Post-partum drug-seeking behavior
Jan 8th, 2008 by Terry
On call this past weekend, I was paged to the post-partum floor to evaluate a young woman who had vaginally delivered a healthy baby boy 16 hours ago. Her chief complaint? Intractable back pain.
[Background: She had delivered 2 babies aided by an epidural block in the past, and complained of back pain during this pregnancy, which she totally attributed to her previous epidurals. She admitted to no previous social or drug abuse history in the past. When she arrive to our hospital in labor, and it was determined that she could have an epidural, the CRNA covering OB tried multiple times, unsuccessfully, to insert one. Both the nurse anesthetist and the anesthesiologist were unable to locate the epidural space. She had what is known as a “difficult back” in our business. She went on to deliver naturally.]
But now, despite 4 Ibuprofens, 2 Tylenols with Codeine, and 2 Percocets, she was still complaining of back pain. I was summoned to see her.
Her pain was completely localized to where her needle punctures were (lower lumbar back), and the area was painful to touch. No redness, no swelling, no bleeding, and no pus was observed. She had no numbness, tingling, or weakness in either lower extremity. She denied headache, stiff neck, or blurred vision. She ambulated in the room without difficulty, and had encountered no problems voiding or moving her bowels.
She claimed to have back pain throughout her pregnancy, but not like this. When she told me that she wanted something liquid like Morphine for the pain, I blinked. When she said that that’s the only thing that helps her when she has bad pain, I blinked twice. Then she told me that Morphine is what they gave her once when she came to the hospital with bronchitis. Blink. Blink, blink.
Direct quote: “I just want to feel knocked out. None of those other drugs are helping me.”
If her pain persists or worsens, she will undoubtedly undergo some radiologic studies and a neurological evaluation. But how does the presentation of her symptoms and her story strike you?
I always believe my patients until given reason to believe otherwise. I do not doubt AT ALL that this woman’s back was sore. But she received enough pain medication to relieve the pain of several patients, IMHO.
I left her room feeling saddened. She did not receive her “liquid pain medication” as requested, only more pain pills to carry her throught the night, and some feeble reassurance on my part that we would take good care of her and get to the bottom of her pain.
Wow! I would have been knocked out with that much on board but, I am a light weight. Benedryl knocks me out.
Sounds like a big puzzle. Could it be a kidney stone? Not that I have a degree or anything I have just experienced bizarre pain before.
It’s unfortunate, but true. Some patients get the drug seeker moniker without trying much.
The only problem is the docs sometimes have to take unusual steps to isolate and resolve the issue. One of my patients had this problem so the doc dropped most of the meds he came to us taking one night.
By the next morning, he was in a world of hurt for a few hours, but once the doc added things back slowly, based on how his pain felt (burning, location, etc.) he was able to get relief. He went from lying perfectly still in pain where we could not touch him or move him to sitting upright smiling in a few hours and eating his pizza.
People think I’m kidding when I ask about the quality of their pain, but I always explain that if we don’t know, we can’t treat it properly. Throwing Percocets (add your favorite pain drug here) at any old pain is not the solution.
As a post-script about this woman. She ended up feeling much better 2 days later, and went home on no pain meds. She was not very happy that night, though.
I think her back really and truly hurt her, but maybe the only way that she can deal with pain is to be totally knocked for a loop. We all respond differently to pain, and have different threshholds.
When my DW Sharon had her posterior fossa decompression for Arnold Chiari malformation(I know , a mouthful) One of the protocols presurgery was to stop Celebrex a week prior to the surgery. By the day before surgery, the neuro surgeon had to admit her for intractable pain. She is lucky that her body shows when she is much head pain, as her cheeks and most of her face get beet red, and of course, and elevated heart rate and bp. The floor nurse said “wow , that ’s quite a sunburn you’ve got going there.” Well, the staff were not happy giving her a pca pump with IV dilaudid at the orders of the neuro surgeon. She was already on 30mg morphine sulfate slow release(Kadien) x2 a day, and neurontin, plus a whole cocktail of other things. They were so terrified of over sedating her, they had a little glass case with a syringe of narcan in it on the shelf, and a crash cart nearby. They were not happy campers. Her surgery was without complication, but it took a little longer than thought, and her scull base compression was worse than thought. Ok, so she was there 5 days, and then discharged home. At 10:00 pm that night, I called 911 because she vomited from the pain, and her face was again beet red, and we didnt want her to tear the sutures in her dura. So, she was admitted by a different doctor than the Neuro surgeon and that doctor said” she cant be on all these drugs at the same time,” and reduced everything. Needless to say , untill they were all brought back up and included oxymorphone (opana), neurontin, Celebrex,and Kadien,and actik(fentynyl), she lay in a darkened room for 5 days with an ice pack. She finally made it home after her pain drugs were brought back up.
http://headsaga.blogspot.com/2007/06/little-by-little.html
http://headsaga.blogspot.com/2007/06/slow-but-sure.html
Bobby, I wrote this article at the risk of possibly offending some people who have truly suffered with pain issues and are not drug-seeking. I cannot begin to imagine what your wife must have gone through, except to say that I have given anesthesia for Arnold-Chiari decompression on many occasions, and the analgesia needs for this type of surgery are very often quite significant. Bone pain (as you well know) and its accompanying muscle/tissue spasms is some of the most intense pain there is.
I hope that the message in my post was clear and not misinterpreted. I do not take patients’ pain issues and complaints lightly. I felt her presentation was not within the normal curve of responses. I did not discount her pain, but I did question how best to approach it.
Thanks for your comments.
Terry, I think you are the most compasionate person I’ve met online. I took NO offense. I can’t help thinking that it’s I who offend and get peoples feathers ruffled. I have been called a troll by some. I sure hope you didn’t get the wrong message by my comment. I do think your patient was a little suspicious.The circumstances were far different, but the reason I told what happened to Sharon, is that she was in obvious pain which was not resolved until an unbelievable amount of opioid analgesic was administered. It was an unusual situation, and I was the most frightened, thinking we were painted into a corner. Sharon says that brain and surgery do not belong in the same sentence. I want to thank you for all of your support, I treasure it.
Terry - after multiple attempts at her epidural placement, without success, I would imagine that her pain was muscular. I’m sure she did want the pain to just be gone, but that was a heck of a lot of p.o. meds that postpartum gave her. Yes, some patients are drug seeking. Did they try anything else for her back pain? Heat? K-pad? Ice?
All unsuccessfully, atyourcervix. I suspected the same about her pain, that it was localized to the needle sites and being stuck multiple times. She had a very low pain threshhold, and a very high pain med tolerance. I mean, she was alert and talking to me after all those pills. She did feel better and go home two days later, and I do think that I (or anyone) would feel quite sore if I was stuck like she was. Sometimes patient responses send up red flags for us, and she was definitely one of them.
Hi Terry, I just discovered your blog and am enjoying your posts. Very interesting.
I had to comment on this one and the woman with her back pain. I think your comment about her thinking tht the only way to deal with it is to be knocked out is probably right on the money.
It’s very difficult to decide in some cases if a patient is truly in pain. The funny thing is that I can be in severe pain and no-one would ever know it. And that makes it really hard when I have to get help for it.
It does sound like you made a good assessment and the best decision that you could given the circumstances.
I’ll be back!
Hope she wasn’t breastfeeding.
I’m a little late to the party. . .
but what about Toredol? Did she try that? I’ve had more than one patient with lots of intractable pain, and, the Toradol really helps. Of course, I can “sell” it when I’m giving it as the best thing ever made, and that makes them “think” it’s going to work well. But still. . .
Maybe she was a CYP450 2D6 poor metabolizer? Codeine barely has any effect on the mu receptor on its own, so it has to be metabolized to morphine to have an effect, and 2D6 poor metabolizers don’t get the job done. Hydrocodone and oxycodone have also been shown to be ineffective in 2D6 poor metabolizers. That would explain why she’d gotten morphine at a prior visit (although not why she’d get opiates for bronchitis). None of that explains why, with a bucket of acetaminophen and ibuprofen on board she wasn’t getting good analgesia, though. Eh. Just a thought.
And a good one, Jen! Thanks for your input.