Unit 5  Section 1Exercise 3 The experience of addiction Narcotics
Clinical correlate #2 Narcotics addiction
The chronic pain patient
Pseudoaddiction
Tom Andrew’s book is an autobiographical account of his experiences as a sometimes reckless hemophiliac. Because of the nature of the illness, he often ends up in emergency rooms. Anyone who has waited in an emergency room knows that if a patient is not triaged properly, many hours might pass before he is evaluated. In the following, the author describes what it is like communicating his condition to the evaluating doctor. In this particular case, his main concern is having his pain taken seriously.
From Codeine Diaries, by Tom Andrews, pp73-77
Of all the transactions I’ve had over the years with doctors, the ugliest and most humiliating by far have been those concerning pain and pain medication. There is a ruthless dialectic at work in the transaction. The hemophiliac with a bleeding joint wants immediate relief; by the time he arrives at the hospital, the pain is often literally unspeakable, beyond utterance. Its wordlessness, however, is precisely what can make the doctor conservative with medication. Emergency room doctors are used to patients howling with pain, even being deranged by it. If a patient is not howling or screaming, but the same time not able to speak coherently about what he or she is suffering (sometimes on can speak coherently about anything but the pain), it’s easy for the doctor to assume pain is not a priority.
“[T]he pain of a bleeding joint is one of the worst known to medical science,” Suzanne Massie wrote in Journey. But a bleeding joint may not look especially painful. The doctor must rely on the patient to articulate the pain—at the very moment when the patient often retreats far from language. If the patient does not howl and scream, how is the doctor to understand? The patient cannot articulate the pain; the doctor cannot see it. Then again, if the patient is able to find language, however inadequate, for his or her suffering, the doctor may take that very articulateness as a sign that the pain must not be as bad as the patient is letting on. Add to all this the fact that doctors (being well aware that hemophiliacs can become addicted to painkillers) need to be cautious when prescribing addictive drugs such as codeine, Darvon, Demrol, and Percodan, and you see the dilemma.
At such times I do my best to convince the doctor that the pain is awful—usually by grunts and groans, it is a humiliating negotiation. Sometimes the doctor understands right away and prescribes serious pain medication, other times the doctor is skeptical and prescribes acetominophen, which is useless. You feel the doctor’s intense gaze, doubting you, wondering why your pain threshold is so low. You try again to make the doctor understand: more grunts. The doctor says, Yes, yes, I understand, but the prescription stays the same. You argue, using whatever methods are available to you. You become a ‘difficult’ patient. The doctor winces. The prescription stays the same. You become enraged at the dynamic of power you’re caught in. The doctor thinks—you can see the thoughts rising like cartoon balloons—the doctor thinks, It doesn’t look so bad, I have certain criteria to consider, I have certain standards, no one tells me what pain medications to administer, don’t be a troublemaker, don’t be a wussy, I’m the voice of reason around here. The prescription stays the same.
The transaction ends—quickly or after some time, depending on the emergency room doctor—with Carry or a nurse calling Sheryl, the hemophilia nurse coordinator at the University of Michigan Hospital. Sheryl quickly finds a hematologist, and he or she phones in a prescription for codeine….
What kind of scene would play itself out with this young doctor, God help him? I wanted codeine now, and I wanted to avoid conflict in getting it. I had not retreated far from language; I had retreated into an absurd language of bad jokes, thinking to woo him. As I watched him inspect my ankle and calf and knee, my spirits plummeted at the thought that I had made a terrible error. Now, I assumed, I would never get an adequate painkiller.
“How’s it feel?” the doctor asked, his right forefinger pressing very gently against the swollen knot on my ankle. The knot was now plum-colored. It went white when he pressed on it, then quickly returned to plum when he removed his finger. It was still very hot. “Not too bad, I hope.”
“It’s not good,” I said. I tried to make my voice sound as dispassionate as possible. “It’s really bad.”
“Really?” he asked.
I thought I heard derision in his repetition of really.
Yes, really,” I said.
(Had I said it too sharply? Did it wounds whiny to him as it did to me? Had I offended him? What’s the matter with me? I’ve given up bad jokes for the language of paranoia—always an attractive conversational ploy.)
Carrie saw a stand-ff approaching and stepped in to intercept it. “Show him the letters,” she said.
“Oh, yeah,” I said. I extracted two well-creased letters from my wallet and handed them to the young doctor. I carry the letters in my wallet for just such an occasion. The first letter, written by Sheryl, is addressed to emergency-room doctors. Sheryl wrote the letter so I could educate the doctors—tactfully, without appearing to—on the proper dosage and preparation of DDAVP, which most of them are unfamiliar with. “This way,” Sheryl said when she gave me the letter during one of my check-ups, “The doctor doesn’t have to suffer the indignity of being taught by a patient…And,” she added, ”all you have to do is produce the letter---at a time when you don’t feel like explaining anything to anybody.”
The doctor took the first letter and read it. The second letter narrated for the doctor the terse autobiography of my blood. [Here follow a list of laboratory values, including the following: Factor VII assay<3%; Factor VIII inhibitor none present).
“This is really interesting,” the doctor said after reading the letters. I made a mental note to thank Sheryl the next time I saw her, “We’ll set up an IV with the DDAVP, but it may take a little while for the pharmacy to make it. In the meantime, we’ll need some X-rays of your ankle. It looks like there may be a fracture. I recommend staying here in the hospital until the bleeding stops. I’ve called upstairs—there’s a room waiting for you. And I’ll get you something for the pain right away. What’s worked for you in the past?”
“Codeine,” I muttered. “Codeine seems to work best for me. Fifty or sixty milligrams."
“Codeine,” he said as he wrote the prescription. “Good. We’ll get that right away. Any questions?”
I almost wept.
Study questions
1. Comment on the following sentence. “If the patient is able to find language, however inadequate, for his or her suffering, the doctor may take that very articulateness as a sign that the pain must not be as bad as the patient is letting on.” Does this observation say anything more generally about the doctor-patient relationship?
2. Read the first pages of the excerpt from Elaine Scarry’s “The body in pain,” through page 7. How does the observation that “to have pain is to have certainty; to hear that another person has pain is to have doubt” structure the doctor-patient relationship? [LINK]
3. On page 9 of the above extract, Elaine Scarry writes about the need for Amnesty International, in its appeal to its members, to represent pain convincingly: Language must at once be characterized with the greatest possible tact (for the most intimate realm of another human being’s body is the implicit or explicit subject) and by the greatest possible immediacy (for the most crucial fact about pain is its presentness…)” How might this combination of tact and immediacy apply to patients in their appeals for help to their physicians and others?
What factors, in your view, lead health care professionals’ negative views of substance users?
4. Look up the definition of pseudoaddiction. Does this concept apply here?
Clinical correlate: approach to the narcotic seeking patient.
How do you detect when your patient is lying?
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