Case Presentation - Treatment of Pain in the Medical Setting
Roger Kathol, M.D.

     With the advent of pain as the 5th vital sign, there has been a dramatic change in the approach to pain management throughout the country. The following patient is one that was seen by a psychiatric consultant in a large general hospital.

     MS is a 37 year old overweight female who was admitted to internal medicine through the emergency room (ER) with excruciating low back pain of 2 years duration. She had been seen in the ER at least 40 times in the past 4 years but had had numerous emergency visits even prior to that time as documented by the patient's medical records. Many of the visits to the ER were pain related, requiring analgesics, though a large number of other complaints in multiple organ systems were registered. On this occasion the patient was admitted with the same discomfort that she had presented to the ER with 2 weeks earlier. At that visit, and on several prior ER visits she had received a 10 mg IM morphine sulfate followed by a prescription of either Vicodin (#30) or Oxycontin 20 mg (#30). She was admitted on this occasion to better evaluate the cause of the pain and thus improve management.
     A review of the records indicated that the patient had a dramatic increase in the number of outpatient and ER visits about two years prior to this admission. Complaints by the patient also became much more consistently related to low back pain, at least in the ER. Numerous evaluations had been performed which failed to reveal a cause for the patient's discomfort. With the advent of pain as the fifth vital sign, the patient was referred to the pain clinical for evaluation. The pain clinic concurred with the referring physicians that an etiology for the pain was elusive. A somatization disorder checklist during the routine pain clinic evaluation was one symptom shy of a diagnosis, nevertheless, it was suggested that narcotic analgesics should be tried in an attempt to control the patient's distress. They assumed responsibility for prescribing Oxycontin and worked with the physician who had referred her. Despite chronic narcotic use, the patient actually increased her use of the ER and outpatient physician's office because of marginal control. She also indicated that she used numerous ERs in town because of the way she was treated when she was seen in one too often.
     Psychiatry was consulted on this admission to determine whether depression could be contributing to the patient's discomfort and management failure. Despite the patient's reluctance to be seen, the psychiatric evaluation revealed that the patient met criteria for major depression. She had been tried on SSRIs in the past but was not taking them at present. There were occasional comments in the old patient records about drug seeking behavior and possible alcohol abuse. No prior psychiatric evaluations were available present in the patient's old records. Review of the notes and medical records also indicated that the patient met criteria for somatization disorder.
     Since the referring physician had specifically asked whether depression could have been contributing to the patient's problem, she was told that depression was present and an antidepressant was suggested. The psychiatric consultant signed off the case.

     This is an interesting and quite frequently seen clinical presentation in general hospitals. Would you have handled this patient differently? Why? How? Please try to make your comments concise. Feel free to respond to comments by others about the approach taken to this patient.

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