By Dr. Geralyn Datz.
There’s a patient in my office, crying. He is also shouting. He can’t get his pain medications. His primary care doctor has told him, “I’m not allowed to write these medications for you any more.” I know this is a lie. His doctor can write the medication. His doctor does not WANT to write the medication. I know his primary care doctor doesn’t want to assume liability for the prescription now, due to the perceived pressures from the opioid epidemic. Or maybe the insurance has limited the supply or type of this pain killer. Now, the patient has been referred to me for “pain coping skills”. This is what providers call a ‘dump’. The patient is dumped on another provider. There is no plan there is no net. No warm hand off. The patient does not want to be here. The patient thinks I can talk some sense into their provider. The patient does not want “pain coping skills.” The patient is not motivated, nor insightful. What do I do? How did we get here? I want to go back, all the way back, to the beginning. I want to go all the way back to the point of when this patient was first hurt. The first week of his injury. And I want to bring my magic wand.
I want to be in the head of the primary care provider who treated him first. I want to enlighten the brain of that provider and I want the words coming out of their mouth to be, “This is going to be okay. The vast majority of these injuries heal.”
“It may take weeks, it may take months. But we will get there. I need you not to despair. You’re going to need to adapt to this problem for now, though. I need you to go to physical therapy for awhile. I know it’s inconvenient, and it may be painful. But it’s the best thing for you. And I need you to do some sort of activity on your own. Walking, doing the Wii with your kids, or maybe some daily stretching and abdominal work at home.” I need the provider to talk to the patient about what he thinks about pain medication, does he want it or not? Has he ever had pain medication before? Does he have a history of addiction or other risk factors for addiction? I want to look through the providers eyes and see what the patient thinks about his injury. What he’s worried about, whether his job will accommodate him or not, and talk to the patient about those fears and figure out solutions, just encourage the “patient to hang in there” so that the patient can be compliant. I want the provider to know if the patient needs a back brace ordered or not, or a TENS unit, so he can use some non-medication based options during the day or at the end of his day. I want the provider to tell the patient to quit smoking because now he has a back problem, and smoking makes back pain worse, and that is not good. Then, I want the provider to write the medications that are needed, and see the patient back within no more than two weeks. And I want the provider to be paid for this time, because it’s going to take longer than the 5 minutes.
Often in medicine we are focused on the injury, and trying to fix it, and we miss three very important things. One, there has to be an acceptance that we can’t always be comfortable that injuries happen, accidents happen, pain happens. Pain is a part of life. Second, we have to focus understand the patient’s response to the injury. How is the person coping and dealing with the injury? If they are not coping well, this needs to be addressed. Third, we have to be careful not to shape expectations towards being fixed, and chasing down cures, but instead to rehabilitation and recovery. Recovery takes time. Most patients are not told this. Several weeks after an injury has not healed, fear and depression may set in. At the very least, severe aggravation! The person begins to resent, even hate, their pain. This is a brain-based process. These thoughts create new circuitry and signals in the brain, followed by neurotransmitter release, and these new pathways get memorized. They became learned associations — pain leads to disgust, which leads to doing less, which leads to negative behaviors (too much rest, smoking, unhealthy eating, alcohol, sleep loss), which leads to more pain, which leads to fear of future pain, which leads to more disgust…..on and on. The neural highway is laid. And because someone told them “There’s nothing more I can do for you, you can only take the medication,” the person believes it. And this belief too, becomes part of the neural pathway.
Here we sit. The patient and I. He senses my compassion. He senses my feelings that we have met too late in the process. He is angry but underneath the anger is fear. Fear of being left alone with this pain. Fear of being tortured by pain. Fear of the unknown. I give him space and listen longer than any provider has listened so far. This calms him down. I know my limits. I am not a magician. But I have knowledge and tools that can help him. And right now, I’m all he has. I tell him his brain has been hijacked by pain, and worry, and sleeplessness and anger. I tell him there is a way through this, even though I can’t write medications for him. I have done this with many patients. I want to help. He agrees to come back. I shake his hand and tell him, thank you.
Dr Datz is a clinical health psychologist and pain educator in Hattiesburg, MS.