I had seen the prior notes. She has all the markers. She has an underlying, painful diagnosis. She has recurrent pain for which I have no good long-term treatment. But, oh, do I have a great short-term treatment. A short-term treatment that ensures repeat business. That sweet, sweet nectar known as 'dee-luadid'. Ask for it by name at your local emergency department.
She has pain contracts. She has pain clinics. She splits them; those 'bad' doctors who don't listen to her, that she has fired in the past. Perhaps she fired them in order to redress the power imbalance, to make it feel less like they're the dealer and she's the mark. Her GI doctor, of course, has deferred to PMD, and she says the PMD has told her to come to the ED for pain control. This may, or may not, be true. Either way, she's here.
I have nine other patients in process. A huge stroke, intubated in the trauma bay. A small, real stroke, in a nice grandmother of a colleague. A dislocated lens. A sodium of 117. A short-of-breath dialysis patient with a pressure of 220/110, wheezing. My pant leg is covered in urine from a spilled urinal that, thankfully, was dilute and not infected. This woman needs to go.
I don't fight the good fight. I cave. I write the script, for a small amount. She requests the methadone, and thankfully I do not have the special license for that. I'm her dealer. And, I've essentially ensured she'll return.
For the same reason that I caved and wrote the prescription, I shake her hand. Head down, I excuse myself from the private room, noting how easily she moves around, how her voice is clear and she shows no sign of distress. I try to mentally wash my hands and move on.
We're creating a new epidemic of drug abuse, and shifting people from street drugs to our own supply. Certainly, in some ways that's safer than before; but I don't remember them talking about this feeling, this dirtiness, when they reminded me a gazillion times in medical school to track the patient's pain on a ten-point scale and always address their pain to the point that a number from 1 to 10 is supposed to rival their heart rate, temperature, or pulse oximetry in importance. Imagine that. Pain is treated on a par with oxygen.