Apparently these days, treating pain requires stones, or does it? See what guest blogger Dr. Morty Fein has top say…
The pain was excruciating – so intense that it woke her out of a sound sleep. The young charge nurse had finished a night shift and was in bed sleeping in the late morning. Diffuse, intense abdominal pain came out of nowhere and she tossed and turned and tried to ignore it but it simply wasn’t possible. She got up, paced the floor and finally got dressed and drove herself to the emergency room of the very same hospital wherein she had just worked a 12-hour shift. By the time she was in the ER, she was doubled over. She was quickly ushered inside and given an injection of a non-steroidal anti-inflammatory (NSAID, ketorolac, aka Toradol). A scan revealed a stone – actually several, kidney stones – with one stuck in her ureter that would have to be passed. After some hydration and feeling a bit better from the Toradol, she was told to go home, hydrate and pass it. No pain medication was given.
Passing a kidney stone is universally recognized as lying along a spectrum from unpleasant to excruciating. In pre-opiophobic times, people suffering with them were routinely given opioids to ease the pain. Concern about addiction and diversion – no matter how rare they might be in a non-addicted person who receives a handful of doses in the setting of a pain crisis – has changed the practice. Additionally, trying to make hay while the opiophobic sun shines, some particularly zealous ERs are bragging about being “opioid free.” And so, with a new, dramatically overstated sense of risk, a new form of sadism has been unleashed.
Upon returning home in the early evening, she laid down to rest. With no sleep she had to call in sick for her night shift. She tried to sleep, took some oral NSAIDs and did until late that night intense pain returned and escalated to excruciating. She woke her family and at 2am they returned to the very same ER, in her very same hospital. A second ER visit within 24 hours. A new scan, a dose of morphine, and a lecture. A male physician assistant told her that passing kidney stones isn’t as bad for women. This time after a bit of a battle, she left with a prescription for hydrocodone and a referral to a urologist. She returned home and called in sick for another shift.
This young nurse’s tale is not unusual, I suspect, and it represents a thumbnail sketch of disturbing national trends. We are witnessing misplaced and overzealous caution manifesting in near complete avoidance of opioids in what otherwise are completely appropriate settings for opioids. We are witnessing a disingenuous abandonment of attention to pain by many practitioners who wouldn’t need bamboo stuck under their fingernails to be pushed to screaming “good riddance.” We are witnessing a shocking loss of empathy. And we are witnessing a resurgence in sadism that was first called out by the late, great Sam Perry in 1980. But that’s not all. It is not just sadism, it is costly sadism.
This nurse missed 2 shifts due to pain and exhaustion (that’s not to say she would have not missed any work with pain this intense even if treated, nor should she, an opioid inexperienced individual, be reporting for duty newly on hydrocodone). But it is emblematic of the bigger issue of loss of productivity in those poorly treated for acute and chronic pain. Her family saw her suffer and families across the country are seeing people with pain terrorized and terrified. Pushed to the brink of suicide. I have often thought that it would be worse to watch my loved one suffer than suffering myself. The young nurse’s pride and faith in her own hospital was shaken.
And her pain caused her to generate double the medical costs for the episode. Data are lacking as to how opioid time, dose and supply limits are affecting costs, let alone opioid avoidance. Extra office visits, extra ER visits, additional drug and procedure costs all justified in some people’s minds if the risks are so dramatically overstated, but the costs, I imagine have gone through the roof in some instances.
Maybe that in the end will lead to better, smarter, opioid policies and elevating the standard of care. If certain parties don’t care much about the human costs, they may be swayed by the healthcare costs.
We need change. We need empathy. We need compassion. Some of us need opioids. Perhaps with some improvement, we will all sleep a bit better at night.
As usual, comments are welcomed with enthusiasm!