(originally posted as a guest blog in Redwood’s Medical Edge)
During my first week of practicing emergency medicine, I remember seeing an elderly woman wearing a baggy blue dress with lace around the collar.
“Doctor, I’ve passed another kidney stone,” she said.
My senses perked. Was this a drug seeker? Renal calculi—kidney stones—are among the most painful ailments known to human beings, like red hot ice picks thrust into the flank over and over again, but there she sat smiling. Marine drill sergeants cry with kidney stones. She must have taken me for an easy mark.
“I see,” I said. “Are you looking for some medication, ma’am?”
“Oh, no,” she said. “I have these all the time. I thought you might like to see it.”
Out of her cloth handbag, she fished a chunk of coarse roadbed gravel and placed it in my hand. Coming up the hospital driveway that muggy Sunday morning I had driven by a pile of similar stuff
“You can keep it if you like,” she said.
Since then I’ve seen hundreds of patients feigning illnesses, but unlike the lady of the road gravel, they want something more than a smidgeon of attention and sympathy. They may have headaches, back spasms, abdominal cramping or severe pelvic pain, but kidney stones do remain a common theme. And, unlike her, they are writhing and wincing. When asked to give some urine, they may prick their fingers and squeeze a drop of blood into the sample so the dipstick comes back positive.
The typical drug seeker will have a history of some genuine disease characterized by recurrent painful episodes, indeed just like kidney stones. Other such conditions include migraine headaches, lumbar disc disease, fibromyalgia, inflammatory intestinal disorders (for example, Crohn’s disease), and pelvic problems such as endometriosis and interstitial cystitis. Their doctors once gave them lots of narcotics to combat the real agony of their disease, but along the way, and for reasons we don’t completely understand, an unfortunate handful became narcotic-dependent and are now driven to replicate the same medication-induced sense of well-being, with the pain minimal or absent. In the jargon—these patients are now all about secondary gain.
The suspicion you’re dealing with such a patient generates a swirl of negative emotions in the healer. You don’t want to reinforce their addiction and you sure as hell don’t like being lied to and manipulated. But, on the other hand, you want to give everyone the benefit of the doubt and you realize that in their own way they are suffering. You just do not really know how much is pain and how much is . . . whatever. And, Lord help the healer who pigeonholes a drug seeker and misses something real. Drug seekers get sick too.
So you examine them carefully and maybe run some tests, and you look for the usual clues. Drug seekers are often frequent users of the local EDs. They’ve had multiple work-ups that never reveal anything new. If you’re blessed with the ability to look up records at other facilities on the Internet (an innovation which can’t come too soon), you may discover they were in the ED at a hospital down the road just last week, and forgot to mention it. They are “allergic” to all the non-narcotic pain relief options and they know exactly which narcotic on the menu works best. They demand it IV and require amounts that would kick most opiate virgins into a coma.
I know some healers who pretty much give in and give the drug seeker whatever he or she wants just to sweep them out quickly, and who may even discharge them with substantial prescriptions for more narcotics (a real mistake). Other healers get angry at them and point to the door. Most of us are in the middle somewhere, but it is never happy. At some level, you always feel like a drug dealer. I assuage my conscience by counseling them on the dangers of secondary addiction, and try referring them to pain centers. I’ve also stopped calling them drug seekers. They are chronic pain patients, which removes some of the tendency to pass judgment.
Regarding the danger of cynicism, not long ago, the doctor going off duty passed me a back-pain case. His plan was to give this young man—who’d visited an urgent care center the day before with the same pain and who admitted to a past history of heroin abuse—a single shot and send him packing in the hope he wouldn’t darken our doorway again.
Sounds like a drug seeker, right? Wait a minute. How many drug seekers volunteer a history of heroin abuse? That’s a pretty dumb drug seeker, or a pretty rare instance of honesty. I sat down and listened to his story, got a sense of his personality and observed the concern of his girl friend, then I re-examined him and ended up ordering a CT. He had surgery the next morning for a massive, acutely herniated lumbar disc.
Then there are the true professional patients—few in number and slippery—who ply their ailments to score drugs for the street trade. One patient I recall from many years ago made the circuit of EDs from Florida to Virginia. He had a draining bone infection—chronic osteomyelitis of the tibia—from a motorcycle accident . If he took his antibiotic, the wound would start to heal. If he stopped taking his antibiotic, the wound would boil and drain pus. He could literally shut it off and on like a faucet.
It was very hard to argue with such an ugly wound, and he reeled me in like a six-foot long catfish on Valium. Then I saw him again a few months later at an ED on the far end of North Carolina. With a different name.