A physician’s personal crisis with pain

Six months ago, I had severe right flank pain. In the ER, I had an ultrasound showing a possible kidney stone. I deferred a CT scan and went home with medication. I fit the textbook picture: I had abnormal imaging, and I was given a treatment and discharged. I was advised to return if the pain worsened or failed to resolve. I briefly improved, but then the pain returned much worse. Ten days later, I returned to the ER. I was given ketorolac and had a CT, which showed no stone. The ER attending advised me to go home and take ibuprofen.

At that point, my pain was 8/10, and I was having significant trouble moving despite the ketorolac. I felt like my physician saw me as a drug seeker, rather than a fellow attending. I had already tried strong NSAIDs, and I remained in unrelenting pain.

But my pain didn’t fit a clinical picture — I had no abnormal imaging, so I was discharged with no diagnosis and no treatment plan. Once a stone was ruled out, the attending didn’t widen his search. He never did more than a 30-second exam. Clearly, I knew something was wrong. I just didn’t know what. I’ve concluded ERs are places to rule out life-threatening issues. I was in severe pain, but I wasn’t dying. So, I was discharged. As a clinician, it was a good lesson in how not to work up an undifferentiated problem.

Little help in mindfulness

Over the next week, I tried different things: ice, heat, ibuprofen, moving more, moving less. Nothing worked. I attended my community’s interfaith Thanksgiving service. There were several readings on gratitude and acceptance. The Shaker song “Simple Gifts” was sung. As I sat in the service, I tried to re-frame my pain.

There is a saying in the mindfulness community that “Pain is inevitable. Suffering is optional.” I tried to have gratitude for my pain. I reflected on what it brought me. My experience that month was making me a better caregiver. I certainly had more sympathy for patients with complaints that don’t fit clear patterns and don’t have easy answers. I was more aware of the challenges patients face when they deal with biases in our medical system. My times of pain made me better appreciate times when I was able to fully participate in activities. But no amount of mindfulness was going to make this pain livable.

I was beginning to get hopeless.

I had to keep looking for treatment.

Finally, a diagnosis

After the service, a friend advised an osteopathic adjustment. At the appointment, I was describing my pain and moving gingerly around the room when the physician asked, “Do you have a rash? Because this sounds like shingles.” On exam, I had no rash.

I was working over Thanksgiving despite my significant discomfort. Thinking about the osteopath’s comment, I turned to a doctor’s last resort: Google. A search for “shingles without a rash” brought up descriptions of zoster sine herpete.

Shortly after that, I went to a pain clinic. The physician sat down near me and respectfully listened to my story. He performed a thorough exam . He concurred that I had severe, unilateral, dermatomal pain with cutaneous allodynia. I had zoster sine herpete.

His treatment plan included antivirals, a nerve block, and other non-opioid modalities. I sat up after the nerve block and could finally take a deep breath. Four weeks of excruciating pain was over. After five doctors, two ER visits and one CT scan, I had a diagnosis and a treatment.

I got perhaps as much relief from having a reason for my pain as I did from the therapies.

Over/under-treatment

I wonder how long I would have suffered had I not been a physician and sought care from multiple specialists. I had the time, motivation, and persistence to seek out additional opinions after being dismissed. I certainly learned that the ER is no place for a pain patient. My second trip in which I was discharged despite incapacitating pain was a medical failure. I can see how people get desperate and turn to unhealthy coping methods or addictive medications when medical providers offer no help.

The opioid epidemic has resulted in both an overtreatment and undertreatment of pain. At times, large supplies of opioids are given freely — for example, after dental or orthopedic procedures. Once a patient of mine was doled out opioids in the ER for painful periods. At other times, even if people have severe pain, but it does not present in a textbook way they aren’t treated at all or they’re treated with minimal and ineffective strategies. There are reports that women, children, minorities and those with mental illness have their pain undertreated. I live in a medical mecca where well-regarded evidence-based pain clinics are an option. Of note, the pain clinic where I sought care doesn’t take Medicaid, so it’s out of reach for 25 percent of the population and an even higher percentage of the disabled population. Luckily, I’m fortunate to have medical insurance that covers multiple modalities of therapies.

Many insurances are more than happy to cover oxycodone but don’t cover strategies that avoid opioids, such as osteopaths, massage, cold compression machines or even the nerve blocks and lidocaine patches I found to be a lifesaver. In many regions, comprehensive pain centers are either nonexistent or pill mills. People in pain are left see-sawing between over and undertreatment.

There is as much a pain crisis in America as an opioid crisis. Chronic pain is perhaps the most common chronic illness in America, and the medical establishment simply doesn’t have a handle on it. There needs to be more calibration in treating pain with therapies that are titrated to the individual in a respectful environment.

Heather Finlay-Morreale is a pediatrician.  This article originally appeared in Doximity’s Op-(m)ed.

Image credit: Shutterstock.com

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