Importantly, he also had a distant history of IV heroin abuse. On admission the night before, he said that he slipped up once a few months prior but swore he hadn't used since then. The admitting intern handed him off to me as a "drug-seeker with functional abdominal pain."
Talking briefly with my patient before rounds, I just didn't get the sense that he was drug-seeking. My resident was more cynical; he called me naive, but he also gave me leeway to do with my patient as I saw fit.
After rounds that morning, I spent a little more time with my patient. "What exactly happened a few months ago that caused you to use heroin again?" I discovered that his wife had committed a violent suicide and that he had found her. He blamed himself for her death. This was a revelation to me. Incredibly, my patient felt that he had put this traumatic event behind him, despite never going through any grieving process. He didn't draw any connection between his wife's suicide and his current abdominal pain, even though his pain began at around the same time.
I gently suggested to him that perhaps his abdominal pain was a result of that psychological trauma. He resisted that idea because, to him, it implied that he was "crazy" or making it up, and the pain felt so real to him. I asked him to just consider it and told him that I would return later in the afternoon to talk more.
During our next conversation later that afternoon, he was surprisingly receptive to the possibility of a psychogenic cause of his abdominal pain. "In all of my hospital visits, not a single doctor has suggested that, but it makes sense." He was in unbearable pain even then, so I suggested that we try a simple breathing relaxation technique. After five minutes of this, we got his pain down to a manageable level, and he seemed bolstered by the improvement. At this point, I was practically convinced that his abdominal pain was psychogenic in nature.
We were treating his abdominal pain with narcotics, which is a poor choice of medication because it can actually cause constipation and exacerbate abdominal pain. I suggested that, overnight, he first try the relaxation technique that I had taught him and only ask for oxycodone if he really needed it. This was the real test: How much pain medication would he ask for? When I came back the next morning, I found that he decreased his oxycodone from 10 mg every two hours to 5 mg every eight hours. This was objective evidence that my patient was not drug-seeking and supported a diagnosis of pain disorder.
My resident and attending were both surprised, to say the least. The management of drug-seeking patients is truly difficult, especially at a safety net hospital that predominantly serves a socioeconomically disadvantaged population with a high proportion of drug addicts. I grant that I am naive and perhaps too trusting when it comes to handling these patients. But I also see that if I hadn't at least been open to believing my patient's story, that he was in fact not drug-seeking, I would have failed to properly identify the underlying cause of this man's abdominal pain. This hospital visit would have been just as unproductive and wasteful as the previous 7 admissions. Most importantly, his abdominal pain would have persisted, with inappropriate medical treatment, and his need for counseling would have continued to go unrecognized.
Before discharging my patient, we started him on an antidepressant and gave him a list of psychiatrists who he could see on an outpatient basis. He had already made an appointment with an outpatient psychiatrist before leaving the hospital.
He was tearful when we said goodbye, thanking me for genuinely helping him after many frustrating hospital visits. Then he handed me a folded piece of paper, a letter addressed to my attending, who later shared it with me and quoted it verbatim in my evaluation:
I have been in and out of the hospital the last few months. No reasons were found for my problem until I was assigned Mr. O. He was able to help me in such a way that I am able to function again. He spent a good deal of time talking to me about my medical and personal life. He personally has brought back faith and recovery for me. He spent his personal time explaining ways to help with pain. I wanted to tell you that I am grateful for all his council, medical advice and help.
