Saturday, September 15, 2007

Drug-Seeking 101

In this video, "Nurse Bob" shows drug-seekers what they need to do to score drugs in the ER. I can't tell whether he's being serious or just joking, maybe he's just trying to be ironic, but I think there are a few lessons for people with real chronic pain in this video because it says a lot about how we are perceived when we come into an ER or doctor's office complaining of pain. He also illustrates a certain behavior many people with cp have that can exacerbate chronic pain.

In the video, Nurse Bob shows you how to get in and out of a chair if you want to be taken seriously by ER staff. I have seen many people with chronic back pain over the years and they do tend to get in and out of chairs like this and I have an interesting story that shows why that's a bad idea.

I have a friend who I met in a chronic pain support group whose primary problem is (or was) severe upper back pain. She had struggled for years with it, went to PT, multiple doctors and had multiple tests done, and of course when they couldn't find anything wrong told her it was all in her head, was the result of repressed anger, stop exaggerating your pain...da da da, da da da. One of the most difficult things for her was getting in and out of chairs, which was extremely painful, and a lot of times it would take multiple attempts for her to get out of a chair, which was painful to watch. She used to lift herself out of her chair with her arms by grabbing the armrests just as Nurse Bob demonstrates in the video.

One day, we had a Feldenkrais practitioner come and give a lecture to our group, and she observed the way my friend got in and out of chairs. Turns out that lifting yourself out of a chair like that is extremely inefficient mechanically, as you are literally lifting almost your entire body weight with your arms, in an extremely awkward position, and then trying to stand up from this position. This places enormous strain on your upper back which can lead to chronic pain problems. The instructor showed my friend the proper way to get out of a chair, which is not to lift yourself slowly with your arms, but to lean forward, placing your center of gravity over your knees while placing your hands on your knees, and then lift yourself up using your legs, rather than your arms, in one smooth motion, maintaining forward momentum as you do so. Your arms should play little role in lifting you up. My friend began to practice getting out of a chair like this, and within three weeks the chronic pain problem she had had for years was gone, and she hasn't had problems since. After all those years of seeing the "experts" at doctor's offices and PTs, no one ever noticed that the way she got out of chairs was extremely problematic, even though difficulty getting out of chairs was her primary complaint in addition to pain. If Nurse Bob is right, if she had gotten out of chairs correctly her pain may have been dismissed.

The moral of the story here is that doctors and PTs don't know everything, and you really need to be proactive and educate yourself about all the alternatives and be aware of factors that can perpetuate or cause your pain. Don't just wait for some doctor to find the answer for you, but engage in a little "solution-seeking" behavior.

Secondly, there is the issue of chronic vs. acute pain. Nurse Bob is correct when he says that doctors and nurses are more suspicious of people who've had pain for a long time than someone who just injured his back moving something heavy. You see this all the time in ER blogs, with doctors complaining of people with chronic pain as opposed to acute pain coming to the ER, as they figure you should have had enough time by now to find a physician to help you, and if you are coming to the ER, it is either because you were too lazy to look for a primary care doctor, or you just got fired by a doctor for a drug abuse issue. The possibility you might have a severe acute exacerbation of your chronic pain escapes many of them, so if you're ever forced to go to the ER, you might want to emphasize that the pain your are dealing with is a lot worse than usual and be specific if there is a causative factor, like you slip and fell.

Either way, they don't look too kindly on cp'ers in the ER, so the best advice here is to avoid the ER like the plague if you have cp, unless you simply can't take the pain. Try and find a pain specialist who understands pain, is not a shot jockey (does nothing but injections) and hopefully can see you in a timely manner. Having a good primary care is important too as you need someone to orchestrate all your treatments, because we do get sick from other things, as well.

Finally, there is the issue of keeping it simple. Nurse Bob's advice to drug-seekers is to claim a back injury and don't rehash a litany of symptoms like abdominal pain or headaches. Unfortunately, this advice applies to us, as well. Many doctors have difficulty with the idea that you can have more than one thing wrong with you at a time, and if you have multiple chronic pain problems, it confuses the hell out of them and they don't know where to begin. But many of us do in fact have complex problems and we want solutions to all those problems, and not just one of them, so this is a real dilemma. I have a very complex cp problem, and I can't tell you how many times I've seen a doctor's eyes glaze over, and then they shake their heads and stop me as I'm explaining what's wrong with me. I've learned to keep it simple. Many doctors can't handle complexity, which is why they reach for simplistic explanations of complex problems, like "psych case," or "drug-seeker."

If you have multiple chronic pain problems, but are in the ER because you just slipped and re-injured your back, try to keep the focus on your back and don't go into excruciating detail about everything that's wrong with you. If you need treatment for everything that's wrong with you, try to find a doctor who can walk and chew gum at the same time. Even with a sympathetic and competent physician, you might want to compartmentalize your problems, and deal with specific pain issues one at time with your doctor rather than throwing them at him in one shot.

I don't think Nurse Bob's intent is to encourage drug-seeking. He is simply acknowledging the reality that drug-seekers exist, and is trying to streamline the process of dealing with them to make it easier for all parties concerned. It is a purely pragmatic approach. We too have to acknowledge reality, and must learn what is expected of us by doctors, what attitudes or behaviors can make or break our medical care, and adjust our behaviors accordingly. Doing so is not manipulative, nor is it a surrender to the unfairness of this system, or acquiescence to the abuses we so often encounter. It is simply dealing with reality, and that's the real lesson you should get from Nurse Bob's video.


Anonymous said...

Nurse bob looks like Dr. House! It would be interesting to know if this guy is really serious. Great blog, very interesting!

Payne Hertz said...

Thanks. I think he is just being pragmatic. There is a problem, and you can complain about the problem or try to hurt people with this problem, or you can try to adjust to reality so that everything goes smoothly for all concerned. He is taking a practical, humane approach and it would be well if the system as a whole could just wake up to the fact that addiction is a reality and the addicts aren't going anywhere anytime soon, so stop treating them like rapists and murderers and deal with it.

Anonymous said...

"Many doctors can't handle complexity"

are you kidding? listen to yourself.

when you get so worked up that you start making absurd comments like this, it's time to take a deep breath and step away from the keyboard for a while... go pop a pill or something constructive like that.

Payne Hertz said...

"Many doctors can't handle complexity"

are you kidding? listen to yourself.

when you get so worked up that you start making absurd comments like this, it's time to take a deep breath and step away from the keyboard for a while... go pop a pill or something constructive like that."

Physician, heal thyself.

When you make 4 anonymous comments on multiple posts in a row, each reducing people with chronic pain to a cardboard caricature, it tends to make the rest of us think you are unable to handle complexity. Any understanding of your patients beyond pill-popping, drug-seeking wusses in need of a shrink who need to shut up and get over it seems to be beyond you. Unfortunately, it seems to be beyond a lot of your colleagues, as well. I stand by my statement.