How do you handle pain management with a patient who admits to severe pain but continues to refuse pain medications? What language do you use to assess pain? Does your pain assessment include a patient’s personal barriers to taking opioids? How often do you revisit those barriers in conversations about pain management?
One of my sons and I have an ongoing debate about which phone App for providing driving directions is better. I like the one that came on my phone while he prefers one he downloaded and that he insists is easier to use. Each time we drive to a new location we resume our good-natured debate. But regardless of which App we use, they both share 2 fundamental features: a starting point and an ending point.
Mr Brown was a large man. He was possibly my “biggest” patient ever. His pain was large, too. And beneath it all were huge concerns on his part about what taking pain medication meant to him.
He had head and neck cancer and was receiving radiation following a surgical resection. He had toughed his way through his surgery and recovery and was determined to “tough it out” as he went through radiation. Before he started treatment our team explained how challenging it would be; throat pain and swelling, dry mouth, and skin desquamation were expected adverse effects. Our goal was to get him through his treatment. But he had a different destination in mind. Of course, he wanted to complete his treatment and he hoped for a good outcome, but his goal was to arrive at the end of therapy having taken as little pain medication as possible.
The start of radiation therapy is easiest. The first few treatments have few or no adverse effects, which can lull patients into believing their symptoms will not be as bad as anticipated. It can trick them into thinking they can get by without pain medication, which perfectly aligned with Mr Brown’s personal plan.
He was scheduled for 30 treatments and made it through the first several treatments with minimal adverse effects. It wasn’t until about the tenth fraction that he agreed to consider taking medication for breakthrough pain (BTP). His willingness to take the medication was actually more of submission than agreement with our plan. He took the paper prescription in his hand but waved it at me trying his best to smile, “I’ll get it filled but only because you say I should. I’ll only take it if I absolutely have to.” It was the closest we had gotten to an admission that his pain was increasing.