WHAT TO DO WHEN A PERSON WITH
UNDERTREATED PAIN DOES NOT ACT PERFECT?
SHOULD WE START A FINISHING SCHOOL
FOR PEOPLE IN MODERATE AND SEVERE PAIN
"When the government fears the people, you have liberty. When the people fear the government, you have tyranny."
In my experience, when people are under massive stress, they do not function like a fine British gentleman from the 1900's. People with undertreated pain have trouble thinking, get impulsive, forget things and have decreased capacity to function. Performing tasks and requirements for a physician may be hard and may not be done, because of the effects of pain on abilities and capacities.
Yet it is at this exact time of limited capacities in virtually every realm, that modern medicine expects the patient to do the most and to jump through many different hoops to have the luxery of getting pain relief. Some self appointed pain experts feel physicians are giving patients a Lexus for the great privilege of having any meaningful pain care. According to one elderly "expert" prostitute witness who is used by state boards around the USA, and who has not even practiced medicine since 1991, if you want to treat a pain patient, you should make sure they have all thier old records sent to you--this is advice for the physician.
of freedom is
Certainly it may be useful to have this information for continuity of care and to make sure the patient does not forget to reveal important information, but basically the patient is expected to work to get these records when they make have trouble cooking dinner. The person in pain is supposed to nag the old doctor, whose staff is likely overworked and underpaid, until the records are pulled and copied, and then they finally are mailed to the new doctor who is merely considering taking the pain patient on as a patient.
If the new physician decides that the chemistry is off, and you are just a little too desperate, he may refuse to accept you. Heck, the doctor knows all his narcotic scripts are being monitered and is not sure he wants to be accused of not following the "standard of care."
He is already not following the standard of care or what most of his peers are doing, because he is actually treating a number of folks with chronic pain aggressively, and using doses that are well researched and safe, but not to dinosaur minds from the 1980's.
Below is a very useful article that takes the pain of patients seriously and explains that some of the impulsive things they do is because of thier poorly treated pain, not because they are murderers.
In the wonderful book, Les Miserables, we see the lead character steal a loaf of bread due to the pain of hunger. It is a shame that this illustration and the severity of his punishment applies to the DEA, state medical boards, and many ignorant politicians. It appears they would rather prevent one severe addict with no pain from tricking a physician into giving them a script, then allow 20 suffering patients to receive full pain medicine relief.
My thanks to this practical physician below who addresses those annoying actions people may do in severe and undertreated pain, which may do to get them labelled "bad patients."
I list only the terse abstract and a sample few paragraphs, please click on the full article in word or acrobat below.
Interpretation of "Aberrant" Drug-Related Behaviors
Frank B. Fisher, M.D.
Diagnosis of opioid addiction in chronic pain sufferers is often triggered by occurrence of what have been called aberrant drug-related behaviors. Ambiguities inherent in this approach affect patient care adversely. Rather than consistently signifying abuse or addiction, these behaviors are often motivated by undertreated pain. Appropriate clinical responses are suggested here, as well as a diagnostic approach prioritizing recognition of undertreated pain.
Reprint courtesy of The Association of American Physicians and Surgeons
Sample paragraphs from above:
The term pseudoaddiction was coined in 1989 to describe chronic pain victims mistakenly diagnosed as suffering from opioid addiction after they were driven, by undertreated pain, to display certain drug-related behaviors.1 Simply stated, pseudoaddiction is a misdiagnosis that results from undertreatment of chronic pain. When this diagnosis is made, the medical system has erred. Recognition that patients are frequently harmed by misdiagnosis of addiction should prompt an aggressive search for undertreatment of pain. Unfortunately, this usually does not happen. Instead, when a patient displays certain behaviors, he is typically threatened with termination of his treatment, rather than questioned about its effectiveness.
Incidence of Opioid Addiction
Over the past 25 years a body of scientific research has developed that reveals that the prevalence of opioid addiction among patients treated for chronic pain is far lower than previously believed. A multitude of studies indicate that the rate of opioid addiction in populations of chronic pain sufferers is similar to the rate of opioid addiction within the general population, falling in the range of one to two percent or less.2-12 Other studies indicate that a history of previous substance abuse isn't predictive of treatment failure in chronic pain sufferers treated with opioids.13,14 An understanding of the neurobiology of opioids makes sense of the information these studies offer. A rational approach to categorizing and interpreting drug-related behaviors follows.
Drug-Related Behaviors Suggestive Primarily of Undertreated Pain
Undertreatment of chronic pain should be considered first on the list of differential diagnoses when considering the cause of worrisome drug-related behaviors. Some of these behaviors include:
- Borrowing another patient's drugs
- Obtaining prescription drugs from non-medical sources
- Unsanctioned dosage escalations
- Aggressive complaining about need for higher doses
- Drug hoarding during periods of reduced symptoms
- Requesting specific drugs
- Acquisition of similar drugs from medical sources
Drug-Related Behaviors Possibly Suggestive of Undertreated Pain
When these behaviors occur, undertreated pain should still be suspected first, but these behaviors are more serious than the first set above and may indicate other problems, occurring either by themselves or in addition to undertreated pain:
- Prescription Forgery
- Stealing Another Patient's Drugs
- Recurrent Prescription Losses
If these behaviors do indicate a substance abuse problem, this should be recognized. It is important to determine whether the abused substance is opioids or something else. Often this doesn't occur because of a socially ordained predisposition on the part of physicians to automatically attribute the drug-related behaviors to opioid abuse. However, this is not a rational assumption because other substance-abuse problems have a much higher prevalence in society than opioid abuse. Correctly diagnosing substance abuse when it is present is important because a mistaken diagnosis of opioid addiction when another substance is actually to blame may result in the patient being denied pain treatment as well as treatment for the real substance-abuse problem.
Behaviors Suggestive of Opioid Addiction
The occurrence of the first two behaviors listed below leaves little doubt that the patient displaying them is engaged in abuse of opioids, but the occurrence of these behaviors does not preclude the existence of a true pain problem. The third item, sale of prescribed drugs, is the most flagrant form of diversion. This may indicate addiction to opioids or the abuse of some other substance, or it may simply reflect a profit motive. The problematic behaviors are:
- Injection of substances prescribed for oral use
- Concurrent use of related illegal drugs
- Selling prescription drugs
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