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.

More on Drug Seekers

In a recent post I talked about how certain online depictions of the "drug-seeker" have taken on the characteristics of an urban legend. While I stand by my remarks, I want to make it clear that I do recognize that drug seekers actually exist, and that they can cause a lot of headaches for doctors and nurses, particularly at times when there are real crises going on. But urban legends are not necessarily completely false; sometimes they are based on actual events or have a grain of truth to them, but they rise to the status of urban legend when that truth gets blown way out of proportion or becomes a self-fulfilling prophesy as confirmation bias sets in and people who are guilty of nothing but displaying one or more characteristics associated with drug-seekers find themselves branded and denied treatment. The reality of drug-seeking has clearly been grossly exaggerated, and due to the problem of confirmation bias, any evidence that a particular person or group of people may not be drug-seekers is discarded, and any "evidence," no matter how tenuous, that the same person or persons are drug-seekers gets reinforced and exaggerated. Confirmation bias is, of course, the basis of bigotry.

But like anything else, there are two sides to every story. We have doctors saying they are inundated with drug seekers, and cp'ers saying they are being falsely accused of drug-seeking and denied treatment as well as being blacklisted. I know without the slightest doubt which of these two events constitutes the greater crime, with denial of treatment being utterly barbaric and drug-seeking amounting to a nuisance, but my opinion on the validity of either viewpoint naturally tends to be biased towards the experience of cp'ers because that is what I know, and because I have experienced what they talk about myself.

But in a recent Usenet debate where I had posted my article "Drug Seekers: an Urban Legend?", a poster named Trisha provided what I thought were very balanced responses to some of my comments which I think are worth repeating here. Trisha has the unique perspective of having been a nurse for many years and experiencing drug seekers firsthand, as well as being a chronic pain patient and experiencing the problem of being falsely accused of drug-seeking and treated contemptuously by the medical profession. I feel her comments provide a much-needed perspective from the middle ground. The comments with the > thingies are mine:

"Even with a letter from my neurologist and approval from my pain management specialist, I've been refused care at an emergency room locally because they thought I was drug-seeking. Never mind that I have documented allergies to NSAID drugs, and that I'm already on Methadone for my pain....they offered me Toradol, an NSAID, or nothing. They said they'd call the neurologist and talk to him, but they weren't changing their minds. Then they had the balls to bill me for "services rendered." What services? The laughing and talking behind my back they didn't think I heard? The snide comments? The implication that I wanted to get stoned? The suggestion that even with a pulse of 136 and a blood pressure of 147/110 I wasn't in pain? Sure. Let me run right to the bank and get your money. Okay. NOT!

> Viewing so many people as drug
> seekers is really the result of ignorance and bigotry, and is
> unscientific. But to treat everyone contemptuously and to deny
> treatment to people on the basis of one's experiences with a handful of
> people is simply uncivilized.

I'm trying to think of how to put this...so that it makes sense to someone but me...
If you go to a place, any place, and there are 586 people acting well, and behaving, and being civilized and such, and one creep is a blathering drunk, yammering at the top of his/her lungs, making inappropriate comments, falling over things, reeking like a brewery... At the end of it all, are you going to remember the 586 well-behaved people, or the jerk? What sticks out more in your memory? "Hey, remember the time we went to ------ and there was that one guy falling all over the place? What an idiot!"

It's not really ignorance. It is bigotry. I will agree with that. It's the cumulation of outstanding and memorable experiences. As an oncology nurse I witnessed the death of hundreds of people, but only a handful stand out in my mind 10 years after leaving that field. They were different. Mostly good different, but different nonetheless.

I agree it's uncivilized, but our society seems to be heading in that direction anyhow. Witness road rage. Where has traffic courtesy gone? How about the Visa commericals where people paying with cash are looked at as holding the line up? It's not so much about being kind or considerate any more...it's each man/woman for themselves, and, yes, that has invaded healthcare just like everything else, and it sucks. I can't argue that point. It also sucks when I go to the grocery store and the cashier acts like she's doing me a favor by ringing up my groceries, forgetting that it's the shoppers that pay her wages. It stinks when someone in a big old nasty Navigator or Hummer thinks that because they are in that behemoth on wheels that screams, "I'm rich and you're not!" and I'm driving a (gasp!) used minivan that they have the right to cut me off, whip in front of me and slow down, or weave into my lane, all the while gabbing on the cell phone, reading the newspaper, and yelling at the kids watching a DVD or 3 in the back seat because they don't have enough time to spend with their kids and choose instead to pacify them with things.

> I suspect there are
> a helluva lot more crooks and creeps in the medical profession,
> percentage wise, then there are drug addicts among cp'ers.

Again, point taken. However, the loud obnoxious ones are the ones that make an impression, and they taint the memory and attitude, and it rolls over to the next person in chronic pain, and if you're already overstaffed and having a bad day, you get cranky and short and take it out on someone who doesn't deserve it. I'm not justifying it. There is no justification. None at all. We need to take each and every person at face value. But we don't. And it's not the good nurses and doctors that get the kudos...it's the jerks and idiots and creeps that treat people like objects that make the news. I know lots of nurses, including myself when I was still able to work, who treat(ed) patients in pain with dignity and humanity and respect. There are many, many of them out there who truly care about a patient who is hurting and who do whatever they have to do to get the pain under control, even if it means fighting with an arrogant doctor at 3 in the morning until he gives the order for the medication the patient needs. And yes, I've done that. I've gotten docs so mad they got out of bed and came in to see for themselves that I was telling the truth. That doctor ate his words because he had nicked the patient's liver during surgery and I saved his life because he was bleeding to death. But do you hear about those nurses? Nope...not often enough. You hear about the ones who act like they never learned a social skill in their lives.

The whole thing sucks. I can't agree more. However, my original point stands...there are, indeed, drug-seeking patients, and they raise hell till they get what they want, and they hospital-hop, and the docs will eventually treat them to shut them up, and they are the ones that leave the impression on people and make them wary of dispensing pain medication to people who truly need it for relief and not for a buzz or a high. It's not right. I won't argue that. But that's how it goes.

~shrug~

Trisha, feeling crappy again (or is that still?)"

The Drug-Seeker: an Urban Legend?

I doubt there are many people involved in the wonderful world of chronic pain on either the treatment side or the lack of treatment side who haven't heard of that malicious and devious creature known as the drug-seeker. Depending on one's point of view, he is either a Svengali-like manipulator able to hypnotize even the most jaded doctors into forking over Vicodin by the jugful or a pathetic, toothless rube claiming to be allergic to every drug known to man except that one beginning with a "d" (Dilaudid, or Demerol). To hear some doctors talk about it, it seems that everyone with pain is either a drug seeker or a wuss who couldn't handle a paper cut without an IV morphine drip. But it seems the drug-seeker is universally blamed by both doctors and patients alike for the hostile and negative attitudes people with chronic pain routinely encounter from the medical profession.

One of the interesting things about the drug-seeker phenomenon as it is often described on many medical blogs is that you often read accounts of drug seekers that are remarkably consistent from one blog to the next, as if everyone has encountered the exact same guy using the same pathetic story to scam for drugs. Usually, it will be an ER nurse or ER doctor talking about a guy who claims to be allergic to "Tylenol, ibuprofen, and every other NSAID, and Toradol doesn't do it for me; but I can take Vicodin and that other drug that begins with a "d"...uh, I had it the last time I was here...what's that thing called...oh, that's right! Dilaudid! (or Demerol, both powerful narcotics). If you read medical blogs a lot, and I do, you will likely encounter some version of this story with only minor variations.

In fact, this story is so common that someone has even begun marketing an assortment of magnets and buttons on cafepress.com with a guy in a hospital gown voicing this very story!

The caption reads:
"YEAH RIGHT!

Well, I hurt my back about three months ago and heat and ice just aren't cutting it. I'm allergic to Tylenol, Ibuprofen and Naproxen and Toradol just doesn't work for me. I had really good luck with that one medicine I got the last time I was here. What was it called? It started with a "D". I think.. Does Demerol sound right?

It starts with a "D" all right!
DRUG SEEKER!"

The thing about this story is that it's obvious that anyone actually using this line is going to earn himself a one-way ticket onto the blacklist and can forget about ever getting drugs in that hospital again. No doctor would be likely to give meds to a guy like this particularly as they all claim to have heard this story a million times, so you would think that by a simple process of evolution the drug scammers would either put their heads together and come up with a better spiel than this, or would be forced to give up on trying to score drugs at the ER.

Yet according to the DEA, drug scammers are so sophisticated that there is allegedly an "epidemic" of prescription drug abuse and diversion going on, and drug seekers must therefore be quite skilled at obtaining drugs (of course, the DEA is full of crap, too, but I digress). This is particularly true as most people with real chronic pain problems report incredible difficulty getting doctors to take their pain seriously and prescribe any painkillers at all, let alone an adequate dose, and frequently report being accused of drug-seeking or of being whimps who can't take pain. If soaking your spear with the blood of your first "drug-seeker" is a rite of passage for many docs, being falsely accused of being one is a rite of passage for people with chronic pain.

In truth I can see how a sophisticated drug addict who knows how to play the game would have a far better chance of getting pain meds than some poor girl who has never had severe pain in her life, but one day injures her back and limps into the ER complaining of severe pain. She naively says she's allergic to NSAIDs, but her friend gave her an OxyContin that worked great for the pain, and "can I have one of those?", not realizing that she just signed her own arrest warrant and won her doctor $50 bucks from the "first drug seeker of the night" pool.

So I would imagine anyone actually dumb enough to use a story like our poster boy above would more likely be a legitimate chronic pain patient who doesn't know any better than a scammer, and that this archetypal drug seeker you encounter on so many many med blogs is in reality just an urban legend, stitched together like Frankenstein from bits and pieces torn from real people with real pain who were too naive to know they were walking into a minefield when they stepped into their doctor's office and used the "P" word for the first time. It is highly improbable that so many different doctors, in so many different places, would have had so many encounters with this many individual patients who all presented with almost identical stories.

Snopes.com, the noted debunker of urban legends, defines urban legends as:

...narratives which put our fears and concerns into the form of stories or are tales which we use to confirm the rightness of our world view. As cautionary tales they warn us against engaging in risky behaviors by pointing out what has supposedly happened to others who did what we might be tempted to try. Other legends confirm our belief that it's a big, bad world out there, one awash with crazed killers, lurking terrorists, unscrupulous companies out to make a buck at any cost, and a government that doesn't give a damn.

Folks commonly equate 'urban legend' with 'false' (i.e., "Oh, that's an urban legend!"). Though the vast majority of such tales are pure invention, a handful do turn out to be based on real incidents, and whether or not something actually happened has no bearing on its status as an urban legend. What lifts true tales of this type out of the world of news and into the genre of contemporary lore is the blurring of details and multiplicity of claims that the events happened locally, alterations which take place as the stories are passed through countless hands. Though there might indeed have been an original actual event, it clearly did not happen to as many people or in as many places as the various recountings of it would have us believe.

It definitely seems as if our archetypal drug seeker story meets the definition of an urban legend, both in the sheer improbability of its being true in so many different areas, as well as the fact that it serves to "confirm the rightness" of the medical profession's "world view," which is to err on the side of undertreating pain in patients with legitimate pain problems. If you can convince yourself that everyone with adverse reactions to drugs or who requests a drug by name is an addict, you don't have to go home and hate the person you see staring back at you in the mirror each morning.

Perhaps you should.

How common is "drug seeking" really? No one has ever done a formal study of actual drug-seeking behavior that I'm aware of, but there have been numerous studies on the incidence of actual opiate addiction in chronic pain patients and in the general population as a whole, and every study I am familiar with show very low rates in both groups, the highest estimate being less than 3 percent for cp'ers using a rather bizarre definition of "opioid use disorder," whatever the hell that is, and 1 percent for the general population. So it is really hard to see where this legion of Toradol-shunning Dilaudid zombies is coming from, given the naked facts.

But facts are things that are readily discarded whenever they prove inconvenient in the world of medicine, just as they are in the rest of our world. Far better to cling to convenient half-truths and urban legends if they make you doctors feel better about yourselves, because after all, it's all about you. Most likely, there is at most a small minority of pain patients who fall into the category of drug-seeker and a very large majority of people with legitimate pain problems being falsely accused of drug-seeking out of ignorance and bigotry. Many of those people are forced into the role of drug-seeker by the very fact that doctors are reluctant and unwilling to treat pain aggressively, thus it becomes a self-fulfilling prophesy. If a guy shows up in your ER with excruciating pain and you give him 10 Vicodin, why are you shocked that he would add a "zero" to the "10?" What choice did you give him? Maybe if you had treated his pain appropriately with an adequate amount of medication for the $1,600 he brought into your hospital he wouldn't have had to do that.

But that fact is just too inconvenient for you to hear, isn't it?

Macho, Macho Man!

You know the type. The guy who drives a 6 ton pickup truck with the bed lifted 5 feet off the ground, fat tires, and a "Fear This!" sticker in the rear window. If you are 65 or older, you have probably noticed this guy driving 10 feet behind your bumper in a brazen attempt to demonstrate his manliness and ownership of the road you dared to drive on with your little 7-year-old Toyota Camry. Or you may have noticed his more sophisticated cousin, wearing a white coat with a stethoscope around his neck, telling you to be a man, stop whining, and learn to cope with the pain. It is amazing how tough some people are when it comes to dealing with someone else's pain. We should all, men and women, girls and boys, aspire to such manliness.

Having a chronic "pain" "condition" (ever notice how manly doctors always put those two words in quotes?), I have often wondered how "Real Men”(TM) cope with pain. Since the medical profession is filled with Real Men, who are always quick to impart their wit and wisdom on the ability of lesser beings to cope with pain, I thought it would be good to begin my search there, especially since they are the self-syled experts on pain and how to deal with it.

Fortunately, it didn't take too long for a good, manly doctor to oblige me, in this case the author of "Scalpel and Sword," a medblog which like many medblogs is often highly critical of all you wusses out there with your "pain." Here he recounts his harrowing tale of pain, terror and eventual triumph as he battled that bane of human existence known as the toothache:

I started to feel the pain during my 45 minute drive home. The skin over my cheek was still totally numb, but my tooth and jaw were aching. I noticed that I was becoming unusually irritated with the idiot drivers who impeded my progress to the pharmacy. I gave my prescription to the pharmacy tech (while feeling a little self-conscious about filling a narcotic). The pain was getting so bad, it began to make me nauseated, so I asked for a prescription pad so I could write myself some Zofran too. "Are you going to wait for the prescription?" she asked. I wanted to yell at her and say "Can't you see me wincing and squeezing my temples? That means yes!" But it might have made my face hurt more, so I just nodded meekly and walked away to pace the aisles....

Vicoprofen, not so amazing. There is still no way I can sleep with this much pain, even though I have only had a total of six hours sleep the past two days. But it's tolerable. Barely. If I didn't have that prescription, I would probably have to go to the ER myself, another "drug-seeker with a toothache."

Okay, nothing unusual here. Basic case of severe tooth pain, easily relieved with a mild narcotic, which we have all experienced at some point in our lives. Of course, his toothache is real as opposed to that of the "drug-seekers" who show up in his ER. But wait, the plot thickens:

The next day, my tooth began hurting again. Not just my tooth, but the entire half of my face. And not just hurting, but HURTING! I called my dentist in the afternoon, and he was nice enough to come in after hours and give me another nerve block, which totally relieved my pain....for two hours. Then it came back worse than ever. My dentist had given me some of the anesthetic to inject myself as a nerve block, but it just wasn't working. I was writhing in agony, crying out with intolerable pain.

So I went to the ER where I work, tears rolling down my face the whole way, running red lights and speeding recklessly to the hospital at 3 am (emphasis mine). My dentist had called one of his colleagues who had agreed to see me in the morning, but I just could not wait. One of my partners took pity on me and gave me a shot of Demerol which allowed me to catch a couple of hours sleep. I'd never had it before. It did help my pain, but I didn't get a "buzz" and it really didn't seem to be the sort of thing that people would malinger for. Maybe it's more enjoyable if you aren't really in pain.

Then I had the root canal, and here I sit back home praying that that horrible awful pain doesn't come back. I have an entirely new respect for dental pain, my fellow patients, and I will not make you wait ever again before medicating you.

UPDATE: Amazingly, 18 hours later, I have zero pain except with pressure on the involved tooth. I really had serious concerns that there might be another coexisting condition (trigeminal neuralgia, brain tumor, aneurysm?) that we were missing, but it seems that it all came from that rotten tooth and exposed nerve.

I had hoped Dr. Scrooge here would have had a Dickensian moment having been visited by the Ghost of Toothaches Past, and indeed he promises to never make his dental patients wait again (which begs the question why he ever made them wait in the first place). But within days of writing this post, he is back in form, swaggering with faux machismo, and accusing people with migraines, fibromyalgia and low back pain of having low tolerance for pain:

In my experience/opinion, it seems that many patients with chronic painful conditions of unclear etiology (fibromyalgia, some chronic back pain, and atypical "migraines" for example) who require large amounts of narcotics often have rather low tolerances for pain, and the true pathology may in fact be a hypersensitivity to what most would consider normal stimuli.

Ironically, these patients will usually claim that they have a "high pain tolerance" when in fact the opposite is true. They do tend to have high narcotic tolerances though. People with truly high pain tolerances don't often require narcotics at all.

So I guess the fact he needed Vicuprofen and a shot of Demerol to deal with his pain means he doesn't have much tolerance for pain himself, particularly as his toothache only lasted a few days. Now, don't get me wrong, I know that tooth pain can be severe, even excruciating, and I don't begrudge anyone, not even Dr Scrooge here, a visit to the ER for enough painkillers to get that pain under control. I don't consider it a reflection on anyone's "manliness" that they would want something for that pain, particularly as there is no sane reason not to control the pain. Scalpels' reaction, with the exception of speeding and running red lights, was perfectly normal and acceptable in my view. Here's what Scalpel thinks of other people forced to go his route:

Oh, and if a patient has multiple ER visits for other painful conditions (toothache, "migraine," back pain, etc.) that is another big red flag. Drug seekers often move from one painful alibi to another. But all of their visits involve something that hurts REALLY BAD!!!!, and often they have little objective evidence of disease or injury.

It has to strike you as rather ironic that this supposed tough guy would criticize anyone else for their ability to tolerate pain, when he basically freaked out over a toothache. When I described this story to a close friend of mine who has fibromyalgia, low back pain and who just happens to be nursing an abscessed tooth at the moment, and also what this guy has to say about fibro patients, her response was, "What a fucking pussy! I have an abscessed tooth right now and the pain of that isn't even close to my fibromyaglia and back pain! I'd like to see how he deals with my pain!" I couldn't agree more. I should point out that I also have fibromyalgia, low back pain and have just had two root canals done, and that tooth pain is nothing compared to the pain of fibromyalgia or low back pain, particularly after you've been dealing with it for decades, let alone a few days. The McGill Pain Index agrees with me, rating chronic low back pain as considerably higher than a toothache.

In all the years I have been to chronic pain and fibromyalgia support groups, I have never met a single person whose tolerance for pain was so low he would speed and run red lights to get to the ER, putting other people's lives at risk, particularly if he knew that he would be able to get treated from the moment he walked in the door, unlike most people who risk having to wait for hours in agony just to be labeled a "drug-seeker" and sent home with a handful of Tylenols. Most have the equanimity to at least wait for the light to change. Indeed, I have been amazed and inspired by just how much many of these people have been able to endure and still retain their sanity, sense of humor and an attitude of compassion towards others.

If you read some of what Scalpel writes on his site, you'll see he takes a particular delight in applying the "drug-seeker" label and blacklisting pain patients who he feels have lied to him in any way to get relief for their pain. The Wikipedia defines pain tolerance as "the amount of pain that a person can withstand before breaking down emotionally and/or physically." Judging by this doctor's panicked and frantic behavior, it is clear the pain broke him emotionally in a matter of days, even having him imagining he had a brain tumor, aneurysm, or trigeminal neuralgia.

It may take months or years of unremitting pain like that to break a person physically, but he'll have to get a visit from the Ghost of Fibromyalgia and Chronic Low Back Pain Yet to Come to find out what that's like. If this is how he deals with a toothache, he better hope and pray he never gets that visit, because he won't last an afternoon before he snaps. I watched a beloved friend with fibromyalgia die of lung cancer recently, and she dealt with that ordeal with more dignity, grace and equanimity than this guy dealt with a toothache. Though I can imagine what would have happened if she had come to Scalpel's ER complaining of fibromyalgia and chest pain. As it was, she waited for 5 hours before they took a chest X-ray, after which the ER doc casually announced she had lung cancer. Friend of Scalpel's, no doubt.

You should read some of Scalpel's comments about chronic pain and fibro patients at his site. I've given some links her for you to follow if you're interested, but for now, here are some highlights from those pages:

"The Objective Pain Scale:"
"ER Dogma:"
"The Flow Stopper:"
"Pain Management:"

Everyone's pain is 10/10, get in line. If you aren't screaming, it isn't a 10.

The longer your list of allergies to medications, the more likely you are to have a psychogenic cause of your physical complaints.

If you think you have a "high pain tolerance," you probably don't. If you think that you have a low pain tolerance, you are likely correct. People with a high pain tolerance don't even mention that term.

Oh, and if a patient has multiple ER visits for other painful conditions (toothache, "migraine," back pain, etc.) that is another big red flag. Drug seekers often move from one painful alibi to another. But all of their visits involve something that hurts REALLY BAD!!!!, and often they have little objective evidence of disease or injury.

If you are able to sit still and keep quiet, you probably aren't in as much pain as the other guy (or as much pain as you think you are in, for that matter). If you aren't screaming, it isn't a 10. If you aren't vomiting, it isn't a 9. Simple enough for me.

Annoying ranters are usually the people who have no objective evidence of disease (like many chronic painers). They tend to have multiple nonphysiologic complaints and heavy psychogenic overtones to their complaints. Fortunately, they often tend to get so worked up they leave prior to evaluation by a physician, cursing and yelling on the way out. We don't miss them. My motto is "if you are sick, you'll stay."

There is no moral or legal requirement for physicians to administer or prescribe narcotics to patients who repeatedly present to the ER, even for visible reasons like dental caries. We certainly aren't obligated to give narcs for clinically subjective conditions like fibromyalgia or migraines.

I personally don't blacklist drug-seeking patients if they "piss me off." Only when they lie to me in an attempt to obtain narcotics. Good luck prosecuting that. If they piss me off, they may just leave empty-handed, but they will still get a bill.

And all a suicide threat will get you is a psych eval and possibly an involuntary hospitalization. But usually not, because it's obvious that someone making such a threat is just being manipulative.

Perhaps its easier for someone like you (who actually has structurally identifiable causes of pain) than someone with fibromyalgia (who is widely considered to have simply a psychiatric problem) to cope with pain. But I doubt it.

I think that pain is like many other neuropsychophysiological conditions that test the human will and our ability to persevere. Some people forge ahead despite their handicaps, and some people curl up into a ball and blame society for their ills.

I think you get the picture: standard, loudmouth macho posturing from medicus fuctardicus arrogansis. You should read some of the comments from the other mouth-breathing Neanderthals at that site, as well.

I have often wondered what makes so many doctors and nurses behave with such casual cruelty to people whose only crime is they are suffering and want relief. I think Scalpel's website gives some telling insights into this kind of behavior and the root causes of it, which in my opinion is a basic insecurity about one's masculinity coupled with narcissism, sadism and fear. Women are clearly prone to this shortcoming as well. They see people coping with horrible, constant pain, and deep down inside they know they would never be able to endure pain like that and still function, so they need to convince themselves that the person is just a weakling and a faker and couldn't possibly be in that much pain. The alternative is a mature confrontation with one's own human limitations, which all of us with chronic pain have been forced to make, but that rarely happens with doctors. It's only when they've been through it themselves and have a little humility beat into them that they, sometimes, begin to see the light. There is an interesting article about the roots of sham machismo at Orcinus. This quote is from "Sara"

My first husband -- who as a Latino, a clinical psychologist, and the son of a Marine Corps drill instructor, knew a thing or two about the anatomy of macho -- used to say that the first rule of real macho was that those who possess it never need to prove it to anyone. If you have to prove it or put it out on display, you don't have it in the first place. And if you are intimidated by seeing it in others, you aren't even in the ballpark.

I may not be a "Real Man" myself, or know what a man really is. I certainly have my share of insecurities. Years of unrelenting pain have broken me physically and mentally, and I am not ashamed to admit that. I am sure there are men and women out there who are stronger than me and who could have handled my ordeal better than I have, but I dealt with it the best I could. No matter how tough you are, or how tough you think you are, severe chronic pain, left untreated, will eventually break you. Water wears away granite in time.

But I know what a real man, and for that matter, a real woman, is not. He is not someone who needs to brag, and swagger, and question anyone else's manliness. He doesn't need to abuse people in horrible pain or accuse them of being whimps or fakers, or question their ability to take pain, just so he can feel good about his own questionable masculinity. He is not cruel, or cowardly, or manipulative, but can deal with other human beings with fairness, grace, equanimity and compassion. He doesn't need a 6 ton pickup unless he's in the construction business, and never needs to tailgate old ladies. He never needs to tell someone in chronic pain to "be a man" or "take the pain." He doesn't whine about a toothache and then turn around and tell people who have dealt with the ordeal of fibromyalgia, migraines or low back pain for years that they have a low pain tolerance.

All these doctors and nurses you see out there with their adolescent macho posturing, looking down their noses in arrogant haughtiness at people who have dealt with horrible pain for years, condemning them for being "weak," or "lazy" or unable to tolerate pain, refusing to treat their pain, accusing them of being drug seekers and psychiatric basket cases, blacklisting them so they can never get their pain treated anywhere...all these guys are clearly compensating for their own inadequacies in the manhood department. And yeah, I'm talking about women, too. A sorry, pathetic lot of swaggering punks who are insecure about their masculinity, and think tough talk and cruel, arrogant, macho behavior is a substitute for genuine manliness. Sorry, assholes, but it's not.

That this behavior is so commonplace in the medical field is a sad reflection on that profession.