Nov 7, 2012

Addicts at 3 am

It's 3 am and you're entering your second cycle of REM sleep dreaming about Haagen-Daz sundae and swimming in Maldives when the phone rang.


"The patient in 16-3 says she has some stomach pain. She was admitted for a percutaneous coronary angioplasty and had had chronic pain problems since then."

My pupils fight against the brightly lit ward corridor as I walk to her room. She's clutching her epigastric area groaning in pain. Not too loudly but loud enough to wake the patient next to her and across her.

"How are you feeling?"

"It's soooo painful! I'm in pain!"

"Does it hurt intermittently in spasms or is it a persistent sensation?"

"Aarrggghh! Painful!"

Somehow the patient looked familiar to me but I can't recall when we met with my brain kicking up from Maldives and determining what to do. I checked her pulse. Strangely it's slow, not more than 80 beats per minute. I ordered the nurse to measure her blood pressure, which turned out to be 135/70 mmHg, not too far off her usual BP. Abdominal palpation and auscultation were unremarkable.

"Did you eat anything different today? When did this start? When is the last time you passed stools?"

She didn't answer any of my questions but kept writhing and groaning.

I went back to her charts and it shocked me. For the past week or so there were orders for morphine, demerol, and tramadol all around 2 to 3 am for some strange pain at different sites. An intern (my partner actually) and his resident had noted this and wrote a note advising on call doctors about potential addiction problems.
Called at 2.45 am about severe substernal pressure-like chest pain. Duration unknown. EKG no changes. Vitals and BP normal. Heart RRR. Review chart and found many episodes of different pain problems. Patient had a below-knee amputation 3 weeks ago and morphine was prescribed thereafter. Give saline IM injection and she stated some improvement in pain. Suspect opioid addiction. Please refer to psychiatrist or social worker in the daytime.
Unfortunately nobody actually reviewed the note. Not even her attending or daytime resident. They even kept prescribing opioids for her whenever she complaints of pain. My brain is now totally awake.
On one hand I'm angry nobody took any action against her addiction, even allowing her to slip deeper into the mess. On another I hate being disturbed from my swimming in Maldives.
I ordered the nurse to inject some normal saline and keep a close eye on her.
I went back to bed but couldn't get any sleep. How could her attending be so irresponsible? How could this happen?
Then I remembered when I last saw her.
Two weeks ago when she was staying at another ward, she called at 11 pm stating the pain at her amputation site is bothering her sleep. I recalled the encounter vividly as her carer is one hell of a bi*ch.

"She's in pain. Give her the injections she gets at the orthopedics ward," her carer said. Lying in bed and yawning.

"Mrs. X, can you tell me where the pain is?" I asked her. Ignoring the carer.

"Just give her the injection and we'll go to sleep!"

I did not. Suspecting phantom limb pain, I prescribed some antipsychotic medications and a mild muscle relaxant for her. She never called after that.
2 hours later she called again. Chest pain this time. I'm prepared.

"It's moved from the stomach to the chest this time eh?" I asked. I know she knew when we are called for chest pain we have to go see the patient no matter what.

"Yup." She replied. Not bothering to groan or wriggle in bed anymore.

Again, her vitals are good and chest auscultation were unremarkable.

"Well, since we just gave you the injection 2 hours ago, I don't think we can administer another until 8 am in the morning." I said, grinning from ear to ear. "If you think you're in trouble, you should tell your attending about it and ask for help."

She stayed silent. Defeated.

I could prescribe morphine or demerol and avoid the second call altogether. However, it is against my believes that I help them in their addiction. Sadly, her attending doesn't think so. Or he didn't even care to question deeper. This is rather prevalent in medicine, as pointed out by Lembke:
In 2010, there were reportedly as many as 2.4 million opioid abusers in this country, and the number of new abusers had increased by 225% between 1992 and 2000. Sixty percent of the opioids that are abused are obtained directly or indirectly through a physician's prescription.
Nevertheless, it is difficult to differentiate between real, objective pain and an addict's plea for more drugs. Recent development in palliative care and pain management seem to take sides with a patient's subjective experience which give them easy access to medications.
It seems that the patient's subjective experience of pain now takes precedence over other, potentially competing, considerations. In contemporary medical culture, self-reports of pain are above question, and the treatment of pain is held up as the holy grail of compassionate medical care.
I couldn't agree more as he reaches his conclusion:
Health care providers have become de facto hostages of these patients, yet the ultimate victims are the patients themselves, who are not getting the treatment for addiction they need and deserve.
I understand when you're covering up to 20 beds daytime and up to 50 during night floats it's easy to just ignore all the signs and order what the patient wants. However, respect for autonomy should not include requests for addictive substances, especially when the patient is already showing obvious signs of dependence.
I feel sorry I couldn't do more than a saline shot and hold on till 8 am. If the social worker is on call I would've called and asked them to arrange her a place at the detox center. And ultimately, I wish her well in her struggle with morphine.