What a pain.

by Your ER Doc on March 5, 2009

overdose drugsNarcotic medications are a big problem in every ER I’ve worked in.  They are powerful medications, and can cause tolerance when used chronically.  We get a lot of patients in the ER who want refills of their pills, and I have heard some far-fetched reasons why.  Lost or stolen pills is pretty common, and one that I hear occasionally is, “I accidentally spilled my pills down the toilet.”  Come on.  Does that really sound believable to anybody?

One thing that continues to surprise me is patients who come in to the ER with a narcotic overdose, but are just awake enough to ask for for more pain medications, usually by name.  One moment completely asleep, then, eyes barely open, asking for a dose of dilaudid.  Umm, no.

Like most ER’s, we use a pain scale from 0-10, to gauge how much pain patients are having.  Seems like 10/10 is the most common response, but sometimes it’s even higher.  One of my former colleagues (not known for subtlety) would become irritated when he got a 10/10 pain level from a patient.  He would roll his eyes and say “Oh really?  So I could take a chain-saw and chop your legs off, and you wouldn’t even notice because you’re having so much pain?”  Really sensitive.  He had various other horribly painful examples to use depending on his mood.  “So if I dropped you into a bathtub full of scorpions, you wouldn’t even notice because of your ankle sprain?”

This same doctor liked to sneak up on patients to see if they appeared to be in pain when they did not think they were being watched.  He would literally creep around the corner, on his tip-toes and then pull back the curtain just a smidge.  If he thought they were faking their pain just to get narcotics, he would be livid.  Come on man, what are we?  Twelve?

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Opiate overuse and Michael Jackson: Time for the pendulum to swing back? | Your ER Doc
07.12.09 at 6:08 pm

{ 17 comments… read them below or add one }

rositta 03.05.09 at 9:35 pm

I have the opposite problem. My Rheumatologist gives me more drugs than I could possibly take. Just recently we switched from percocet to fioronal for migraine and I didn’t check the scrip until I was in the pharmacy. She prescribed 100! I told the druggist forget that, give me 25, that should last a year. It is way too easy to become addicted but some people just can’t help themselves sadly…ciao

hannah 03.08.09 at 5:52 pm

I dropped my anti-depressants down the toilet once. By accident.

Other things that have ended up in the toilet:
a twenty dollar bill
my cellphone
my car keys (xseveral times)

Rogue Medic 03.09.09 at 5:16 pm

I don’t think it is being immature, but a part of the assessment that your colleague considers to be important. I have protocols that forbid treating a patient with less than a Glasgow Coma Score of 15.

If a patient truly has 10/10 pain, are they likely to be fully oriented?

Consider a patient on fire.

Name, Time, Location?

Does the person with 10/10 pain even care?

MLP 03.09.09 at 7:52 pm

Yeah, I’ve heard some crazy stuff. The past 2 weeks I had 2 different patients who came in via ambulance for back pain about an hour after they were discharged from our ER! What the heck? It’s always important to make sure they do not have organic disease before disposition without anymore narcs.
I talk about Cauda Equina syndrome in the link below…


Thanks for the blog.

SeaSpray 03.09.09 at 10:13 pm

Kidney stone. A stuck kidney stone distal ureter is 10 worthy.

Chainsaw..sawed off legs?

Kidney stone trumps that.

I think the shock would inhibit the chainsaw pain.

Kidney stone..no shock..just hideous…worse the labor pain… plus vomiting.

BTW and the narcotics… must help..but pain comes right through the meds.

(I know y’all take the kidney stones seriously)

Heck the pain is a 25! I’m teasing. I know med people get squirrelly when they hear numbers over 10. ;)

Nurse K 03.10.09 at 7:26 am

I understand your colleague…it’s irritating and demoralizing to constantly be manipulated and used for things like narcotics or whatever the patient is addicted to. Regardless, even the FDA has come out telling people not to prescribe narcs for twisted ankles and stuff like that recently. At least your colleague cares about appropriate prescribing practices based on more than “the pain is whatever the patient says it is.” Some doctors at my ER will literally prescribe narcotics for anyone who rates their pain above like a 3 or 4 for any condition, even if the patient doesn’t want narcs.

PS–Fiorinal/percocet for migraines? Eek. Rebound headache choices from Hell right there (if you’re getting them frequently) as well as a first-class ticket to addiction.

Jones 03.18.09 at 4:43 am

Actually, what really bothers me about ER Doctors and nurses, is that they are 30 years behind the rest of medicine in terms of pain management. Nurse K — the appropriate standard of care, in acute situations, IS to accept at face value that “the pain is whatever the patient says it is.” It is NOT acceptable for an ER doctor to attempt an investigation designed to evaluate the veracity of the patient’s self-statement. Hypo: Patient rates pain level 9/10; Doctor cannot diagnose any condition that would cause any pain. Outcome: Doctor must continue assuming that the 9/10 level pain exists and is coming from some other source. Provide narcotics in reasonably high doses as one would for an honest patient experiencing 9/10 pain + NSAIDS. Refer to f/u by pain team. Oh, and by the way, all of these rules apply even when you have a real basis for believing the patient is an addict. Even addicts suffer (non-withdrawal related) pain. Follow the same protocol, and make sure you get addiction psych/pain team in on the treatment for f/u.

Chuck 03.25.09 at 7:24 am

I have occasionally dropped a pill in the sink, and the sink is still wet, and the pill starts dissolving immediately, so I toss out that pill. Also in the 1960′s and 1970′s it was common to have this box on 2 legs above the toilet. It was used to store medications because it would be (conceivable) out of the reach of children who had not learned to climb the toilet. Those are still in use in some old houses. But, in general, the “I dropped it in the toilet” excuse is weak. Especially for anyone under age 50.

Bronnie Thompson 03.31.09 at 11:58 pm

I can appreciate the difficulty of assessing pain intensity in ED. Trying to ‘trick’ a person to find out whether they are faking or not isn’t very helpful – but neither is using an opioid medication when the person actually has a chronic pain problem.
Once any acute medical problem is identified (if one can be found), management is more likely to be successful if it includes psychosocial management – and often this is about finding out what the person believes is going on and helping to reduce their distress through reassurance, empathic responses and helping them reduce their physiological arousal – breathing mainly! A referral to a chronic pain team will also be really helpful. I think it’s important to avoid using opioids, they have too many side effects and can actually contribute to wind-up of chronic pain. Distress can be confused with pain intensity…treat the distress and pain intensity can reduce itself.

carey 04.12.09 at 3:18 pm

I work as a medic for about 7 yrs now and we always get those pt’s with 10/10 pain and it just cracks me up when I am asking about drug allergies and the are allergic to every pain drug that does not give them the “high feeling” or even better they are allergic to cert, doses. I do know there are patients who really do have 10/10 and I am careful to watch for those but if your ankle is sprained I am sorry first you don’t need an ambulance and two you don’t have 10/10 pain. I did have a doctor tell me who am I to tell a pt what their pain is, and that all pt’s don’t feel pain the same or maybe this is the worst pain they have felt but he didn’t last to long as an ER doctor last I heard he went into private practice and is now under investigation due to his constant prescription writing of narcotics and other highly abused drugs.

Dodge Porter 07.14.09 at 10:14 am

I’ve been a paramedic for fifteen years. I am also a chronic pain patient. I love people who call an ambulance because they’re 10/10 pain and yet chatter and laugh all the way to the hospital.

Do I think people are in pain? Sure. I am one. Do I think it is the ER doc’s responsibility to “trick” a person to see if he is really “suffering”? I do not. The pain should be taken at face value unless the doctor has clear evidence that the patient is a frequent fldrug abuser/addict. If the doc thinks that there might be a problem, or has a doubt about a patient’s truthfulness, ask to speak to the prescribing physician. If a patient can’t produce a physician who’s prescribing Oxycontin, there’s something wrong there. And when in doubt, call him!

I’ve been asked a few times for my doc’s number. I’ve even had UA screen done in the ER. Do I like it? No. Do I think it’s a necessary thing? Yes.

I had one nurse tell me, “You don’t look like you’re in pain.” I responded with, “Well, I would be screaming and writhing on the floor, but I don’t have the energy.”


Spencer 08.30.09 at 8:05 pm

I and amazed at you guys, everything everyone of you have said is spot on- the dead truth. i just wish the doc, and nurses all over would feel the same way. there is no true way to tell how much pain someone is in because everyone experiences it differently and on pending conditions such as dehydration, your energy levels, so and and so forth ( not sure if those are crucial factors, but i am aware there are several factors) . You can never turn your back on a patient unless you have reasonable evidence to support that they are a full blown addict. If they are then give them 5cc of morphine and tell them that they got 30. Not sure if that would work because they would more than likely know but what do i know i am not a doc or a certified nurse. Im just a person who deals with pain alot and happy to hear the certified ones stating the truth about the release of opiates in the ER

Late Fred 12.31.09 at 1:30 pm

I, as a layman, think the problem with the pain scale is the way it’s described to the patients.

The first time I ever went to the hospital as an adult, the triage nurse asked me to rate my pain, “with 1 being almost no pain at all, and 10 being the worst pain you have ever experienced.” Well, I’d just dislocated my jaw (long story) and set it back in place by myself (even longer story), and I couldn’t remember anything that hurt worse. So I told her it had been a 10 at the time it happened, and was somewhat lower as I stood there in her ER.

I didn’t think that was the worst pain I could ever experience. I was only answering the question I was asked. It might have been more informative if I elaborated, but I was not thinking calmly and the nurse seemed busy, so I just answered literally.

I have since had worse injuries, and also a couple of kidney stones, so if that had happened to me today I’d rate the same amount of pain as a 7 at most. Yet it would be no less painful and I would be no less in need of some relief. The only difference is that my personal scale got recalibrated.

melissa 10.04.10 at 1:53 pm

Doesn’t the 0-10 scale depend on how sensitive to the pain they are in? I would be offended if I said a ten and they “made a joke out of it” You DON’T experience my pain. I do! I had a baby AND I have kidney stones, it IS SO MUCH worse then labor. I would rather have a 3 headed baby vaginally.

Dan hayes 04.12.11 at 12:19 am

I think it’s amazing how different every doctor is when it comes to pain management. I have been to the er many of times. The worst pain was a kidney stone that was just leaving my kidney and they gave me 2 percocet for the pain. Another was strep throat, and I needed antibiodics so I could work. They also gave me some sort of steroid to help with the swollen throat. They asked me what my pain was I said a low 2. Then the PA said he could give me some dilaudid(sp) but I wouldn’t be able to drive. It’s like some Drs care too much. And some don’t care. All they care is that they get paid.

jessica noble 04.25.11 at 6:23 am

yes there all true but all of the pill abuse is giving people like me a bad rep im only 27 and i have had cronic pain for year legs problems spin and now ive been dignosed with high risk HVP and now i cant get help for the pain i now have so all you addicts find a new drug or rehab and let the people have them who need them

Sam 10.26.11 at 6:37 pm

I have Crohns Disease and with this has had many trips to the e.r. usually ending up in a week long hospital stay. I also have four children which makes this difficult. Sometimes I get doctors who care about pain relief and some who treat me like a drug addict untill they get a call from my G.I. who verfies yes I’am in real pain, yes I may need another surgery. The biggest problem I have is with severe nausea. I have had an issue with an e.r. doctor who didnt want to give me nausea medicine! I guess he didnt believe me untill I threw up on his shoes. I guess I just dont understand if the e.r. doctors know I have a verifable disease…..why treat me like a drug addict. Esp if I get my pain meds from my G.i. not the er doc and part of the reason Iam there is because the g.i. sent me in for bledding and to get scans. I guess because Iam a stay at home mom my husbands works for b.p. and I dont have a medical degree so I dont matter.

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