Saturday, 19 April 2014

The 'F' word

I know I'm going to catch hell for this post, but if I really cared about naysayers saying nay, I would bother posting about controversial subjects.  Hopefully by now you know that I don't shy away from such things, but before you crucify me or make a comment blasting me into the stratosphere, hear me out. 

Pain is subjective.  I understand that completely, having suffered from chronic low back pain for years.  I've seen multiple doctors, tried exercises and physical therapy, had the full workup including an MRI, and everything is completely normal.  But goddammit my back still hurts, sometimes to the point where I can barely stand.  So I rest a moment, take some pain medicine, try not to exacerbate it too much more (which is difficult when my children want to treat me like their own personal jungle gym), and get back to my life.

Yes, the pain is bothersome.  But what bothers me even more is patients like this next one. 

At 3AM Molly (not her real name) was on her way home from a tryst at Bob's house. I have no idea who Bob is, but Molly's husband, who came to pick her up later that night, was most definitely NOT named Bob.  But I digress.  Molly took a turn way too fast, went off the road, hit a tree, and passed out. When she arrived she was groggy and whiny.  Very groggy.  And very whiny.  I asked her where it hurt. 

"Everywhere!  Aah!"

I asked her to try to be more specific so I could tell the X-ray tech what to shoot. 

"Aaah!  Everything!"

I did my best not to groan audibly. 

There was not a single mark on her - not a drop of blood, not a scrape, scratch, or bruise.  I immediately suspected something else was going on.  I asked her medical history, and that's when she hit me with the "f" word. 

Fibromyalgia. 

This disease is the bane of my existence.  It is sometimes known as the "invisible disease" because there are no tests, studies, or imaging modalities which can either confirm it or rule it out.  Because of this, savvy drug-seekers can claim they have it, and there isn't a thing we can do other than treat their "pain".  I am not in any way saying fibromyalgia doesn't exist (there is evidence that it is due to altered blood flow in the cerebral pain center).  What I'm saying is that fibromyalgia, as a disease, is abused almost as much as the drugs used to treat it.

The nurse and I gave each other knowing looks, and she murmured to me "I wonder how many pain meds she takes."

Molly listed her pain medications for us, including a relatively new one designed to treat chronic pain.  What she did not list, however, were any narcotics, which surprised me and made me think she may be telling the truth.  And that thought lasted all of about 2.3 seconds, because in a move that surprised exactly no one, she said she was allergic to all NSAIDs. 

Bingo. That was the red flag I knew was coming.  And of course her adverse reactions to all these medications weren't nausea or itching.  No, in another huge shocker they all happened to (supposedly) cause anaphylaxis, a potentially-deadly adverse reaction.  I'm sorry, but almost no one is actually that severely allergic to paracetamol/acetaminophen, aspirin, ibuprofen, diclofenac, tramadol, naproxen, AND ketorolac. 

We did a full workup which demonstrated (please, make sure you're sitting down) no injuries.  As I was looking through her scans, our security officer was cataloguing everything in her purse, including the bottles of Valium and oxycodone that she failed to mention to us.

Right.

A quick look at her prescription history showed 31 prescriptions for narcotics or benzodiazepines (a class of highly-abusable sedatives which includes Valium, Ativan, and Klonipin) from 7 different prescribers over the past 3 months alone. 

I explained to her slowly and carefully that she had no serious injuries.  As I started instructing her to follow up with her regular doctor (since I have no interest in inheriting a drug addict), she started sobbing uncontrollably. 

"Oh but doctor, I JUST run out of my hydromorphone this morning, and my next appointment with my pain doctor isn't until next week!  Can you PLEASE just write me for a few to get me through the weekend?"

"Hydromorphone?  Oh, but you didn't mention that one to me when I asked you earlier," I said in a grave tone.  "I suppose the 4 other narcotic prescriptions you've had filled in the past week written by 4 different doctors and filled at 4 different pharmacies will have to tide you over."

"But . . ." she started . . . and then stopped.  She realised she was busted.  The look on Molly's face initially turned to outrage (like she was about to argue with me), but it quickly changed to pure guilt.  I could almost see the negotiations for just a few pills forming in her brain, but I stared back with such a steely gaze that the bullshit idea immediately dissipated.  Without another word she stood up and started getting dressed without even a hint of the excruciating whole-body pain about which she had been complaining just 2 minutes prior. 

I truly feel bad for people afflicted with fibromyalgia.  But I feel nothing but disdain for those unscrupulous twits who take advantage of its existence for the satiation of their own addiction. 

20 comments:

  1. Thank you for posting this. People like her are the reason my father can't get the treatment he deserves.

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  2. Thank you. A doctor once diagnosed me with fibromyalgia and chronic fatigue syndrome after a cursery exam. I told him not to embarrass himself or me by writing that in my record. I have hyperaldosteronism caused by a tumor on my left adrenal gland (not known at the time). My potassium level was at 120. I even told the doctor that my pain would go away if he would give me potassium. He treated me as if I was seeking drugs. When I was hospitalized and given potassium the pain abated. The whole experience has left me resentful of patients like yours. I have pain from an unusual source and can't get anyone to believe that I'm not just seeking drugs.

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  3. I have Chronic migraines and who knows what else. I was treated very unfairly for about 6 years by doctors. I was told all the classic reasons that my pain wasn't real because I was young and always treated like a drug seeker (even though I wasn't asking for drugs I was asking to find out why I was in so much pain) it took seeing another new doctor to send me to a neurologist when I was 19 to move a step forward (and by this time my migraines were (are) so severe I'm registered disabled as I cannot work.
    I am intolerant to NSAIDS due to how many meds I've been on, however my reaction is mainly stomach upset and a night on the loo!

    Thank you for posting this doc, so many people use illnesses that are very much real as an excuse for their own personal benefit which just adds to the stigma we face on a daily basis.

    Wishing you low pain Doc

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  4. Sending pain relieving thoughts for your lower back, as I sit here with a heating pad on my lumbar spine and an icy hot on my upper trapezius to stop it's spasms.

    I was on cyclosporine for 12 months because of Urticaria of unknown reasons. Tried all the 1st and 2nd line antihistamines and corticosteroids and nothing worked. Hence the cyclosporine. So no Nsaids for me. Try explaining that to an urgent care doc or ER one.

    Now I take 1 klonopin BID and run on an even keel. I'd prefer Valium 5mg but they won't let me take it. That's for the chronic rheumatic pain in my back.

    For my poor shoulder I take Ultram and Flexeril as needed. I can manage with the Voltaren but there are days I when the pain level is so high I have to hit it with the big guns.

    I have a chart with all my meds and their interactions so I don't take the Ultram when I'm taking the Effexor. IT's like a fricking chess match.

    Peace.

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  5. I'm sorry Fibro is the bane of your existence. Frankly, it isn't doing much for mine either. That, with chronic migraine and hypothyroid, make life....interesting. I work 55+ hours a week, get pain meds (plain old Percocet and Fiorecet, nothing interesting, and low dosages at that) from only one doc, and even if severe pain from a protracted migraine land me in the ER, I never ask for a prescription.
    Here's my question; how can someone like me, who has had chronic pain for over 40 years, NOT trigger the "you must be a drug seeker" on the rare occasions (twice in the last 3 years) I need the ER? Yes, I ask for Dilaudid, but I also request an antiemetic and a large dose of steroids, along with oxygen and IV fluids. I don't need a "workup." I need the combo that I can't do at home but will shut the migraine off. If I am in the ER, I am SHOT and I cannot wait for Tramadol to fail. What do you recommend?

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    1. this is me. well, I only have the chronic migraines. they aren't as bad currently (topamax, much as I hate how sluggish it makes me, magnesium, and riboflavin have lessened the frequency, and when I get them, I can usually get rid of them with at-home injections of sumitriptan and ketorolac, as well as oral percocet.)
      but on the rare occasion I get a migraine that lasts more than a few days with blinding pain, it is a torturous catch-22. I can lay at home in the dark and silence and pray to all the gods that it goes away, or I can go to the ER, argue with doctors in a loud place with bright lights and pray to all the gods they will listen to me and give me the medicine that I know from 10+ years of experience works. (I've had migraines since I was a preteen.)
      the only thing I've found that worked was going to the hospital my neurologist is a practitioner at (even though there are two closer ones) and immediately telling the doctor what worked for me, and just telling him to call my neurologist and have him authorize the prescriptions for whatever IV stuff I need (Dilaudid, magnesium, antiemetic, benadryl, steroid) if the ER doc isn't comfortable taking my word for it.
      after you do that once, or if you have a successful ER visit where you get everything you need to halt the migraine, tell the ER doc to look up your last visit and ask for the same medications.
      just my experience.

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  6. My sister was just like your patient. Multiple doctors, multiple prescriptions. She had oral Demerol from one doc and Dilaudid from another. She was a walking pharmacy. She died from a heroin overdose.

    I'm in the back pain club, too. At this point my pain is facet disease. I can't take NSAIDS long-term due to a history of bleeding gastric and duodenal ulcers that caused anemia. Should not, and therefore won't, take Cox-2 inhibitors because of cardiovascular complications. For me, the "safest" medications are narcotics, and I make do with vicodin.

    When I had a kidney stone decide to vacate my kidney two summers ago, I presented to the local ER and a doc I used to work with was working. I stated I had adverse reactions to Demerol (severe itching and I get all twitchy) and an anesthesiologist told me not to use it. He kind of made a face, but when I started explaining the normeperidine thing, he nodded that he believed me. I got dilaudid—had never had it until then.

    People like my sister and your patient make it tough for us who need the stuff, use it responsibly, and who go out of our way NOT to doctor-shop.

    Consider your facets as the source of your pain, Doc. Facet rhizotomies work wonders for me. Easy to diagnose with a diagnostic block first.

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  7. Molly. She pisses me off. She is the bane of my existence as a chronic illness and chronic pain warrior. I have fibromyalgia. I have been through all the workups and all the scans to rule out auto immune diseases such as lupus, scleroderma, connective tissue diseases, etc. etc. etc. It is like jumping through flaming hoops being juggled by a ten foot and four foot clown that are jumping on pogo sticks while yodeling Yankee Doodle just to get a monthly prescription for a pain reliever that doesn't keep up with the ever increasing amounts of pain… and so I find myself disabled and bed bound at age 26. I'm not the only one with fibromyalgia that has an unduly difficult time getting pain meds. Sure, they don't do all that we wish they would, but it's better than nothing. I know from personal experience (thanks to dick moves on the parts of certain doctors who are no longer a part of my medical team) how incredibly, violently ill I become from the unfathomably high levels of pain when I have no pain killers at all in my system. I will take the lesser of two evils.

    So. Back to Molly. I don't know what started her down this path. I would love to just blindly hate her and all those like her, but I can't. I don't know her story. I know that people who abuse the system and who abuse the disease title make it that. much. harder. for those of us who are already struggling so much to receive the care that we so badly need… Many doctors don't believe that fibromyalgia is a real disease. It's disheartening at times, and instances like this do nothing to dispel the dark cloud of disbelief that hangs about the "F" word. It makes me think of people who claim to have cancer and have a bunch of money raised for them and then use the money for selfish things. It makes people wary and untrusting, unwilling to give freely to the next needy, worthy person who comes along for fear of getting burned and taken for the fool again. It's not fair, really. Because of the selfishness of a few, the welfare of the majority suffers. *sigh*

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    1. I have CFS which has some similar symptoms, thanks to having no insurance and mono that was undiagnosed for too long... like you, I can't STAND people who abuse the system for meds! I've managed mine via lifestyle because I am so sensitive to a lot of pain meds and can't hold any natural opiates down. I broke both bones in my lower leg and- because I asked for a specific pain medicine- I was denied for two hours. TWO HOURS! No one would listen to my explanation that morphine and vicodine cause me to re-enact a scene from the Exorcist and Percocet at 1/4 tab actually works. It's only natural that one wants to avoid severe reactions during a compound fracture, right?

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    2. I am a molly. I had an addiction. I am clean and i never use the doc or er. I will save you the story of addiction

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  8. I'm glad I didn't run into you. I can't take acetominiphen or ibuprofen because they aggravate my asthma in a big way. Not unusual. Also, after two total renal failures, dialysis and nearly dying, I was told by nephrologists not to ever take an NSAID again as long as I live. Even ibu affects my kidneys. However, for pain I have oxy minus any aceto and, in addition, gabapentin. I have diabetic neuropathy. I have had the same internal medicine guy for nearly 20 years, and patients like the above make life really hard for me with new doctors. Or ER visits. Thank god my daughter works for the hospital and I'm known not to be a Frequent Flyer.

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  9. on behalf of my wife, who has fibro, and is allergic to NSAIDS (causing documentable stomach trouble, not anaphalaxis) thank you for catching this person.

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  10. I think that there are three kinds of people who say they have fibro. Those who have it, those who have pain from depression and anxiety and those who totally fake it for drugs. Those with depression and anxiety need to treat the depression and anxiety, not just make their pain go away. Their doctors need to be firm but considerate and make sure they get the treatment they really need. Those that fake it for drugs most likely have an underlying reason they are wanting the drugs, as is true for most addicts. However, they shouldn't be clogging up the ER faking it for drugs and they should be booted from the ER. It's a shame we don't put more resources to treating the underlying issues behind addiction and instead spend billions of dollars fighting the drugs themselves. These people have also fucked it for people in real pain. I was hit by a car as a pedestrian and it's totally screwed my life. I don't take pain medication to hide from things, I take it so I can get through my days but I'm also one of those people who don't go to the ER for anything. I am moving and I'm scared of moving my pharmacy, because of all the pharmacists who have the DEA breathing down their backs about filling pain meds and they cut off valid patients as a result. I'm thrilled I don't have to switch doctors, but I'm moving far enough that I can't afford the cab to keep my pharmacy and I have to find a closer one.

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  11. Is it just me or does drug seeking seem more and more prevalent? And it's making it harder and harder for everyone else to get treatment.
    For an (anecdotal) example, take my husband. He's allergic to Codeine, true anaphylaxis on even secondary contact. When he was suffering from a persistent cough he asked his GP what he could use to ease the bouts as they were disrupting his sleep and giving him a nasty headache. The doctor immediately offered a codeine based cough syrup. Funnily enough my husband declined that offer and asked for further advice on how to ease his cough.
    You'd think he'd told the doctor he wanted a 12 month supply of valium and an infinite refill prescription for morphine. All he actually wanted was a recommendation for an over the counter cough syrup and to know if there was anything we could do at home (humid air, decongestants etc)
    The doctor eventually decided that the cough was "psychosomatic" because my husband suffers from depression and anxiety and sent him away.
    Just as an aside, not two months later he was diagnosed with classic, chronic asthma. *facepalm* He now uses a preventer inhaler daily and the cough and shortness of breath has completely gone.
    On a similar note I had a tonsillectomy a few years ago and promptly discovered that narcotic pain releif doesn't work on me. I had to beg for ibuprofen.

    Med seekers spoil it for everyone else.

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  12. I realize this post is from 2 years ago but the subject matter is still as relevant now as it was then. I have Fibro, along with Chronic Fatigue Syndrome, Osteoarthritis in all my major joints, hip impingement on both sides (waiting for THR on right hip this year), D.I.S.H. affecting my thoracic spine, with bone spurs on my hips and several finger joints, Trigeminal Neuralgia and Type 2 Diabetes. Oh, and I've finally received a diagnosis of Bipolar disorder at the age of 54.

    I am in pain 24/7. I am on Oxycodone, Cymbalta, Topiramate, Seroquel, Tramacet, Crestor and an estrogen. I see ONE Doctor. I get my prescriptions filled at ONE pharmacy. I have a long history with both. Because I live in Canada, all my health info is linked, so it's easy to see that I'm not coming into an ER seeking drugs when I come in for pain issues. Each time I've come for pain, it's been a ruptured cyst on an ovary, or gallstones, or a serious reaction to a new Diabetes drug.....

    The Mollys of the world piss me off, not because I've personally been affected, or treated like a drug seeker, but for other people who ARE treated poorly. I'll take anything you want to give me if you think it's legit going to help, but let's be honest too Dr. - given my health background, I'd say we're past the NSAIDS anyway.

    For you Mollys out there...GROW THE FUCK UP and start helping yourselves. Face the fact you're an addict and ask for treatment. It's doable, but YOU have to do it.

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  13. I know that this is an old post, but I'm reading through your whole back catalog, and one unfortunate thing struck me. We currently have a patient in my ICU who encountered a doctor who clearly did not believe that any patient could be allergic to all NSAIDs, and ordered ketorolac for his renal colic. Unfortunately, this patient has Sampter's triad, and promptly went into anaphylactic shock. He has yet to be extubated two weeks later.

    The difference between him and Molly, of course, is if the doc had bothered to look at past clinical notes, he would not have seen lots of narcotics prescriptions, but rather three or four ICU stays for similar mistakes. So I guess what I'm saying is, all things in their context.

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    1. That is an unusual intensive care doctor, in that the overwhelming majority of them that I have met have been scrupulously diligent. Sadly, doctors like him do exist.

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    2. Ah, to clarify, the original doc who gave Ketorolac was in the emergency room. Not the easiest environment for any doctor to encounter a patient in pain who says he's allergic to all NSAIDs.... And I would never say a word against emergency physicians, but they definitely are different in work environment and temperament from intensivists.

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  14. Fibromyalgia is a medical condition characterised by chronic widespread pain and a heightened pain response to pressure. The cause of fibromyalgia is unknown; however, it is believed to involve a combination of genetic and environmental factors, with half the risk attributed to each. Find what is fibromyalgia treatment

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