A Patient in Pain

So I need to vent this really quickly.

Today we saw a patient that is in the middle of a sickle cell crisis. She is having pain throughout her body, deep bone pain. She is normally on a decently high dose of pain medications and the pain is so bad that her normal pain medications aren't working. See where this is going?

Well, after listening to resident physicians and nurses talk about her being a 'frequent flyer', 'annoying', and saying don't give her anything more than her normal pain meds because she is 'drug seeking'... I listened as they planned to give her a very low dose of PRN hyrdomorphone (2 mg q 4) and stop all of her home meds including (!!!) her 90mg of oxycontin. Which ... fine if you are going to try to control pain with another narcotic convert it! 90 of Oxycontin is 8mg q 4-6 of hydromorphone. I'm a medical student I can figure that out with a simple table! 2mg of hydromorphone is not going to TOUCH this ladies pain without a baseline on top of it. I was sooo frustrated. So I asked... If you stop this ladies Oxycontin isn't she going to withdraw? The answer I got... uhhhh I don't really deal with pain medications... What?!?!? You have patients on 12-18 different medications and you consider them a welcomed challenge and you're telling me you don't deal with a whole class of meds? You don't understand simple equivalence conversions? You admit patients and you don't understand narcotic dependency and withdrawal? You don't understand that a person on a high dose of Oxycontin has tolerance to narcotics and HAS to take more for breakthrough pain? So unfortunately they left her on that BS dose of hydromorphone and she was probably never not it pain. I did ask them to at least consult people who aren't afraid of narcotics and they said they would if that lady still has pain tomorrow.

They then said.. Oh we've had this lady before she's going to be asking for more and more pain medications she will be such a headache watch. YOURE DAMN RIGHT SHES GOING TO BE ASKING FOR MORE... HELLLLLO. Now she will exhibit drug seeking behavior because everyone runs from proper treatment with narcotics.

Then, I almost went off on one of my seniors but then remembered my role. He said... Yeah, I've dealt with a fair number of 'sicklers' and they are really irritating to deal with. I almost got sick to my stomach. The attending said well they do have miserable lives (thank goodness she said that), and I quickly chimed, Can you imagine living a life where you get frequent attacks of intractable deep bone pain some that never goes away and also being susceptible to all types of infections and everything else and every time you go to the hospital you get a new set of doctors afraid to treat you. He didn't say anything else.

This situation really upset me. After doing pain managemnt I've seen a fair number of obviously criminal tendancies, but most people that end up there have not been therapeutically treated and thus are made to buy meds on the street or look desperate in the pain mgmt clinic because NO doctor has made them feel relief or explained to them that some pain is expected. If our patient is addicted then she deserves treatment for that too. She probably been on narcotics since childhood and she's almost 30 now. She. can't sell medications she gets in the hospital. Its hard for someone on 90mg of q 12 oxycontin to get snowed by a little bit of hydromorphone and that can EASILY be monitored since all of her medications are being given by a nurse who has to look at her.

This was crazy injustice to me and I felt so helpless. I do feel much more motivated to be really good at all major medication classes within my practice INCLUDING narcotics.