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82 Reflections on ED analgesia
chemotherapy, what we have left is comfort provision. Ethically, at this point,
we do not need to worry about the unwanted side effects of the analgesic.
What difference does it make if it slows respirations, produces coma, or drops
blood pressure? We are trying to produce comfort.
The problem is even greater when we are dealing with a chronic pain
syndrome or a recurrent disease (like migraine) for which there are no cures,
but for which the patient wishes pain relief. Here, it is absolutely essential
that patients have a physician for ongoing care, but here it is also quite
probable that the patient has no access to such care. Sometimes we are
forced to make compromises in what we wish to do, because the patient is
from out of town, from another community, or because the patient’s physician
is simply unavailable. There are no patients with greater potential for
making trouble for the emergency physician, and it is simply impossible to
fight with every patient over whether or not to give more opioid. Each
physician has to make a judgment on which patient to accommodate, how
much analgesic to give, and how to arrange follow-up. A great deal of the
solution is institutionally dependent, and also financially dependent. For
those patients who are clearly pain-pill seeking, we recommend the “they
law.” You the physician tell the patient that you would love to honor a request
for pain medications, and will be happy to provide non-opioid prescriptions,
but that “they” won’t let you prescribe opiates. It keeps you from getting into
power struggles and gives the patient a courteous way of saving face. Of
course, if the physician is not sure that the patient does not, in fact, have a
new condition causing pain, pain should be treated.
The somatizing patient is also a source of considerable burden to the
emergency physician. It does not help the physician to do a complete
workup; often these patients have had hundreds of complete workups.
They frequently are incredibly savvy about the kind of history to give,
which mandates yet another complete workup. Yet even if the physician
falls into the trap of once again yielding to the needs to be ill, and performs
yet another thorough and expensive workup, there is still no good answer for
how to manage the patient’s persistent symptoms. We recommend the
“stupidity law.” Tell the patient first of all that they have real problems.
Even if their real problem is a somatizing syndrome, the patient does not