Patients on the Pain Service

I saw a lot of fascinating cases on pain service. One woman who had never taken a pain medication in her life was admitted with a fracture. Her primary doctor put her on escalating doses of morphine but she didn't get any relief. She continued to report severe pain, and finally we were consulted. We suggested patient-controlled analgesia with hydromorphone, a related opiate. She controlled how much she could get; this would allow us to calculate her needs. With one push, she fell asleep and her pain was completely eliminated. For some reason, this woman responded to one opiate but not another. Yet when we tapered her off of her morphine, she showed signs of withdrawal. Although she got no pain relief from morphine, she got all the side effects.

Another patient was a woman who had her arm amputated in a work accident. It was awful; she underwent plastic surgery, but afterwards, had the sensation of phantom limb pain. Even though she had no hand, she could feel her fingers, intertwined, knotted up, highly uncomfortable. Her brain was still sending signals assuming her hand was there. We approached this aggressively; she normally takes no medications, and we immediately put her on six. Yet that strange sensation never left; I realized how elusive certain forms of pain can be.

Lastly, I took care of a patient who had anaphylaxis, a life-threatening allergy, to fifteen different medicines, most of which were pain medications. She could not tolerate codeine, hydrocodone, oxycodone, morphine, hydromorphone. Her chronic pain was controlled with methadone. But she was getting a shoulder surgery, and afterwards we had to tackle her pain despite her allergies. Interestingly, the other medication she tolerated well is meperidine which has a similar chemical structure to methadone. Although negotiating her pain was a challenge, it was also a highly educational experience.