Reflection

[adel elmoghrabi]

Mr. X presented to establish care and particularly requesting Pain medication. Gave a long standing history of chronic back, hip and LLE pain. States he has hx of MVA, fall from height and GSW to the abdomen which subsequently led to herniated thoracic discs, s/p LLE plate and screws, colostomy which was reversed years back and extradural hematoma which was evacuated. Also has hx of cancer prostate managed with active surveillance however did not follow up for repeat biopsy. He presents with his 2 y/o child and states he that his baby mother was poisoned last March after accompanying her friend on an outing to meet with a starnger who her friend had met on facebook.
Finally after explaining to me the above info, stated that he is in alot of pain and was following up at a pain clinic which no longer accepts his insurance and that he is coming today to have oxycodone 30mg TID prescribed.
As my very first time faced with a direct request to prescribe pain meds in the clinic i was faced with possible implicit bias that patients presenting requesting pain medications are exhibiting pain seeking behaviour until proven otherwise. Although i am certain that we all have some form of implicit bias that we are unaware of i generally attemept not to judge any person to avoid implicit bias as much as possible. However on this occasion i decided to intentionally have explicit bias that Mr. X was not truthful about various aspects of his story and that he is exhibiting pain seeking behaviour until proven otherwise and hoped that i could prove myself wrong. Explained to him clinic policy of not prescribing opiod meds during first visit until reviewing previous records, UDS and MAPS. Patient became very aggressive and did not accept this but had no other choice. Presented for follow up 3days later. UDS negative for opioids although he states that he had just run out of his last pill. Previous records confirmed all previous surgeries and Disc herniations. MAPS showed consistently receiving oxycodone from 1 provider until 3months back which he claims no longer accepted his insurance than saw 3 different providers who prescribed 1 time refills. Other than refer him for a bone scan to exclude metastatic bone disease and othropedic surgery to evaluate the need for intervention on his herniated discs i was faced with making a decision of to give or not to give this gentleman. Based on the results of our initial work up and review he seemed to be genuine about most aspects of his story which i was able to confirm although others did not make sense such as negative UDS for opioids, so should i prescribe him this very high dose of morphine equivalent. During my first encounter and on the physical exam he exhibited marked limitiation in anterior and lateral flexion of his spine. Conversely when i was walking into the clinic that that day i happened to see him standing by his car and then bending over to pick something up form the floor of his car with almost full flexion of his spine. Although that was a strange coincidence and i can never be certain if that maneuver was painful for him or not nor could i see his face this senario did not help in my test of forced explicit bias. The decision was not to undermine his pain but to deescalate therapy given that his pain was controlled on this very high dose and to refer to a pain clinic as well as follow up on the result of his bone scan and ortho recs on possible intervention. The patient again became very aggressive and rude and initially got up to leave but than bargained to take the prescription of Norco prior to leaving although initially refusing. At my conclusion of this encounter i was still unable to comfortably reaching my decision and whether this gentleman was genuine about his pain particularly that he appeared very comfortable at rest and again that is probably implicit bias that patients in pain have to appear in agony i decided to search form something more objective and although i could not find something objective persay i was able to find a nice video on youtube at the following link https://www.youtube.com/watch?v=roBMsx5Aw2s by Dr. David green who is a pain specialist that describes 10 ways that help identifying pain medication seekers from pain who are genuinely in pain. Although this does not completely solve the issue this can help us deal with out implicit and explicit biases regarding patients presenting requesting pain medications until we are able to innovate newer strategies or technologies to idenitify and gain who really is in pain.

[Ghaith Alhatemi]

When it comes to bias, It Is also an important part that affects our work up and needs to be addressed. One example is that we had a patient who used to have jaundice because of his sickle cell disease and we were aware of this. One day he was admitted for intractable nausea and vomiting causing alkalosis and significant hypokalemia requiring icu admission. He subsequently developed a vasoocclusive crisis while inpatient and his bilirubin jumped to 20. Again, it is still tempting to say it is related to the crisis. But we took our time and thought about it throughly. At the end we concluded he never had just bad hyperbilirubinemia during his crises before!. There was something going on for sure and figured it out the at the end. We learned a lesson that we should never assume easy explanations without a thorough research and after ruling out potentially treatable other scenarios.

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