown-up's hand don't need a professional to tell them to try Tylenol or ice packs if they're hurting. If somebody had offered me such an obvious "treatment plan" I'd have got up and walked out, after telling them that they were a condescending git and in the wrong business.

Luckily I was fortunate enough to be seen by a gentle and compassionate doctor who prescribed pain meds and muscle relaxers (ooooh! potentially habit forming!) to keep me reasonably comfortable while physical therapy and some changes in my workspace addressed the underlying issue. Suffice it to say that worked, I don't think I finished either prescription, and I didn't wind up injecting heroin in the webs of my toes in an alley someplace.

If you can't do anything for somebody in pain they can't do for themselves, what good are you?

[we can do it]

30. My MIL Is a Pain Killer Shopper - You Can't Ignore That They Are Everywhere

Just because your mom needs narcotics doesn't mean that there are many who are addicted. Irresponsible docs keep pouring the pills in MIL, she is cons them with one "problem" after another. She just spent $7000 on a test trying to prove she had "something" so the concerned family members would back off on her getting off the narcotics. After test after test she has- NOTHING. She has become unstable on her feet and sometimes gets to the point of slurring speech.

sorry about your mom, but don't put everyone in the same boat. you'd never suspect MIL was a junkie.

[kick-ass-bob]

32. That was quite a leap there, buddy.

Trained professionals are trained (!) shock, I know - to tell the difference between your mother and someone who needs a fix.

Just because someone is on thsee pills long term doesn't mean they are a junkie, and the OP did not insinuate this anywhere in the post.

It's only you projecting your anger about your situation.

[Riftaxe]

68. Trained professionals kill people by accident

every day. Since when does being a trained professional preclude being an ignorant twit?

[rbnyc]

33. I both suffer from chronic pain AND have a history of substance abuse.

I have to say that I truly appreciate that a doctor seeing a patient for the first time would offer a non-narcotic solution in the immediate, buying time to determine more about the patient's history.

I really don't think that the OP assumed she was a junkie because of her pain, I think he suspected it because of her behavior and was trying to be responsible.

I have terrible pain every day and every night. I have not had a day without pain since July 24, 2003. I also know myself and my propensity to become substance-dependent. I use non-narcotic treatments most of the time. I have decided to tolerate a certain amount of pain to reduce my risk of abusing narcotics. I do use narcotic pain relief when I must. I do all this with the guidance of my doctor who knows me and knows my history. I would never expect a doctor who doesn't know my full history to give me narcotics, especially if I were being vague and abusive.

I'm very sorry about your mother's situation and I do understand having an emotional reaction when there is a topic that relates to someone you love, especially when that person is suffering. But from my perspective, it looks like you've treated the OP unfairly. I certainly don't think the OP deserves to get a chronic illness.

[Rabrrrrrr]

53. Oh, of course - because your experience is universally normative, and everything else is a fiction

and one doctor's dealing with one specific patient in one specific situation is universally normative for how that doctor treats not every patient, but probably every other human being in the world, consistently, every time, without change.

And thanks for wishing a chronic illness on me. It's so wonderfully childish of you.

[Dystopian]

18. There is another option

1. Condition
2. Symptom
3. Person

peace & love~

[freshwest]

21. Not going to happen.

[seamonkey71]

74. It doesn't ever occur to Dr's that people might have tried these things at home

*before* coming in? I have high deductible co-insurance. I always minimize how often I see a Dr (meaning I suffer until I can't take it anymore). Because until I hit my $5000 deductible, it all comes out of my pocket. If I come in to see you in pain, I have likely spent a week or more using ice, Tylenol, Nsaids, stretching, massage, resting, heat and any other "remedy" my grandmother may have offered. If I am paying $$$ to see a Dr, I expect something more than my grandmother would offer. Otherwise, what the heck is the point of paying for medical care? You really think people don't try these things *before* seeing a Dr? That they want to pay $150 or more for an office visit to be told "Take Tylenol and stretch and use ice"??

[Aristus]

77. You might be surprised at the seemingly obvious things I tell my patients

I have obese patients ask me how they can lose weight. When I take their history and find out that they have a sedentary lifestyle and eat KFC at every meal, I advise them to eat less and exercise more. I have patients with asthma who still insist on smoking two packs a day, and then complain to me that they're always short of breath. I tell them "Cut down on your smoking. You're getting plenty of carbon monoxide, but not enough oxygen." If these are solutions your Grandmother would have offered, well then, she was very sensible. Some conditions don't come with "magic pills". Some conditions require a trained professional to give a patient an otherwise obvious solution to their problem.

Why do we need teachers, when one can just go to the public library and get all the information you want?

Why do we need firefighters, when we all have a spigot and a garden hose?

Why eat right and exercise, when the guy on Channel 73 at 1am will sell you a pill that will make you thin?

[seamonkey71]

78. So you just run under the assumption all your patients are ignorant?

Why do we need teachers, when one can just go to the public library and get all the information you want?

Why do we need firefighters, when we all have a spigot and a garden hose?

Why eat right and exercise, when the guy on Channel 73 at 1am will sell you a pill that will make you thin?

In all these examples, these professionals are providing a service that most people can't duplicate at home, at least easily. If my dinner starts to burn and sets off the fire alarm, I don't automatically call the fire department. I would turn the burner off, move the pot and try to extinguish any flames myself first. If all that failed, I would then seek professional help and would not be happy if the fire dept told me to try turning off the heat source, moving the pot and try covering the flame. I would expect they would be aware by that point, it was out of control and more drastic measures are necessary.

[Aristus]

94. I don't run under the assumption that any of my patients are ignorant.

The ones who are will make me aware of that fact with some questioning.

And it doesn't have to be glaringly obvious things that your grandmother would have known right off. For example, I have a lot of diabetic patients who are concerned about eating healthily in order to control their glucose levels. So they stay away from sugared sodas, and coffee and tea with sugar. Then they tell me they drink lots of fruit juice in order to stay healthy. I have to tell them that, despite the good impulse toward healthy fluid intake, that fruit juice is just pure sugar, and will play havoc with their blood sugar. Glucose is used by every cell in the body for energy. Fructose, or fruit sugar, goes right to the liver and can cause hepatic steatosis, or fatty liver disease, if too much is consumed. Fruit juice doesn't have all of the things that make fruit healthy, the pulp and the fiber, etc. These things slow the progression of fructose to the liver. I tell these patients, "If you want orange juice, eat an orange. If you want apple juice, eat an apple."

Such things seem simple, but get lost amidst a barrage of TV commercials hounding people to buy and drink lots of fruit juice. Patients are being taken in by convincing half-truths. That is ignorance; and it's not a bad thing. It can be cured with simple good medical advice.

I had one patient, obese, and with his teeth rotting out of his head. He told me: "I drink lots and lots of Gatorade. It's good for you, right?" I had to set him straight about that.

I can't tell if you're angry with my patients for not being aware of these things, or angry at me for giving them good medical advice.

[CaliforniaPeggy]

2. Good for you, my dear Aristus!

Doing what you did takes courage...

I always knew you had it.

Congrats!

:yourock:

[Aristus]

6. Thanks, CalPeg.

It's always good when you understand. :hug: You were a nurse; you know how these things go. My assistant and I talked after the patient left, and I told her: "We won't see her again. She'll try someplace else."

She said: "I agree. She just didn't like you."

I laughed: "You think?"

[Vanje]

4. Tramadol?

Thats not very euphoria-generating. That stuff is only really good for making one's back feel better.
A serious seeker would ask for Oxicontin or Vicodan.

[Aristus]

7. I disagree. A serious seeker knows that the provider knows what's up

when they ask for Oxycontin or Vicodin.

Tramadol is an attenuated narcotic, but it is still a narcotic, carrying the risk of tolerance and dependence. I had a patient try to convince me that tramadol is not a narcotic. I offered to show her the relevant passage in my Pharmacology textbook, and she stopped asking...

[murielm99]

69. My doctor gave me tramadol for a back injury

earlier in the month. I broke out in hives. I was better off resting and using non-drug treatments.

Of course, some people have constant pain and need to find other remedies.

I did not know until I researched the side effects that it was a narcotic. There were some serious cautions about people who use street drugs and tramadol. They are told not to use that drug.

I am not sure I would have accepted the prescription if I had known all of that earlier. I am allergic to morphine, too, and my doctor knows it. I had a bad reaction to morphine some years ago after surgery.

You did the right thing. Good for you.

[sarge43]

111. It's also not recommended for pregnant or nursing women

Could have serious effects for a neonate.

[RebelOne]

38. Yes, tramadol was what I gave my Rottweiler for her arthritis.

She went to doggie heaven last July, but I still have a full bottle of it. I was going to throw it away because I thought it was only for dogs. Guess I keep it in case I ever need a pain pill.

[Maine-ah]

49. check the expiration date on it

[RebelOne]

90. Thanks. I didn't think of that. n/t

[LiberalAndProud]

5. Could you refer a patient somewhere for detox?

I know it must be difficult to deal with patients who want a pill pusher rather than health care. Maybe a referral would be a good thing to have in your arsenal.

[Aristus]

8. That would mean getting to know the patient better. She absolutely would NOT

let me have a straight medical history. Now that I think of it, she was probably pretty miffed about getting a good-faith workup for chronic pain, when all she probably wanted was a no-questions-asked prescription.

As I said above, I will have to review her records from other providers before deciding what the best referral option is; physical therapy, orthopedic consult, orthopedic surgery, etc...

[LiberalAndProud]

9. Good. I just have a soft spot for people who get hooked on stuff.

I'm sure you did the best that could be done. Here's that hug you needed. :hug:

[Dystopian]

11. I was living in the past

when you posted this.....

Thank you...

I will not edit my post.......

I'm sorry....I'm sure you'll understand...I could never do what you do...I don't have the strength.
You're doing the best that you can...and the right thing. Those on drugs are difficult to deal with on a professional level when they hide what's inside.
But you already know that.

I'm only letting my first post stand...because I must. Too close to the heart.


With much respect...
peace and love to you~

[sarge43]

79. Good on you

That woman may have a chronic physical pain problem, but you had no way of knowing that. That she wasn't forthcoming with her medical history and specifics is a red flag on the field. Diagnosis is an investigative process. A health care provider (HCP) asks the right questions; a patient, especially a first time one, answers them honestly and in detail. I believe you were right. It's not even clear she was experiencing pain.

Do no harm and throwing pills at an unknown or vague symptom can do just that.

[Aristus]

95. Oh sarge...

:hug:

Your support always means so much to me...

[sarge43]

97. Hugs backatcha.

I've taken a big ration of the stuff for doing my job correctly. I know exactly how you felt. 20 minutes is a long time to put up with crap. "Yes sir!" (thought balloon "asshat!").

She was trying to game the system ... and badly, too.

[Dystopian]

10. Where will she go?

I hope that she'll find someone who will help her with rehab...and save her life.

My husband would be alive today if someone had done that.
But that was long ago...

USMC Vietnam vet...HE KILLED PEOPLE.
Died by the needle. I wish he could have lived long enough to see his beautiful daughter become an R.N....
She would never walk out on anyone...

I will keep your patient in my thoughts...the broken person who needs compassion and professional help.
Yes. I have hope for her....There is a special place in my heart for those whose lives have been broken.
We never know....
Some lives have been fixed....I've seen it.

peace~

[Kali]

12. ...

:hug: :cry:

[Dystopian]

14. ........

Kali:hug:
It's okay, sweetie...I'm still standing...
For what...I don't know...

Life goes on....


Thank you...


peace~

[Tuesday Afternoon]

13. hey Dystopian

:hug:

good to see you.

~peace

[Dystopian]

15. Sweetie!

Tuesday Afternoon

:hi:

:loveya:

Good to see you too!
Sometimes I come out of the dark...into the light...

You are a ray of light...


peace & love~

[Tuesday Afternoon]

16. actually, I was just thinking

that you are one of the kindest, gentlest posters on here. I wish I was half as gracious.

[rbnyc]

48. Thanks for this perspective.

I have sympathy for the OP and have expressed support, but your post provides a truly meaningful perspective.

One tricky thing is, how do you help someone who doesn't want to be helped. A drug-seeker who goes to a new doctor to scam a prescription - how do you turn that situation into an intervention? I don't know.

peace

[Aristus]

20. Okay, this thread has had some emotional rough spots, so I'd like to add

that I had another new patient today, who is a recovering alcoholic. Three months sober, and she couldn't be happier. She is attending AA meetings daily, sometimes several times a day, and I think she's going to make it. I love the success stories. She was a sweet woman. I think I'm going to like being her provider... :-)

[Boudica the Lyoness]

22. How uncaring of you.

I cannot believe what I have read on this cruel thread....By so called liberals as well! Shame shame shame on you!

You treat with "Non-steroidal anti-inflammatories or anti-pyritics (like Tylenol), plus

plus, regular applied ice/heat treatments, stretching, and ice massage".

I have taken hydrocodone (a narcotic) for over three years and it has helped me live a more pleasant, productive and normal life. But according to what I have read here; I should not take hydrocodone for chronic pain and I should be in treatment for drug abuse! Both of my doctors (GP and specialist) encourage me take it whenever I need it, but I only take two or three pills a day. Right now I'm back on the prednisone and take (need) much less of the narcotics, but I'm weaning off the steroids again now and soon I will be packed in ice in the mornings waiting for the so called evil narcotics to kick in. I have a rare form of a rare disease. There is no cure....just toxic treatments that haven't helped me and can in fact, make things worse. In the last three weeks two of my on-line fellow sufferers have died from it and another almost died but was brought back to life...for now.

After 2 C-sections, and even a unrelated joint replacement surgery, I refused to take strong pain meds...just tylenol for a few days, because I knew I was healing and the pain was getting less every day. But when you become chronically ill and the pain just gets worse year after year, all you want is to be be free of the pain so you can think of other things besides the constant and worsening condition.

Constant and severe pain changes the brain. Some people have told me it has made them depressed and they sound and act depressed... and desperate. Lucky for me, I have doctors that want to keep me jolly and pleasant. They know they have little else to offer me. My doctors want to help me feel better, any way they can. Two good men!

Even though the disease I have can become very painful and crippling, according to some of my on-line fellow sufferers, there are doctors out there who won't prescribe narcotics because they are afraid of the patient abusing them. I never thought I'd find such a person on DU! Maybe your patient had more going on than a crooked spine. Sometimes those hoof beats turn out to be zebras after all...I should know. I had acute & short term symptoms of the disease for 14 years before it became chronic and I was finally DX'd. Nobody bothered to do a proper job of figuring out what was going on. I had really bad doctors for a long time.

By the way..there is no non-steroid anti-inflammatory that works for me. Indomethacin helped for a while...at the beginning. The only thing that helps me now is prednisone, hydrocodone and a very healthy diet. I'm optimistic and I believe I will get completely better if I stick to this fantastic diet and keep my sprites up.

I'm stunned that there are people here who think you are some kind of hero. I would have given her something to hold her over till I got her blood work, X-rays, bone scans etc came back. Or, because your so called clinic doesn't prescribe narcotics...instead of making her feeling worse than she already did, I would have told her right away that the clinic was sub-standard and kindly recommended somewhere else she could go.

[REP]

27. I just plain can't take NSAIDs due to severe kidney disease

I also have really bad arthritis in both shoulders - cartilage completely gone, bone spurs, severely reduced range of motion, etc. It hurts like fucking hell all the time. There's a chance that sawing off the end of my clavicle on one side and reversing the joint on the other might help. Maybe. In the meantime, I get as many cortisone injections as is safe and take the only pain relievers that are safe for me - narcotics. I would LOVE to take naproxyn but I have a snowball's chance in hell of getting a kidney if mine go end stage since I'm B-, so I'll stick with what won't kill me.

Fortunately, my doctors don't consider me drug-seeking at all. Bastards accuse me of having a good attitude. Me! Harumph.

[hack89]

29. Did you start your odyssey by demanding narcotics?

and being evasive about your history or did you work faithfully with your doctors to find a fix? Did you respect their professionalism and judgment or just simply demanded narcotics from the very beginning? Just wondering.

[Aristus]

55. Thanks for the words of support, hack89. I needed that.

:thumbsup:

There's a lot of arguing from the specific to the general in this thread. By not caving in to an abusive, evasive, and highly uncooperative patient, I managed to make myself everybody's asshole.

I'm the Chairman of the Death Panels. I'm going to pull the plug on Grandma. I love to see people suffer. I work in a "so-called clinic". (Yeah, by the way; everybody calls it a clinic; it is a clinic, so-called...)

[hack89]

60. No problem. nt

[Tuesday Afternoon]

37. well said.

[Duer 157099]

39. I hear you

Thanks for saying it :thumbsup:

[TZ]

40. So you really don't believe there are such things as people addicted to drugs

Really? I'm sorry but thats completely ignorant. Some people do indeed NEED pain medications and some people don't--they are addicts who will indulge in deceitful and sometimes dangerous and violent behavior to get their fix (anyone who has worked either as a medical professional or in a drug store can tell you that). I know many in the medical field and thats something they are trained to do..Its NOT "callous" to stop people from abusing themselves and OTHERS by getting illegal meds. Or perhaps you've ignored the fact that many people die from overdosing on painkillers?
Wow, people like you scare the crap out of me..Not because I'm uncaring, I'm not...but because its attitudes and ignorance like yours that do lead to horrible horrible results including death.

[Blue-Jay]

51. Shame shame shame, poo-poo is your name.

[Name removed]

52. Deleted message

Message removed by moderator. Click here to review the message board rules.

[Bunny]

24. The compassion is stunning.

[TZ]

41. Yeah denying a junkie a fix is so horrible

Why they might keep someone from accidently overdosing...HORRIBLE!!

[Bunny]

42. Because you are 100% certain that they're a junkie.

How omniscient of you! And of course there's no difference whatsoever between a fix and an overdose - they're IDENTICAL! Your powers are incredible. :eyes:

[alarimer]

44. People who are truly in pain do sometimes have trouble getting someone to believe them.

Because a lot of people (even I guess in the medical profession) assume they are junkies.

I am not saying that is the case in the OP at all but, from what I hear and read, it often is.

[Tuesday Afternoon]

45. I wish we could hear the patient's version of this.

:shrug:

[Aristus]

56. Well, I was in the same room with her for twenty minutes.

I couldn't even make SENSE of her side of this...

:shrug:

[Tuesday Afternoon]

61. I hate this happened for you and her . . .

challenging patients are not easy. I understand about dealing with the chronic pain and the plan you had for that but, the acute pain that she was currently experiencing is what bothers me. Also, I know how some patients present irritable and uncommunicative until their pain is managed.

Not knowing anymore details, I hate to pass judgment on this situation.

very sad.

[Aristus]

66. I don't know about stunning. But my compassion has been stunned more than once.

Just about six weeks ago, I had a new patient present with a complaint of chronic arm and hand pain. She was pushy, rude, and demanded narcotics straight off. Plus, 30 years old and not a tooth in her head; the edentulous mouth of meth. I did what I always do, even with my patient in the OP: a good-faith workup for chronic pain. I took a very careful history (my Adult Medicine instructor in school told us you can get 80% of your diagnoses from the history alone.)

It sounded an awful lot like carpal tunnel syndrome. I referred her for an EMG, an electromyogram, a positive test of which is diagnostic for carpal tunnel. As I concluded the visit, she whipped out her phone and started thumb-texting one of her kids. She was a whiz. Someone as uncompassionate as you think me to be might have thought: 'Yeah, real bad pain there. Texting at lightning speed and all.' But I came at it from the other direction; the medical direction. I asked her 'Do you text a lot?'

'20-30 times a day! Got to keep my kids in line!'

'It occurred to me that that might be part of the problem right there. Repetitive stress is the major cause of carpal tunnel. You should scale it back some.'

As in the OP, she didn't take my refusal of narcotic analgesia well. But I decided to wait for the results of the EMG, and see whether she would need surgery or not.

A week later, I got a FAX from the neurological testing clinic. She had no-showed for her EMG appointment. Haven't heard from her since.

If doing everything in good faith, using sound medical judgement, and following standard of care shows a stunning lack of compassion, I'm afraid I don't know what else to tell you...

[Spider Jerusalem]

25. Welcome to more unintended consequences of the war on drugs

physicians who won't prescribe mild narcotics for pain relief because of either some moral judgement regarding addicts or else fear of losing their license to prescribe. While in Canada, the UK, Australia, and several other countries, analgesics containing low-dosage codeine in combination with aspirin/paracetamol/ibuprofen are sold over the counter. (And strangely those countries aren't overrun with addicts.)

[REP]

26. I thought Ultram was non-narcotic ... shows what I know. Drs used to push it on me

I thought it was some spiffy replacement for codeine. For a while, it seems like doctors were giving me samples by the handful (I'm nephrotic; can't take NSAIDs ... still have to fight off Toradol injections every now and then, but that's another story). Ultram doesn't do shit for me; I can't imagine anyone wanting it!

[Liberal Veteran]

50. I wouldn't classify tramadol as a narcotic.

Tramadol is similar in some respect to narcotics in the receptors that it binds to, but in most states it is not even classified as a controlled medication. There is some abuse potential, but my understanding is that potential is higher than ibuprofen but much lower than vicodin.

[REP]

67. I wouldn't classify it as an analgesic!

When it was being thrown at me years ago, I gave it the old college try, but it didn't do much except upset my stomach.

The shoulder with the bone cysts is really acting up tonight, and I really really want naproxyn ... but I can't even take Clinoril any more (severe kidney disease). More needles for me (cortisone injections) and narcotics until my appointment.

I am so lucky to have doctors who can read X-rays and MRIs.

[Liberal Veteran]

70. I'd guess it depends on the type of pain and probably the patient.

I've taken it with fair results for moderate pain. My husband took one once and 30 minutes later was throwing up. I'm just not seeing it as a drug anyone would use recreationally.

[REP]

72. I know - I was just being an ass :-)

[HopeHoops]

28. Tramadol didn't work that well for me, but it did land me in the hospital when I took it with....

Cyclobenzaprene. Both were legitimate prescriptions within the same calendar year, but long enough apart that I guess the GP and pharmacy didn't see a reason to flag them as a conflict. I looked it up AFTER the fact and found that they can in fact cause seizures when taken together. I check EVERYTHING now and BEFORE taking it. I can't take Fentanyl at all - makes me puke constantly. Hydrocodone sort of works, but Oxycodone really does the trick. Fortunately, I only need to take it occasionally and a 5/325 generally does the trick, but sometimes I need two and other times a half works. I don't like the tripped out feeling but it only lasts a couple of hours. At least it takes care of the pain and I can still function. I absolutely can NOT understand why anyone would use such substances for "recreational" purposes - and I was a major league pot head 20+ years ago. I did at least 3 huge bong hits before each of my senior finals in college and graduated magna cum laude! The narcotic pills thing just eludes me.

[blueamy66]

31. bah.....she didn't know how to work the system

maybe she can work on her skills and find someone else

}(

[LynneSin]

34. I watched a Intervention special about the business of pain pills

I guess in Kentucky and Ohio they have very lax laws when it comes to these 'Pain Center' clinics - which really are a shopping place for addicts to buy their drugs. Just need enough cash and you can almost walk away daily with 25-50 pain pills of your choice.

It seems Ohio recently made changes to these places but not sure what's happening in Kentucky.

[sinkingfeeling]

35. And here I thought tramadol was only used on dogs! I really didn't know it is a human drug.

[suninvited]

36. I have noticed in the last few years

signs posted in doctors offices that state "We do not prescribe narcotic pain killers at this clinic". Maybe you should have one posted so as not to waste your own time, or the patient.

I remember my doctor in Pensacola telling me what a hard time he had with recognizing the difference in a pill seeker and a patient truly in pain. He said while there were a lot of legal issues in prescribing narcotics a doctor would be negligent not to give relief to patient in pain. He went into it at length but I cant remember what all of the legal issues were. We had this discussion when I was having some serious pain in my hip and he was looking at my chart. I had been a patient of his for ten years and had never had a pain issue before so he felt okay writing me a prescription for vicodin. Turns out I was allergic to codiene (had a bad reaction, maybe not truly allergic) anyway.

[Enthusiast]

43. Narcotic addiction is at epidemic levels.

You would not believe what has happened to the beautiful rural area where I live.

[applegrove]

46. Do you post it loud and proud in your waiting room that you don't prescribe

narcotics?

[Aristus]

58. They're on the wall of every exam room, as well as the waiting room.

Stop lights and stop signs are everywhere, but there are still people who want to try their luck at the intersection... ;-)

[rbnyc]

47. Total support.

I hope you saw my post: http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=105&topic_id=9729106&mesg_id=9729371

I'm totally with you on this.

[JackBeck]

54. Does your clinic have case managers? Social workers? Medical Case Managers?

Anyone on staff who is able to step in and do some harm reduction counseling?

How awful that this individual would be left alone without someone else that you could have referred them to for further care.

In fact, from what I understand, denying ANYONE full access to care, regardless if they agreed with your clinical assessment or not, is actually illegal.

[Tuesday Afternoon]

57. +1

[Aristus]

59. I think you're confusing "full access" with "proper access".

If you don't agree, then come at it from the opposite direction: suppose I HAD offered her narcotics, and she had declined them? Where would be the denial of access then?

The patient is free to accept or decline any treatment plan he or she chooses. The provider, however, is bound by certain strictures in prescribing treatments. It's called 'standard of care.' Deviation from the standard of care can be due to incompetence, or be unethical. And depending on the deviation, it can be illegal. I try to avoid all three.

[burrfoot]

62. O villain, villain, smiling, damned villain!

Oh wait, no.

You did the right thing. Obviously there are some very sad stories out there, but I think some of your detractors here are somehow assuming that you just made an off the cuff judgement. Clearly- even from the initial post, not to mention your follow ups- this was not the case.

Sorry you had to deal with it, but well done.

Everyone in a "helping" profession has to deal with people who don't think they're doing it right, and it's never easy. Keep up the good work.

What did you do in your pre-PA life?


:toast:

[Aristus]

63. First of all, burrfoot:

:fistbump::pals:

Thank you... :-)

Second of all: Thank you, Hamlet! (And Will) ;-)

Truth is, I have been able to help a lot of patients with genuine chronic pain. Some see improvement with physical therapy, some with surgery, and still others with simple regular exercise. Regular exercise has shown a great deal of efficacy in treating chronic pain, and, paradoxically, chronic fatigue. Not everyone achieves a pain-free state, but most see improvement.

I was a Medical Assistant for five years before beginning training as a P.A. CaliforniaPeggy remembers when I was just a novice, still wet behind the ears, and she's has been an encouragement every step of the way. Thanks for your own encouragement, by the way... B-)

[burrfoot]

64. Very cool....

I'm happy to hear of someone who successfully transitioned into PA-hood after...well, let's just say not-right-out-of-college :)

(I'm also, of course, happy that slick Willie could provide us with an appropriate quote :) )



I'm heading along a sort of similar path- I've been working with kids in group homes/foster care for about 8 years now, and for the last couple of those I've also been catching up on the science and math classes I never had to take for my degree in psychology; so that eventually I'll be able to apply to PA school. I'm chipping away at them one at a time while I work, so it's taking a while...but I'm getting there.

In fact, most of the day tomorrow, I'll have my nose buried in my Microbiology textbook :evilgrin:

Have a great weekend. I look forward to more stories of clinic Saturdays and the like!


:toast:


EDIT: I'm certain it's a very fine line, trying to decide who is genuinely in need of narcotics, who is simply drug seeking, and who might fall in between (i.e. have been on narcotics and they're working...or sort of working...but afraid to try something new...just give me the pills, I know they work...). I'm sure that some people truly can't be helped by anything other than narcotics...but I'm glad to hear that you're out there offering and encouraging alternative pain management strategies. I'm in Florida, and we have our significant pill mill problems here...not a pretty situation.

[Tuesday Afternoon]

84. oh great

another callous condescending PA coming along.

oh well, at least you guys can pay your contry club and HOA dues.

slap each other on the back and go play a round of golf.

[burrfoot]

101. I guess I walked into that one...teach me to share something personal on line...but....

Really, Tuesday?

Can you really not see that there are, in fact, individuals in this world who are purely seeking narcotic prescriptions in order to fuel an addiction, and for no other reason?

Can you truly not comprehend that it is possible for a professional to make an accurate assessment?

Could you please point out to me anywhere, in any of these posts, where it has been indicated that every person who asks for narcotics is an addict?

Do you genuinely believe that it is not possible for someone to accurately determine the difference between a patient who is in pain and in need of narcotics, and one who is a drug addict?

I have a very hard time believing that you are truly that closed-minded about the issue.

And on a side note- why don't you give the personal attacks a rest? They are patently absurd- you don't know me, and have no idea what kind of person I am. Contrary to your apparent belief...you know, nevermind. Your responses are doing a much more thorough job of showing people who you are than anything I could say.

All the best, Tuesday.

EDITS: typos/clarity

[sarge43]

112. You do overestimate the average income of a PA. n/t

[Lyric]

65. *sigh* Paranoid American doctors are killing us.

I have declined similar plans. Why? Because at several points in the past, I *didn't* decline, and it flat-out did not work. Narcotic pain medication works. Steroids work, for the short time you can take them. Tylenol, heat, and massage? Doesn't work--at least not well enough to be able to actually function normally. I suppose it might work for a leg muscle strain or something, but Jesus...even moderate back pain can pretty much destroy your life if you end up spending too much time in bed trying not to hurt. Those muscles get weak, and that makes the problem worse.

Doctors go on and on and on about how we patients "own" our bodies and need to be "active participants" in our treatment. "Nobody knows you better than you!", they say. But when you tell them what WORKS and what DOESN'T? Well then you're just a freaking junkie, because only a junkie would know exactly what to ask for, right? :eyes: I don't know how many times I've sat in a doctor's office pretending to be stupid and ignorant, just to avoid having them think that I'm some kind of druggie. It makes me SICK that people have to do that.

If I were your patient, you're right--you probably WOULDN'T see me again. I'd be too demoralized and hopeless to bother going back to see you or any OTHER doctor for a long while. Pain or not, you can only face humiliation and rejection so many times before you just give up.

You'd be SHOCKED at the level of pain that people can get used to when they truly believe that nobody believes them, and nobody's going to help them. I watched my Mom go through it. *I* have gone through it. God forbid if you're intelligent, informed, and capable of telling the doctor what works for you and what doesn't. God forbid if you should ASK for pain relief, as if you have some kind of fucking RIGHT to it. You either wait silently and pray to God that the doctor brings it up first, or you're faced with that terrible moment--do I ask or not? If you ask, chances are that the doctor will draw the same prejudiced conclusions that YOU did, and you leave feeling humiliated, depressed, and hopeless in ADDITION to still being in pain. If you don't ask, then you're sentencing yourself to another few months of hopeless agony, blaming yourself for not being "brave" enough to face that moment.

Here's a clue. If someone tells you that they're in pain, and you offer them Tylenol? Most people interpret that as "I do not believe that your pain is important or worthy of any serious treatment."

You have no idea how horrible it is to be in pain and not be believed--or worse, to be actively suspected of "drug seeking". Of COURSE I'm drug-seeking. It fucking HURTS. If I have an ear infection, I seek the correct drug for THAT, too.

Sorry. This is a major, MAJOR sore spot of mine.

[LiberalAndProud]

71. If you were seeing a doctor for the first time, would you be able to

sketch in your medical background for him a bit?

We have a pain clinic here that holds "Living With Pain" seminars. Yeah, really! They refuse to prescribe narcotics of any kind. They will administer spinal blocks, and I've seen those both work and not work.

I agree that it's cruel not to offer meds if that's what helps. I hope you are getting the care that you need.

[burrfoot]

75. Lyric,

it sounds to me like you've been through this, you're educated about your condition, and, presumably, you've tried other things and found out that, for you, only narcotic medication helps. That's fine. I don't think anyone begrudges you that.

However, that is you. Your very valid need for those medications does not translate to everyone who asks for narcotics being in the same type of situation. No one has suggested that patients who come in, can logically and coherently discuss their medical history and the treatments they've tried in the past- both what worked and what didn't- shouldn't be able to get the treatment that works for them.

What the OP was discussing- at least the way I understand it- is a situation in which someone came into a clinic asking for narcotics right off, and was unable or unwilling to give straightforward answers as to why that was the only option they would accept. Further, when told narcotics were not an option because the clinic does not prescribe narcotics, the patient, in the OP's words, "got a little abusive."

I'm sympathetic, if you've found yourself in a position where you've felt you had to "act dumb" in order to get the treatment you need without being labeled a drug seeker. On the other hand, I don't believe it is out of the question for a medical practitioner who is seeing a patient for the first time to ask questions about that patient's treatment history. If there is a genuine reason why only narcotics will do, why wouldn't the patient in the story just explain what that reason was?

If someone came to you, saying they were starving, and when you offered to buy them a meal they said "how about you just give me some cash?", wouldn't you think that was a little suspicious? Wouldn't you at least ask a couple more questions about why cash and only cash would suffice, when a meal would remedy the stated situation as well? Maybe there's a legitimate reason only cash will do, but maybe not. The insistence is enough to warrant some extra investigation.

Aside from what I expect will be our continued disagreement on this point, I do hope that you are getting whatever treatment is working best for you right now.

[sarge43]

80. Well said

Taking your analogy further, what if you gave the starving person money. Rather than buy food, they buy a gun and commit murder or suicide? Are you exempt from all blame, no responsibility for the consequences?

[burrfoot]

81. Great point- I hadn't even thought about the potential liability issue n/t

[sarge43]

82. There is that. Moreover, there's the ethical liability.

If they're not careful, heed their training and instincts, health care providers can do terrible harm. No matter what they are doing, a person with an ethical standard more advanced than a jackal's considers consequences.

As one of my EMT instructors said, "If in doubt, don't. If warning bells are ringing, listen to them."

[burrfoot]

104. I was considering liability to include ethical as well :)

In my current line of work I don't provide medical care, but I do make decisions that impact children and families on a regular basis. We are constantly making assessments of the risk of various treatments, interventions, and placements; and trying to find the least restrictive options that still address the safety concerns of the kids, their families, and the community at large. It takes a bit of foresight and the ability to actually care about the people you're working with in order to make those kinds of plans successful- and even then, like everyone else, we're only human. Bad things happen despite the best of intentions.

I guess the key is to use your head, try and see the forest as well as the trees, and be compassionate.

Nothing like a non-stop balancing act to keep you on your toes, eh?


:toast:




EDIT: typo

[sarge43]

106. Life: A high wire act.

Bless you for the work you do.

[burrfoot]

108. Thanks, sarge, and right back atcha-

for the work you do/did :)

[Lucian]

76. +1

Well said. And that sucks that you're in pain.

[pitohui]

93. what lyric said

my friend's father was screaming in agony, for a year, with terminal cancer because his oncologist was more concerned with not triggering DEA "alerts" than with relieving pain

the first concern should always be to treat pain

if a junkie happens to get some cheap drugs, instead of needing to go shoot someone to steal their drugs, frankly, as far as i'm concerned, that's a perfectly acceptable outcome but there is NEVER anything acceptable about denying relief to someone in pain, when we have perfectly good tech to remove that pain

i see no decent reason why doctors should be refusing the proper pain medicine to people in agony, whether the agony is chronic pain, terminal cancer -- or whatever agony of the soul causes a person to become an addict

no good comes from refusing the drugs, the junkie will get the drugs elsewhere, probably by robbing or hurting someone in the process, the person in physical pain will remain in pain

i am not gonna congratulate anyone in the medical field for covering their own ass, i don't BLAME you for covering your own ass but there is no one thing kind or nobel about ass covering, and i would be ashamed to brag about my personal ass covering on DU by pretending i'm some kinda hero

addiction is a sickness too, a sickness that affects the brain

[zanana1]

83. I go to a pain clinic...

But first, I went through three years of trying different ways of alleviating my pain. I even tried acupuncture for a year. Two rounds of physical therapy, Nsaids, cortisone injections, using a walker with a seat on it, etc. Finally, I had to give in and see a pain specialist. I had become a prisoner in my home, only able to walk from one room to another, and with pain.

The pain clinic saved me. Now, I can function like a normal human being. I can do housework again, I can exercise, I can swim, etc. I just thank God the pain center was there for me. I have run in to doctors like you; what I would call you is paranoid, seeing everything in black and white. I realize there are people out there who are drug-seeking, but they aren't ALL drug seeking. Dismissing someone in severe pain is cruel.

[LeftishBrit]

86. Does she have medical records about this?

Because while some people are drug seekers, there are some people who do need quite strong medications. My octogenarian mother suffered for some months from agonizing leg and other body pains due to severe spinal stenosis. In the end, she had an operation, which improved matters a lot. But when she was at her worst she really did need to take Tramadol, because without it the pain was absolutely unbearable. Frankly, I think she could have ended up committing suicide otherwise - she was considering it, and she's not a suicidal person by nature. She didn't *like* taking Tramadol; it had some disagreeable side-effects; but she'd tried less strong medications, and they weren't effective for her pain.

As I say, I know some people are drug addicts, but I'd have thought they usually went after morphine and the like, not Tramadol.

[alphafemale]

87. When I reiterated that my clinic does not prescribe narcotics, she got a little abusive.

That's really all you needed to say to tell me you did the right thing.

Your clinic DOES NOT PRESCRIBE these drugs. She GOT ABUSIVE.

People attacking you on this thread are clueless.

Yes. Of course narcotic pain meds are life savers for some people and allow them to lead normal lives.

But then you have people that get abusive when narcotics are denied in a place where they couldn't get them in the first place.

[pitohui]

96. people in terrible pain tend to be grumpy and abusive

anyone who doesn't know THAT much about human nature should not be allowed to work in the health care field, the assumption that every yelling, "abusive" person is a drug addict is just plain ridiculous and contrary to the real world

it is impossible to keep begging sweetly and submissively and treating health care workers as the little gods they believe they are when you are suffering terribly

people in pain ARE IN PAIN, and when they are repeatly shit on, wrongly dx'd, and out and out scorned, then yah sometimes they're gonna get abusive

it's unfortunate that, by definition, drug addicts have a brain disease which causes them to lack self control and they ALSO get abusive but if you think everyone who chews somebody out for being an unfeeling ass is a drug addict...well...that's just silly, sometimes if you're getting chewed out for being an unfeeling ass then it's because the person "abusing" you genuinely feels that you're being an unfeeling ass...on the face of it, it does seem like a "pain clinic" that doesn't even have the option of offering narcotics should be shut down for fraud, just as we should shut down those "abortion counseling clinics" that don't offer abortion, lying is cruel and lying to sick people in pain is doubly so in my view

[sarge43]

88. A couple of facts Aristus'' critics are willfully ignoring

1. As he has said, he can not prescribe other than OTC drugs; no one in his clinic can. Unless she was blind or unable to read English, the woman knew this before she even talked with him. Further, as soon as she said Tramadol, I'm sure he informed her he legally couldn't prescribe it.

2. Tramadol is an opiate. It is potentially dangerous and addictive. For example, if a person is abusing alcohol, using Tramadol can cause seizures. In some situations seizures are fatal.

3. Aristus gave her a return appointment; he didn't blow her off. He followed proper medical protocols.

Are you all seriously demanding a potentially dangerous and addictive drug be illegally prescribed without a detailed medical history and a thorough physical exam? Would you want your health care team to do that?

[LeftishBrit]

91. I would certainly NOT recommed prescribing it without a detailed medical history or thorough exam

Apart from anything else, it can have bad side effects.

I wasn't saying he should have prescribed it; just that some people do depend on such drugs for pain, rather than out of addiction.

[sarge43]

92. I have degenerative arthritis and had cancer twice.

I am well aware pain meds can be the difference between hell and something resembling a normal life. I'm also aware that they shouldn't be used without very careful consideration and awareness on the part of both prescriber and patient. I can't take anything with codeine else I flip out and throw up everything I've eaten. I make damn sure every medico knows this.

Re the arthritis: Yes, it can be managed with pain meds, but only managed, certainly not cured. Surgery and physical therapy worked much better and I'm no longer doing a number on my liver, kidneys and bladder.

[LeftishBrit]

98. Hope you continue to improve!

Yes, people have to be very careful about drugs and their side effects. My mother can't take aspirin. I can't take even small amounts of morphine (I know this not through extensive experience of the drug, but because when I was a little kid I was given Kaolin and Morphine, not an uncommon medication in those days, and ended up being rushed to hospital with such a bad stomach ache that my GP suspected appendicitis).

Glad that surgery and physio worked well for you.

[sarge43]

99. Thank you. I have.

Just hope it doesn't start in the knees. They can be a problem to correct.

Adjusting body chemistry is tricky business and must be done with great care.

[Supply Side Jesus]

89. Dealing with people with such problems becomes tiring

they don't listen, they will do anything to get what they want.

hang in there

[burrfoot]

107. Off topic...but that .gif made me laugh out loud. Thanks :) n/t

[Supply Side Jesus]

116. grab it while you can, it's too big, and i have to remove it :(

;(

[burrfoot]

118. Ah, well.

The golden kraken of Greyjoy....a brave replacment! ;)



:toast:

[ismnotwasm]

100. Isn't it true

Long term opioid use damaged the nervous system so that narcotics are less effective? I forget the reasons for that right now.

I'm a not a prescriber and I work on a med-surg floor. The seriously opioid dependent are difficult patients indeed when it comes to pain management after surgery, but that is NOT the same as drug seeking. That's a whole different set of behaviors. Someone who is doctor shopping for narcs should be flagged at different ER's and such--some sort of paper trail, but often that information is hard to come by. I suspect you didn't put many details in your post, what with HIPAA and all.

I always feel bad for the drug-seeking type of patient. Unless they get exactly what they want when they want, they're miserable and very easy to dislike. When they get what they want, we're feeding an addiction that will lead to more health problems, with early mortality the most likely result. It's a difficult place to be in, hard to maintain sympathy, impossible to safely practice with these folks unless strict and consistant limits are set. Discerning the difference between chronic pain, chronic opioid use with subsequent tolerance and drug seeking isn't very easy either.

I think it's kind of cool your clinic is non-narcotic.

[Fire Walk With Me]

102. Guard your prescription sheets.

[Aristus]

105. No need. I e-FAX prescriptions right from my laptop. They're usually ready to pick

up by the time the patient arrives at the pharmacy. The miracle of modern technology. And the e-FAXing application is password-protected.

It's a real time-saver. By pointing and clicking, I can refill, say, six prescriptions in about 30 seconds. Writing out six prescriptions on a pad could take up to five minutes, and in a busy day of clinical medicine, every minute counts.

[Fire Walk With Me]

110. Build a better prescription sheet, they'll just build a better addict.

;)

Sorry about the negative experience, I hope that the majority of your work doesn't take the wind out of your day! :hug::hi:

[Lilyhoney]

103. Funny xtranormal videos of drug-seekers

http://www.youtube.com/watch?v=SZODNAum3Kw&feature=related

http://www.youtube.com/watch?v=vca7xmAhvO8&feature=related

http://www.youtube.com/watch?v=EUDJXQNP9yg&feature=related

http://www.youtube.com/watch?v=NZRwSPrI_HM&feature=related

http://www.youtube.com/watch?v=GuA2QUlCmqg&feature=fvwrel


Addiction is not funny.

[bluesbassman]

109. Understandable Aristus.

You did the right thing based on the info provided. I've followed your journey for some time and I know you to be a caring and compassionate person and provider. Your clinic obviously has a well defined policy in place and that really settles the issue whether the patient in question was a drug seeker or not.

Hang in there my friend. :)

[Kali]

113. I bet this thread would AWESOME in gd

Let me go on record here by saying I see both sides to this. Try getting pain meds when you are fairly pain tolerant but know you need them say, for sleeping comfortably. Or worse, show up with some long hair, body modification and clothes that say "not mainstream." good luck. Can you imagine being addicted AND having an acute pain event??? What happens for that?

on the other side - love the way many here are projecting their personal experience onto the OP's story. Nobody here but Aristus really knows how this person presented, yet many seem sure he is wrong.

Seems like we could do a better job helping him understand the other possible explanations for his experience than jumping all over him. I know he can handle it, but sheesh.

[Aristus]

114. Thanks for understanding, my lovely, many-armed death goddess!

;-)

Truth is, I don't register hairstyles, piercings or tattoos when sizing up a new patient. Those go under "distinguishing physical characteristics", and that's it. What matters to me is behavior. It was not this patient's chief complaint, or even her up-front request that mattered in this situation. It was her behavior.

[billyclem]

115. I use a lot of narcotic pain medication

and I find nothing wrong at all in how Aristus handled the situation. I have been with my physician for 30 years and when there is a need to increase the dosage (I use fentanyl and morphine) we discuss how the pain, from a severe lumbar injury, has changed and any other possible factors including newer non-narcotic meds. Prior to increasing the narcotics we might try out newer non-narcotic for 6-8 weeks. Nothing makes the pain go away, the best I can hope for is to only need one cane, most days I need two and one out of five days I have to stay flat. It does help to have been with the same doc for 30 years. There is a paper trail to make even the DEA happy.

It must be kept in mind that the DEA is looking over the physician's shoulder and if they are prescribing narcotics too often without trying non-narcotics first, sooner or later they will want to know why. It has become too difficult to go after the real drug dealers, the doctors are easy targets and make headlines and help them maintain budget. SAD :wtf:

[auntAgonist]

117. It would seem to me, not having been there mind you...

That there was NOTHING Aristus could have done re her demand for Tramadol.

read the OP "When I reiterated that my clinic does not prescribe narcotics,..."


This wasn't HIS decision.

Or am I missing something here?