How do I figure out if a patient is trying to score drugs?

On a scale of zero to ten, how often do you wish you could somehow wave a magic wand and know how much pain your patient is in—zero being never and ten being every day? Four? Ten? Twenty?
ER Doc Brady Pregerson and Nurse Rebekah are ready to “go there” in the first of a four-part series on pain management.

Dr. Brady: The can of worms I’d like to open up is one that I think raises more hackles than almost any other patient care issue in medicine: the use of narcotics to treat pain.

We’re all well aware of the fact that mixed in with our usual patients is a smattering of those who are addicted to narcotics or, even worse, fill their prescriptions and then sell the drugs on the street.

Prescription drug abuse is becoming a bigger and bigger problem. But oligoanalgesia—the under-use or sometimes non-use of opiates to treat legitimate pain—is also a problem. And we doctors and nurses are caught in the middle of this dilemma.

As a physician, I read in a quarterly newsletter from the Medical Board of California about all of the physicians whose licenses have been revoked or placed on probation. This litany of doctors and their bad deeds is there in black and white as a warning to the rest of us not to stray from the path of Hippocrates.

Each month, a good part of those whose licenses are under restriction have ended up where they are through the inappropriate prescribing of narcotics. Inappropriate narcotic prescription can do more than feed an addiction; it can get you in trouble.

On the other hand, if I don’t treat a patient’s pain appropriately, not only does the patient suffer, but she’ll probably write a letter to my boss. If I mess up either way, there’s trouble.

This wouldn’t be such a big deal if I could accurately gauge pain all of the time, but I can’t. I rely mostly on what my patients say. That’s accurate if they’re telling the truth, but what if they’re lying? You can’t fake hypoxia, you can’t fake hypotension, you can’t fake hyperkalemia or rales or vomiting up blood, but it’s not that hard to fake pain. And as the Bard said, “There’s the rub.”

Nurse Rebekah: I love this hot topic. There is a continuum of people in real pain, people in fake pain, people in pain who refuse to acknowledge the pain, people in pain who acknowledge it too much…the list goes on and on. From my perspective, scaling the pain can prove to be the biggest obstacle.

I love when I’m asking a patient for his pain scale and the following scenario occurs:

Me: “On a scale of zero to ten, ten being the worst pain you’ve ever had in your life and zero being no pain, what would you rate your pain?”

Patient: “Twenty.”

This kills me! I gave you ten integers, eleven if you include zero, and you still go off the scale! You don’t get more pain points if you make up your own pain scale…you probably won’t even get a higher degree out of this faux original research because there are, like, a MILLION pain scales out there.

Or this one:

Me: “On a scale of zero to ten, ten being the worst pain you’ve ever had in your life and zero being no pain, what would you rate your pain?”

Patient: “Uh, I don’t really know…[pause]…lemme think…

[Insert “Jeopardy!” theme here.]

[Ten minutes go by.]

…uh, maybe a five and a half.”

Well, I’ve fallen asleep waiting for the patient to scale his abdominal pain, and his appendix has probably burst by now. I’m so glad he put that much thought into it.

Okay, there’s really no right or wrong answer here. Your pain can be whatever you want it to be (as long as you stay within the 0–10 range; otherwise I get irritated). I won’t yell at you if you lowball or highball your pain. IT IS YOUR PAIN. Embrace it, own it, rate it.