I just completed the new mandated continuing education for prescribers on controlled substances in New York State. It’s part of a nationwide effort to stem the opioid abuse problem in this country, which is growing exponentially. The program was very well executed with many suggestions on how to prevent opioid abuse while still treating a patient’s chronic pain. There was also information on state-specific guidelines on prescribing, many of which have become more stringent in light of the opioid epidemic. A month ago, I also completed a similar program for the state of Massachusetts where I also hold a license, and this was through Massachusetts General Hospital. This presentation featured re-enactments of typical patient encounters. They brought back some painful memories.
It was probably my second week at the community health center. A new patient (in this particular scenario it’s always a new patient), a clean-cut while male in his late 20’s, sat on the exam table. I had noticed that he had walked in stiffly past my office door, lagging behind the medical assistant and holding the small of his back. He was with his girlfriend. He said he was visiting from Florida and his back was acting up. He had been in an MVA (car accident) 5 years ago which “broke my back” and resulted in excruciating back pain which came and went. His girlfriend held an envelope which contained an xray film. His last name was written on the corner with marker. He was disappointed when I informed him we didn’t have a light table to read the xray.
His vital signs and reflexes were normal. His lower back appeared normal without bruising or redness or swelling, but was hypersensitive to the touch. He denied fever or urinary symptoms which could signal a kidney infection. He denied loss of bowel or bladder function – a red flag which would indicate an emergent condition called cauda equina syndrome, requiring quick surgical intervention. He denied prior use of IV drugs which would make him more susceptible to a bone infection called osteomyelitis.
He did say that the pain radiated down both legs suggesting sciatica. Every motion I instructed him to do hurt – bending forward, backward, twisting. Any manipulation of his leg while he was supine was painful. Even pushing down on his head while he was sitting was painful.
He said surgery was suggested for his condition, described as “many herniated discs” but he didn’t have insurance. His doctor in Florida gave him Vicodin – the generic didn’t work. Yes he tried physical therapy but it made the condition worse. He was extremely polite and kept calling me “ma’am.”
I held up my hand and began my spiel about how opioids were not the most effective drugs for pain management. I talked about how NSAID/acetaminophen in combination had more efficacy. Suggested we start such a regimen in addition to a muscle relaxant for 5 nights. I talked about alternative therapies such as heating packs or topical lidocaine. I encouraged him to speak with our advocate to start the process of acquiring insurance so that he could get his problem re-evaluated by orthopedics and perhaps start physical therapy again. I spoke about referral to a pain management doctor if all else failed.
He listened politely and then asked, “So you can’t give me any Vicodin?” I told him I was not comfortable doing that. “Well they told me you could help me when I made the appointment.” His voice started getting louder. His girlfriend started to look anxious. “Let’s get out of here, baby” she whispered. She was too thin.
“I’m not f-ing paying for this appointment.” He continued, almost shouting. “I wanted to see a real doctor.”
“They told you I was a nurse practitioner when you made the appointment. Do you still want your prescription for the muscle relaxant? If so, which pharmacy?” I kept my tone level and neutral.
He reluctantly named one and I sent it off. I got up and said I would bring back the instructions for taking the ibuprofen and acetaminophen in rotation and a referral to our patient advocate.
When I returned to the exam room a few minutes later, it was empty. The exam table paper appeared to give one last rustle in the abandoned room, like tumbleweed. 30 minutes spent on a visit allotted 15 and I still had to write the note.