"Hey, you're a doctor. What's this rash on my back?"
"Oh, you're a doctor? Hey, why does my knee hurt when it rains?"
"So you're a doctor! Well you see I have this, uh, friend, and he...no it isn't me, I swear! Anyway, this friend of mine has had a problem with...do you think you could get him some Viagra?"
Get the idea? Most of the questions I get are completely unrelated to my field of expertise, which mostly has to do with either holes or sick organs inside the abdomen. Some, however, are relevant, and one I got recently from a reader named Miss A (not her real name) is particularly germane:
Hey Doc, I've been reading your FML posts for a while and graduated to your blog a few nights ago (which by the way is great reading material when your brain refuses to turn off and allow sleep), and I've noticed you have a few posts about drug seeking. My questions are, when is it ok to ask for medication, when is it ok to ask for stronger medication, and how do you approach the topic with your doctor?Asking for medication is always tricky as some of my patients have found out. The problem with pain is that it's 100% subjective. There is no test I can run on you that proves that you are in agony. There are warnings that most people emit unconsciously that we can easily detect that tell us that you're in bullshit mode. So having said that, here are some answers that may help.
Thanks for your time and opinions. Miss A
When is it ok to ask for medication? It's always ok to ask for pain medicine. That doesn't mean you'll get any, but if you're in pain, let someone know.
When is it ok to ask for stronger medicine? This is where you start to get into that grey zone. There are some lines that we hear over and over, and all of them raise huge red flags.
"I can only take XXXXX. It's the only one that works for me." If you start off by demanding a certain narcotic, especially one that has a side effect of euphoria, chances are very good you will NOT get it from me. Morphine, demerol, codeine, hydromorphone, fentanyl, and heroin all work the exact same way by binding to the exact same receptor. Their chemistries are all a little different, so they work to varying degrees. But if one of them works, chances are another one will work too.
"I'm allergic to all of the over-the-counter medicines." Sure you are. I can say with 99.99% certainty that isn't true, because the chance of actually having an allergy to paracetamol (Tylenol), aspirin, ibuprofen, and naproxen is very near 0. And the people who are supposedly allergic to them usually aren't quite sure what the allergy is ("Uh, they all make me sick"). Sorry, but nausea isn't an allergy.
"None of the over-the-counter medicines work for me." This is probably one of the biggest red flags. Of course they don't work - you've been abusing narcotics for so long, the only thing that WILL work is more narcotics.
"It all just hurts! I need pain medicine!" If you have no identifiable reason for having excruciating pain all over your body, we can rest assured that you aren't having excruciating pain all over your body. Yes, there are very rare disorders where very unfortunate patients have pain for no detectable reason. Fortunately for us (and unfortunately for you), these disorders are exceedingly rare.
How do you approach the topic with your doctor? Be open, honest, and frank. Don't be whiny, demanding, or aggressive. Let your doctor handle the details, and don't try to guide him in one direction. Understand that there are more and more non-narcotic analgesics available now than ever before, and if your doctor prescribes one for you, don't complain that it isn't Vicodin. Trust me when I tell you that you do NOT want to take narcotics for your chronic low back pain or your severe menstrual cramps. Once you start, it can be VERY difficult to stop - if you've ever seen a narcotic withdrawal scene in a movie, they are usually startlingly accurate.
I hope this helps not only the people with real pain who are seeking answers, but also the idiots who still think they are smart enough to con narcotics from me.
Wait a second...is Miss A tell me that this blog puts her to sleep? I suppose she can stop asking her doctor for sleeping pills now.
Great blog doc. I'm a nursing student and it really shocked me during my ER rotation when I had a patient who listed allergies to ibuprofen, Tylenol, ultracet, tramadol, and toradol. My first thought was "wow, that sucks, this patient can't take anything" and then it dawned on me "how in the world are you only allergic to non-narcotic pain medications?" Yeah, doesn't happen.ReplyDelete
On another note... I actually am allergic to aspirin. The salicylic acid makes my throat swell and boy does it make my body itch! Also face washes with salicylic acid in them turn my face bright pink and puffy!
Love your blog!
Where I am(US KY) tramadol, which is the only thing that I have found works for my chronic pain from a car accident months ago, is considered a controlled substance. I wish I lived somewhere it wasn't considered a controlled substance, because the looks I get when I turn down hospital heroine via IV or norcos to go home with, requesting tramadol instead are interesting.Delete
I have had a PA "yell" at me about my dispense history and I can't understand why they were so angry that I didn't want norco. I am severely afraid of becoming addicted to anything. Addiction has waltzed into my family and several are all too happy to dance. Ranging from two gallons of vodka or rum a week to a ridiculous shopping addiction.
The ER I go to is a military one and they seemingly hand out 20 norco like candy. It's hard to leave that ER without a narcotic either via IV or given to go home with. I have been to the ER at least 15 times in the last three months and every time they want to give me norco. My PCM is hard to get an appointment with otherwise it'd be a non-issue.
Last night being the most recent and I finally got an answer about my abdominal pain and he just poked the area with his fingers, doctor educated poking, but poking none the less and two lidacain shots later it was like magic! First doc in that ER who listened to see the whole picture instead of throwing narcotics at me. I got a treatment that I wish I could repeat at home but I can't see the needle; if I do I have a mini freak out.
I know tramadol has addictive possibilities but not nearly the same as norco. Yet I have been yelled at for requesting the lesser of two evils. Ugh.
Thank goodness for good doctors who listen.
I was on tramadol for a while due to unexplained severe abdominal pain plus chronic migraines, I had such severe withdrawal from it, one of the worst experiences of my life, then they put me on oxycodone, which my Neuro wasn't too happy about (neither was I) so I started to come off that too... More horrible withdrawal. If I go to a&e they get pissed at me for REFUSING the pain meds, I want to know why I'm in excruciating pain. A nurse actually told me most docs will see me as a drug chaser when I explain I've had these problems from age 11, and once I became a teen they listened even less.... Which of course made my health even worse!Delete
I'm a horrible patient when it comes to anything related to pain. Asprin causes my throat to swell, ibuprofen causes a horrible rash, paracetamol and my liver don't like each other and this also causes a bit of throat swelling and tinging in my face, ketoprofin isn't an option because of another medication and that's about all of the over-the-counter medicines in Finland. Meloxicam, etoricoxib (I think that's the name, in Finland the "brand name" is something like Arcoxia.) and naproxen are really the only ones I can take. Thankfully hydroxychloride and meloxicam make the pain bearable and I haven't had any need for narcotics. I'd probably be allergic to those too, I'm allergic to really everything and I've become quite thankful that the hospital (and it's adrenaline shots!) is 500 meters down the street.ReplyDelete
Oh, and by the way Doc, do you know if the melatonin that I think can be bought over the counter in the states, is the same drug as the one sold here http://tinyurl.com/crsd3zo? I've heard it's much cheaper there, paying around 30 dollars even with a prescription for it sucks.
I have the same problem, Docbastard! I usually dont mention my profession in conversation unless someone asks specific questions!ReplyDelete
I agree with Miss A, though. This is a wonderful blog to read when one is awake in the dead of the night for some reason. It doesn't necessarily put me to sleep, but it does make the otherwise wasted time enjoyable. (And I suppose exercising my mind isn't going to really put it to sleep, either.)ReplyDelete
Lurker coming out of the darkness, here.ReplyDelete
I'm a weird exception who actually can't take any NSAID-class drugs - my medical pedigree includes such wonders as SLE, and years of being on increasing doses and strengths of those drugs made me get stomach ulcers. If I take Advil for two days, I'll start vomiting blood, and the doctors have led me to believe that this is Not Good.
HOWEVER, I carry papers with me from my GP explaining what my medical craziness is whenever I go anywhere, really, because I'm disabled (use crutches to help with balance and coordination) and I never know when I'll end up in a hospital. I also carry a drug list, stored carefully in my iPhone. I usually have the drugs on me, too. I have a good memory for names and doses, if that should fail me. And not everyone can remember hydrooxychloroquine off the top of their head.
Up until last December, when a wonderful beast called endometriosis and his pal ovarian cyst the size of a softball showed up, I'd never taken any narcotic stronger than a Tylenol-3. I've been on increasing doses of morphine while awaiting surgery, which has been cancelled FOUR times so far. Once by a moronic doctor who decided I was cured because I came into the ER with a pelvic infection and they cured it (uh, no, I came in with crippling abdominal pain, and I still had it). She discharged me with a prescription for naproxen, which I can't take (and even if I could, I took that one for months for arthritis, it doesn't do anything for pain anymore).
I immediately sought a second opinion, and he put me on 5mg of morphine for three months to wait out and see if the cyst went away. Nope, so he scheduled the surgery for the summer. Then he got suspended for two months for not filing paperwork correctly (and Quebec is ANAL about it, even though you get four hours of paperwork per patient visit, a backlog should be expected...). Third time was Nov. 23rd, which is when I was rescheduled to. I was sitting in a hospital gown awaiting the doctor, when he showed up to explain that there was a gastro outbreak in the hospital and therefore no beds. Some moron had gone visiting, great. I was supposed to go back in Nov. 29th, but due to potentially contaminated blood from Hema-Quebec, there is no surgery other than trauma and emergency being done for an indefinite period of time.
I *hate* being on narcotics. They don't make me high, which is fine, I hate that too (no caffeine, no alcohol, no nothing goes in me), but if I forget to take a pill (frequently), I get to go through junkie withdrawal and feel pathetic.
I know how you feel about people being a pain outside of work. Until I became disabled, I was an illustrator and graphic designer. For some reason people think that this job is 'fun' and not at all actual work, and therefore I get asked by complete strangers to design their tattoo/draw this amazing comic book they wrote for a share in the profit/design a logo for their company, it won't take long. Dude, I need to eat.
Oh yes, evidence that I have a tolerance to these drugs:Delete
At midnight I took my night dose of morphine (90mg), two Valium (totalling 10mg), and two Gravol pills (anti-nausea, also often causes drowsiness).
It's almost 4 am, and I CAN'T SLEEP.
That is not normal. I have zero stimulants in my system. And this happens a lot even if all I take before bed is morphine. >.> I hate these stupid drugs.
Hey, I'm wondering how this all turned out. I assume you everyday got your surgery?Delete
I'm the type who hates narcotics! I hate the way they make me feel :/ I used to take neurontin, hydrocodone, oxicodone and Dilantin everyday... If I'm in pain, I just take 800mg of ibuprofen and if that doesn't stop the pain, I'll take a Tylenol 3 with codeine.... But the pain had better be pretty severe for that pill! When i do ask for pain meds- I ask the dr if there is anything I can take that is non-narcotic... Other than that- i just try to deal with the pain- mind over matter :)ReplyDelete
I just started reading your blog & got directed here from FML. & this is definitely one of the more interesting things to read late at night.ReplyDelete
anyway, last year I got my wisdom teeth pulled and I was in some obvious pain when the numbing wore off and I expected to get a prescription for ibuprofen or Tylenol but instead I got a prescription for Oxycodone. They told me to take two and they knocked me on my ass. Everyone else I know of only took ibuprofen or Tylenol so I was wondering (even though dentistry is not your field of expertise) if that seemed extreme for a routine wisdom teeth extraction.
I was given ibuprofen at first (I had my wisdom teeth removed before I was diagnosed with Lupus), and it did absolutely nothing. I spent a night in agony with ice packs on my cheeks, lying on the floor in the kitchen so I could change the packs as needed.Delete
The next day I called, and he gave me low dose codeine, which seemed to work better. I had really impacted teeth, and the surgeon said he expected me to need stronger painkillers (why not give me a prescription right away? I don't get it. ) Then I got dry socket and SCREW THAT OW.
Maybe your teeth were impacted enough that they anticipated having more pain? Every dentist/dental surgeon operates differently.
I actually have a pain condition that causes pain everywhere (though it usually isn't everywhere at once). It's RND or Reflex Neurovascular Dystrophy. Not very many people have it and most that do only have it in one part of their body. There's been times where I was in the hospital for months because I was having so much pain and the docs wanted to observe me for one reason or another. But I refuse any pain meds. The only thing thats ever helped is morphine and I hate the stuff. The side effects and the risk of addiction are just not worth it. I will never understand why people would want to take that stuff without a real reason. Are they really that stupid?ReplyDelete
The only time I take pain meds is when I have a migraine. Cause fuck that shit. Sometimes they are so bad I can't see out of my left eye, my ears are ringing, and the pain makes me so nauseas that I puke.ReplyDelete
However I also had major spinal cord surgery. I was 4 when they found out I had a tethered cord due to undiagnosed spina bifida, back then they had to cut the whole back open. Result: so much scar tissue you can't feel my spine, nerve damage, arthritis and just general pain (especially when the weather changes). Even when that is having its flareups all I want/need is a heating pad and a muscle relaxer. Does it still hurt? Heck yes. But I don't like feeling high so I deal with it. Breathing techniques and muttering long strings of curse words also help.