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How do I deal with “the candyman conundrum” when treating pain?

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ER doc Brady Pregerson and Nurse Rebekah perform a raid and bust on that sketchy personality, the “Candyman.” Why does he exist? And what is he thinking?

In Part I of our Pain Management series, we looked at the challenge of gauging your patient’s pain. In this article, we examine the many consequences of taking a too-easy approach to a complex issue.

Dr. Brady: Treating pain and other symptoms such as nausea and anxiety is a core competency in many medical specialties. Sometimes it’s all we can do.

As doctors, nurses and PAs, we should take pride in easing the suffering of our patients. It’s morally superior to over-treat 100 drug-seekers than it is to withhold analgesia to a single patient who is truly suffering.

Some physicians have the philosophy that if they just assume all of their patients are telling the truth and treat them accordingly, everything will work out for the best. This is an attractive way to approach pain management and surely simplifies the job. It completely avoids the added task of being the narcotics police in addition to being the doctor, and your patients will love you. Also, you can often discharge patients more quickly this way, because instead of giving them a long explanation after telling them “No,” you can instead just say “Yes.” Perhaps this is the best approach.

Of course, there are downsides to being the “Candyman.” Will your nurses respect you for it? Will your DEA number be used to buy prescription drugs that are later sold to junior high school students for profit? Will your behavior encourage repeat visits from drug-seekers who back up the waiting room and put sick patients at higher risk of a bad outcome due to delays in care? After all, it has been frequently said, “If you feed the bears, the bears come back.”

Nurse Rebekah: Oh, and we have some bears! But we also have some legitimately ill patients. I remember taking care of a Japanese man who fell a good amount of feet off a ladder and broke eight ribs. He was tachycardic, hypertensive and breathing way too fast. Every time I would ask him if he was in pain, he would emphatically say, “No.” I didn’t believe him. There’s no way that you can break eight ribs and not be in pain. It’s physiologically impossible. For him, it was part of his culture to not admit weakness. For me, it was part of my culture to give him the good stuff! I finally convinced him to take a little morphine IV and, lo and behold, he calmed down, his heart rate came within normal limits and his furrowed brow looked like he had just received a good dose of Botox.

We used to give out Vicodin six-packs for patients to take home. And we actually had a doctor we referred to as the “Candyman.” These six-packs were a pain to get. They required two signatures, a copy of the scrip, an extra trip back to the Pyxis—they took up way too much time. No one liked to work with this doc in our quick care area because we all feared that we might lose our nursing licenses for “suspicious use of narcotics.” This problem was recently solved, though—the laws changed and we can’t give out those packs anymore! It has shaved a good half an hour off each shift, and we no longer live in fear of the next Pyxis audit.

Most people are pretty funny with narcotics. They say funny things, do funny things (sometimes it depends if you think cessation of respirations is funny…) and are usually quite happy to be taken out of their pain. I look like the good gal then! That almost makes up for any patient who is using narcotics “recreationally.”
So what’s the best approach when those hungry bears come knocking on your door? In Parts III and IV of our Pain Management series, Dr. Brady and Nurse Rebekah share how they discern a “seeker” personality and how best to deal with it.

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Brady Pregerson, MD

Brady Pregerson, MD, a returned Peace Corps volunteer and winner of the 1995 Wise Preventive Medicine Scholarship, completed his medical school at the University of California, San Diego, and his residency at Los Angeles County General Hospital. He has authored three medical pocket books for nurses and doctors, as well as the educational web sites erpocketbooks.com and gotsafety.org. Dr. Pregerson currently works as an emergency physician in Southern California. He writes, "Although the ED environment may be quite different from working on the hospital floor or in an office setting, I am hopeful that you can take these tips and apply them to your own specific work situation." You can buy his books on lessons from the ER, including Don't Try This At Home: Lessons from the Emergency Department and Think Twice: More Lessons from the ER, at amazon.com.
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