Here's the problem, pain management, addiction, anxiety, depression...

I'm going to give you an example of the type of thing I deal with every day, and how I work through some solutions.

A patient comes to us complaining of back pain. Originally he was complaining of other problems. He's complaining of back pain today. I sat with him in the exam room. I think everybody knows what that's like, you go into an exam room and you have a limited amount of time with the health care provider. But sometimes you need a little bit extra. This is one of those days. So he's got an IV, and it's connected to antibiotics. I heard that he'd been in the hospital. He's an individual we've been seeing for some time. 

He came in today, and he's a little disheveled, hair a little out of place. He looked like he's probably hurting and that he's just not feeling well. He has this back pain, so he was slumped over a little sideways, we'll call it “antalgic”, a medical term. 

So I’m thinking, what do I have in front of me, and what do I need to do? A big question mark is  - how do I treat his back pain? 

Problem-Solving Using History, Physical Exam, and Medical Decision-Making

Let's expand the questioning. When I approach a problem, I look at  history, physical examination, and medical decision-making. Those are the three elements. We have to have those down. Within those three elements is a differential diagnosis. 

My five rules:

Rule number one, pain is a description, it's not an entity. 

Rule number two, you must have a diagnosis  - in this situation,  I don't have a diagnosis right now. Back pain, that's a symptom. 

Number three, if you don't believe in the problem and you think it's entirely psychosomatic, you can't treat it - in this case, this is not a psychosomatic problem. This guy's got a real issue going on here. 

Number four, know thy meds. Know thy meds means you check thy meds. I did some drug screens, and I did what's called a “pdmp”, I checked the data registry on who's prescribing what in this area. (I wish it went across the United States. We had a system we were working on that would do that. It's called NASPER. National All Schedules Prescription Electronic Reporting Act, signed by Bush. It just never got implemented.)

But we got what we got, and I also did a criminal background check as we do, it's a good idea. Do we change how we treat people? Not always, but it's important to know this information. With rule five, from a compassionate standpoint, I want to get rid of everybody's pain. But from a realistic standpoint I want to improve function.

This guy's not very functional. 

Do you have a fever, cough, chills? What do you have going on here? 

• Well, I had that, and I started on antibiotics.

Okay, that's helpful. What do they say in the hospital?

• Well, I have an infection in my back.

You do? Do you have meningitis, which is inflammation in the central nervous system?  (that's bad)

• Nope, it's in my bone.

Now that's odd. Having an infection in the bone is rare, and odd, and it starts narrowing the differential diagnosis. What's that diagnosis, rule two? 

There’s back pain from an infection in the bone. What is a common reason there is an infection in the bone?  Well, one of the common reasons is uncommonly seen. I have to ask those questions:

A type of systemic infection from something?

Do you have a cut, an infection from somewhere?

Are you diabetic, are you predisposed to having these problems?

• No, not a diabetic.

Do you use iv drugs?  I'm obligated to look, but you can have needle sticks anywhere. I didn't see any, but it's winter time, and I didn't do a complete inventory, but let's just say that he said no to that question.

He’s getting IV antibiotics, they were concerned, and that's staying in, it's not coming out immediately, it's been in a while. So an ongoing infection is being assessed by blood work and by individuals that are sincerely interested in his best outcome because something's up.

Methamphetamine in Drug Screen Results

I'm looking through his drug screens and I go back, and there's a couple of hints that there may be some problems. Then I got back a drug screen that says methamphetamine. He says, oh no, I don't do that. 

So I get another drug screen, that says methamphetamine. Now I have two. These drug screens are highly accurate. Crime labs use them. They use technology that is really accurate.

The most reliable thing we can take from a patient is their own description, but the most important thing we do is trust and verify.

Medical Records Show He Was Already Getting Oxycodone Prescribed

I'm going to get some records, as many records as I can. Those come at a snail's pace. We try to get them quickly, but even though this is the world of electronic health records and medical records, and you think it'd be digital speed, it's not at all.

We call for those records, but I have to first do no harm. Well, I'm looking, and I'm seeing that he's getting oxycodone from somebody. I can run down that doctor's name, and there it is - oxycodone 10 milligrams. 

He has a legitimate need. He's got a back problem and it's a painful back. So I did a urine drug screen today with nothing in there. It's a point of care cup, it's not always completely accurate, but it's pretty good.

There's no evidence of oxycodone. Where's the oxycodone? The patient said that he didn't take it today.

We probably see some oxycodone or metabolites. The metabolites tell a story. It's easy for some folks to come in and fool a drug screen or attempt to fool a drug screen by just dipping a pill in the urine and it says oxycodone. But if there's no metabolites or they are really low, it means they're not taking it. We have to know how to interpret drug screens. 

Still, we are not accusing anybody of anything. We have got to take care of this guy, he has a legitimate need and legitimate pain. I don't want to hurt him and he's getting meds from another source. We've got a couple appearances on the drug screens of methamphetamine  - where did that come? 

Well, you can't just look at somebody and be judgmental. You've got to use the skills you have and your educational experience to better help the individual.

Let's just say there were some IV drugs, or some drugs somehow, that got this guy infected here. The next question is, what else is getting bothered.

If somebody does use IV drugs, and it's a contamination issue or a process, what else am I going to look at? We got to make sure the kidneys are okay. We've got to make sure everything else is okay, the brain's okay., he was talking fine, good orientation. Has he had an echocardiogram?

Well, I don't know that, so I got to talk to the primary care. So I'm going to put a call into primary care. I don't know who the other individual is that was writing for all this oxycodone, but this individual has a patient care agreement with us that they'll only obtain medication from us, one source (pharmacy). If there's a problem, they'll communicate with us. We're pretty clear on that, and this didn't happen. So that, coupled with the fact there's nothing in his urine, we have some questions.

I Did Not Prescribe

So what did I do? Well, I did not prescribe to him. First of all, he has meds, or should have meds. Number two, I need him to come in and do a pill count and show me where the rest of the meds are. He didn't have them with him. We do pill counts. Number three, communication. When all is said and done and the dust settles at the end of the day, communication is everything with what we do.

What we do requires a clear understanding of how to take a foundation of information, do no harm, and move to the next level. He's got an IV, he's got a problem, let's look at other potential problems.

Number four, we have to reduce the risk to the community -  is that medicine being diverted? I don't know. We will have him come back in the next couple of days. Well anyway, incidentally, for the record, he did bounce a check. That's okay, I'm gonna see him anyway. I'm not getting hung up over that. It's just a number of events that lead us to a direction we have to go to help this guy. If it's a problem with dependence and addiction, we need to know that. If it's a problem with pain, we need to understand that, but there has to be a distinction. Lines can be a little blurred, it can be a little gray. 

I Am Going to Treat Him

Pain and addiction can be together, we have to understand the pathways and processes to best arrive at an outcome. Acute pain happens chronically and chronic pain happens acutely. One of my five rules, rule number three, if you don't believe in the disease or you think it's entirely psychosomatic or you think there's another issue, you can't adequately treat them, then refer them out. Well I'm gonna treat him, and I believe in the guy. I'm going to do what I can to get him to a better place and that's what I do.