Pain crises and racism

[Anonymous M4]

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http://www.npr.org/blogs/health/201...=tw&utm_source=twitterfeed&utm_medium=twitter

 

[Rendar5]

Sorry, gotta call BS on sickle cell being racist (and if you actually know me in real life, I'm well that racism is real and very prevalent).

People get crap treatment and a stigma associated with sickle cell because it's a chronic pain condition that is hard to treat with mostly subjective findings, not because it affects blacks more than whites.

 

[SpecterGT260]

That is ridiculous....

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[Bojack Horseman]

Yeah, she compares sickle cell disease to cystic fibrosis as if the treatments are that much more advanced due to targeted research. A quick google will tell you that sickle cell patients live longer than cystic fibrosis patients.

 

[SoCuteMD]

Such crap. Of course sicklers take 30 minutes longer to get IV pain medications - HAVE YOU SEEN THEIR VEINS? Yeah, me neither, that's the problem!

 

[southerndoc]

Interestingly, the sicklers who I see visiting us only once or twice per year get a lot of relief from ketorolac and morphine. Sometimes they require hydromorphone.

However, there are plenty of patients who are out of the hospital for only 2 days and who come in requesting hydromorphone by name. I've had people tell me they usually get 4 mg at a time, which is something I'm not comfortable giving to someone whom I've never seen before, plus it's against our policy to administer more than 2 mg at a time.

I'm not suspicious of patients who seem to be in pain. It's the sicklers who are texting on their phone, laughing, appearing in no distress as they eat a Big Mac telling me they are in 10/10 pain, and requesting Dilaudid by name... with Benadryl and Phenergan. One patient actually asked me "hey doc, can I get another shot of D?" We now have a nickname for it.

There are hospitals in Atlanta that no longer carry hydromorphone in the ED. Some even prohibit prescribing schedule II narcotics unless there is a clear cut reason behind it. We no longer give promethazine IV, and patients hate it when I order it IM. When they request the Benadryl? I usually give it PO if I think they're FOS.

SoCute has a point. I've never seen a sickler get an IV quickly unless they're there infrequently. Most of them in my area have ports because they are hospitalized so much. One of the sicklers I saw last year spent 325 days in the hospital for 2012 alone when our case manager counted up the days. Turns out her "sickle cell crises" were actually her way of seeking a place to stay and some hot meals because she was unemployed and homeless.

 

[Anonymous M4]

Interesting points, guys. BTW though I was informed by a pedi hem onc guy I rotated with that "sickler" is a stigmatizing term his patients preferred the medical community stop using. I thought the race angle was a bit too easily confoundable with the chronic pain issue, but I think they probably both contribute to the difficulty faced by some sickle cell patients in the ED.

 

[Rendar5]

Interesting points, guys. BTW though I was informed by a pedi hem onc guy I rotated with that "sickler" is a stigmatizing term his patients preferred the medical community stop using. I thought the race angle was a bit too easily confoundable with the chronic pain issue, but I think they probably both contribute to the difficulty faced by some sickle cell patients in the ED.

No, it really just is the chronic pain issue and multiple IV's that compounds the issue. Race, while it may play a role in a lot of things in medicine and healthcare, really doesn't play much role in sickle cell at all.

 

[Daiphon]

I see a *lot* of sicklers in my shop, and I agree w/ above - time to analgesia is directly proportional to frequency of crises (e.g. crap veins = delay).

But the plural of anecdote is not data; and association does not equal causation. IMHO, the race thing is laughable. With HbS & HbC being much more prevalent in those of African descent, it's a function of prevalence not racism.

Oi.

-d

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[SpecterGT260]

Interesting points, guys. BTW though I was informed by a pedi hem onc guy I rotated with that "sickler" is a stigmatizing term his patients preferred the medical community stop using. I thought the race angle was a bit too easily confoundable with the chronic pain issue, but I think they probably both contribute to the difficulty faced by some sickle cell patients in the ED.

The issue is the author is attempting to place blame here. SCD is a "black" disease, and CF is a "white" disease . They also compare pain to kidney stones, which.... I'm pretty sure is crap. Regardless the metric used (subjective pain scores) in no way rules out abuse.

The thing is, scd has traits which both can mimic seeking behavior and logically lead to dependence through chronic treatment (she says there is no link but I am pretty sure there is a ling between chronic pain pts and abuse). It would be racist to NOT think abuse, just like you would for any other patient. This is flagrant misuse of the race card and it is shameful

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[strongboy2005]

I'm not suspicious of patients who seem to be in pain. It's the sicklers who are texting on their phone, laughing, appearing in no distress as they eat a Big Mac telling me they are in 10/10 pain, and requesting Dilaudid by name...

A few points here:
1) You can be in 10/10 pain while still eating a Big Mac, laughing, and talking on your cell phone.
2) Knowing the name and dosage of the pain medicine that provides you relief does not indicate a drug seeker or an addict any more than a diabetic knowing they need insulin.

I look forward to discussing these two points because until we can get these preconceived notions addressed we will continue to under treat pain in the ED.

 

[deleted109597]

A few points here:
1) You can be in 10/10 pain while still eating a Big Mac, laughing, and talking on your cell phone.
2) Knowing the name and dosage of the pain medicine that provides you relief does not indicate a drug seeker or an addict any more than a diabetic knowing they need insulin.

I look forward to discussing these two points because until we can get these preconceived notions addressed we will continue to under treat pain in the ED.

1)By definition, if you are laughing, you can't be in 10/10 pain.
Nobody is saying they have no pain. And nobody is saying they haven't become accustomed to pain. But 10/10 is the worst pain you can imagine. Thus, being skinned, then dipped in rubbing alcohol, while people jam 18 gauge needles under your finger nails, while passing a kidney stone, while....
2)While it does not prove causation, it does have a decent correlation. Your argument is valid for insulin, but it's also valid for heroin junkies who know how much to buy to get their next fix. It's simply knowledge of what you need.

I point you to the statistics of pain medicine caused deaths in the US. If we are doing such a bad job of treating pain, why are so many people dying from pain medicine (and yet, nobody has every died of pain)?

 

[SpecterGT260]

A few points here:
1) You can be in 10/10 pain while still eating a Big Mac, laughing, and talking on your cell phone.
2) Knowing the name and dosage of the pain medicine that provides you relief does not indicate a drug seeker or an addict any more than a diabetic knowing they need insulin.

I look forward to discussing these two points because until we can get these preconceived notions addressed we will continue to under treat pain in the ED.

Have you ever experienced a seeker in the clinic?

True, it is theoretically possible to be a 10/10 while doing those things. Until you shoot them in the kneecap. Do you think they will re-assess?

And seekers often come in with arbitrary drug allergies that require opiates- many allergies which aren't even recognized by medical science. These associations may have exceptions, but they are still useful. Objection to them on some faux-moral high ground is more naive than open-minded.

 

[Arcan57]

The issue is the author is attempting to place blame here. SCD is a "black" disease, and CF is a "white" disease . They also compare pain to kidney stones, which.... I'm pretty sure is crap. Regardless the metric used (subjective pain scores) in no way rules out abuse.

The thing is, scd has traits which both can mimic seeking behavior and logically lead to dependence through chronic treatment (she says there is no link but I am pretty sure there is a ling between chronic pain pts and abuse). It would be racist to NOT think abuse, just like you would for any other patient. This is flagrant misuse of the race card and it is shameful

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If you don't think the average patient with sickle cell disease (the preferred nomenclature) doesn't receive poor care in the ED, then you either haven't had enough experience with them or are willfully blind. If you make the standard for treating a pain crisis that the patient has to lose their dignity before you'll treat them, then that's exactly what's going to happen. Patient's with sickle cell disease are a vulnerable population as many of them (especially SS patients that didn't get hydroxyurea and regular transfusions if they needed them) have had multiple sub-clinical strokes leading to at least mild cognitive empairment combined with difficulty in maintaining education and employment because of frequent pain crises preventing them from moving up the socio-economic ladder and often difficult or even toxic) home environments that were worsened by the burden of trying to care for a chronically ill child. This doesn't describe every patient with sickle cell disease, but it's a pretty good generalization of our "frequent flyers". Many of them are profoundly ignorant regarding their disease, inclduing what subtype they have or what their baseline Hgb runs. This is compounded by generally poor in-patient care were they are often inappropriately transfused raising their viscousity and actually leading to more vaso-occlusive crises.

While I'd like to think that race had nothing to do with this cycle (and it's probably a lesser contributor than SES), African-Americans tend to do worse then whites in almost every chronic disease study that's looked at race. While I'm sure they exist, when's the last time you saw a young (20s) white woman with lupus that was on hemodialysis vist your ED? Every shop I've worked in has had at least 3 AAs with that story (and they're usually coming in with chest pain which is such an awful work-up since they're at risk for everything and have usually had a complete work-up within the last month).

We do a crap job of managing chronic disease in the ED (because it's not our job), minorities (especially low SES) tend not to have their chronic disease managed well as outpatients, and pt's with unmanaged chronic diseases come to the ED frequently. The system doesn't require us to be racist for minorities to get poor care, although I'd be shocked if racism was not at least a contributing factor. I'd agree that CF is a very poor comparison disease (there are definitely objective markers of pulmonary dysfunction).

 

[Rendar5]

Have you ever experienced a seeker in the clinic?

True, it is theoretically possible to be a 10/10 while doing those things. Until you shoot them in the kneecap. Do you think they will re-assess?

And seekers often come in with arbitrary drug allergies that require opiates- many allergies which aren't even recognized by medical science. These associations may have exceptions, but they are still useful. Objection to them on some faux-moral high ground is more naive than open-minded.

To be fair to him, a sickler knowing the name of a drug that works for them and the dose of that drug is pretty standard as they have received that drug at that dose hundreds of times. And if they get histamine release from narcotics, they know it and they know they need benadryl. What else do you expect them to do? That's simple and pure pain relief seeking behavior.

Now if they're demanding the drugs be IV push only, that may be something else. If I suspect abuse by someone, I just give them IM drugs. But I don't play games with them and try to trick them. If I don't have dilaudid for some reason, I just give them an equivalent dose of morphine, and I explain to them that my dose is based off their dilaudid dose. If their requested dose of dilaudid is very high (over 2mg), I either tell them I can only give 2 at a time, and that I'll keep giving it to them until they receive adequate pain relief. My sicklers also know that if they ever hit 6mg, they bought themselves an admission, and if they want medicine to go home with, they have to wait for their hematologist to call my clerk back and for a check of their narcotic use. I have maybe 1 unhappy sickler a year. Most of my sicklers in my shop prefer to go home, fortunately.

 

[deleted109597]

Lots of better designed studies have shown that racism is present in EDs. That shouldn't be surprising, because lots of studies have shown that racism is present everywhere. Humans are pack animals, and they treat other "packs" differently. I'm not arguing it is right, I'm arguing it is human nature.

That being said, having read those studies, I made a point always having a "minimum" amount of pain medicine that I'll give to people, regardless of race, complaint, etc. Only time I change that is if I have documented evidence of drug seeking behavior from either the chart, or the prescription drug database. Number of pills by itself isn't a reason. It's number of providers and pharmacies.
I can always give more if the minimum isn't enough.
But at the same time, when I do give it, and they're laughing and eating Big Macs, I consider that adequate criteria for discharge.

Caveat: I no longer have a sickle cell population.


As an aside, if these hematology nurses have a problem with the way we provide care for their patients, perhaps they could be more forgiving and take care of their patients at all hours, especially since they know them better.

 

[SpecterGT260]

If you don't think the average patient with sickle cell disease (the preferred nomenclature) doesn't receive poor care in the ED, then you either haven't had enough experience with them or are willfully blind. If you make the standard for treating a pain crisis that the patient has to lose their dignity before you'll treat them, then that's exactly what's going to happen. Patient's with sickle cell disease are a vulnerable population as many of them (especially SS patients that didn't get hydroxyurea and regular transfusions if they needed them) have had multiple sub-clinical strokes leading to at least mild cognitive empairment combined with difficulty in maintaining education and employment because of frequent pain crises preventing them from moving up the socio-economic ladder and often difficult or even toxic) home environments that were worsened by the burden of trying to care for a chronically ill child. This doesn't describe every patient with sickle cell disease, but it's a pretty good generalization of our "frequent flyers". Many of them are profoundly ignorant regarding their disease, inclduing what subtype they have or what their baseline Hgb runs. This is compounded by generally poor in-patient care were they are often inappropriately transfused raising their viscousity and actually leading to more vaso-occlusive crises.

While I'd like to think that race had nothing to do with this cycle (and it's probably a lesser contributor than SES), African-Americans tend to do worse then whites in almost every chronic disease study that's looked at race. While I'm sure they exist, when's the last time you saw a young (20s) white woman with lupus that was on hemodialysis vist your ED? Every shop I've worked in has had at least 3 AAs with that story (and they're usually coming in with chest pain which is such an awful work-up since they're at risk for everything and have usually had a complete work-up within the last month).

We do a crap job of managing chronic disease in the ED (because it's not our job), minorities (especially low SES) tend not to have their chronic disease managed well as outpatients, and pt's with unmanaged chronic diseases come to the ED frequently. The system doesn't require us to be racist for minorities to get poor care, although I'd be shocked if racism was not at least a contributing factor. I'd agree that CF is a very poor comparison disease (there are definitely objective markers of pulmonary dysfunction).

I am a little confused where you interpreted from my post that I was saying SCD pts get optimum treatment

He nitpicked, I nitpicked back. I was stating that there are similarities between this and real seeking behavior such that the job of the physician becomes more complicated. I didn't say it was right and I didn't say it was fair. I said it happens. I also said that telling physicians to magically do away with all such behaviors is paramount to assuming that NOBODY is seeking. This is not a viable option.

To be fair to him, a sickler knowing the name of a drug that works for them and the dose of that drug is pretty standard as they have received that drug at that dose hundreds of times. And if they get histamine release from narcotics, they know it and they know they need benadryl. What else do you expect them to do? That's simple and pure pain relief seeking behavior.

Now if they're demanding the drugs be IV push only, that may be something else. If I suspect abuse by someone, I just give them IM drugs. But I don't play games with them and try to trick them. If I don't have dilaudid for some reason, I just give them an equivalent dose of morphine, and I explain to them that my dose is based off their dilaudid dose. If their requested dose of dilaudid is very high (over 2mg), I either tell them I can only give 2 at a time, and that I'll keep giving it to them until they receive adequate pain relief. My sicklers also know that if they ever hit 6mg, they bought themselves an admission, and if they want medicine to go home with, they have to wait for their hematologist to call my clerk back and for a check of their narcotic use. I have maybe 1 unhappy sickler a year. Most of my sicklers in my shop prefer to go home, fortunately.

Again, I have no idea why this is relevant to my response to him. I didn't say an SCD pt shouldnt know his or her drug by name and dosage. I said interpreting it as seeking with a new pt in the ED is not so unreasonable and certainly not to be called racist.

Now, a valid history documented for SCD and id suddenly be much more generous. But this isn't exactly what was on the table. I do like your approach here: minimum dosages or admit and wait for the primary doc to contact. This seems reasonable for any pain condition seen in the ED. My point is that it isn't racist as the article implies. It is responsible to ensure that abuse isn't a factor whenever giving these drugs. A population that has a higher rate of need vs abuse doesn't suddenly diminish the need to combat abuse.

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[southerndoc]

A few points here:
1) You can be in 10/10 pain while still eating a Big Mac, laughing, and talking on your cell phone.
2) Knowing the name and dosage of the pain medicine that provides you relief does not indicate a drug seeker or an addict any more than a diabetic knowing they need insulin.

I look forward to discussing these two points because until we can get these preconceived notions addressed we will continue to under treat pain in the ED.

There is nothing to discuss.

 

[deleted65604]

A few points here:
1) You can be in 10/10 pain while still eating a Big Mac, laughing, and talking on your cell phone.
2) Knowing the name and dosage of the pain medicine that provides you relief does not indicate a drug seeker or an addict any more than a diabetic knowing they need insulin.

I look forward to discussing these two points because until we can get these preconceived notions addressed we will continue to under treat pain in the ED.

I believe YOUR preconceived notions are wrong. I agree with previous posters. You can't have 10/10 pain and be laughing. The attitude that we undertreat pain in the ER has the potential to cripple the system. The bioavailability of oral narcotics is just as good as IV. These people should have pain management doctors for their chronic pain. The ER can't function as an opium den, or we would have a line around the block and we would cease to be able to treat emergencies.

 

[SpecterGT260]

I believe YOUR preconceived notions are wrong. I agree with previous posters. You can't have 10/10 pain and be laughing. The attitude that we undertreat pain in the ER has the potential to cripple the system. The bioavailability of oral narcotics is just as good as IV. These people should have pain management doctors for their chronic pain. The ER can't function as an opium den, or we would have a line around the block and we would cease to be able to treat emergencies.

He may have been referencing the notion that "a person's pain is relative to their experience so a 10/10 for one person may be a 3/10 for anothet".

This idea is, of course, completely absurd, hence the kneecapping comment earlier.

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