My Pain Philosophy
1) The smallest dose of narcotics that is effective in relieving pain is the optimum dose.
2) Higher doses of narcotics than are required to relieve pain cause problematic and sometimes dangerous side effects.
3) The optimum endpoint for a patient who presents to the ER with a painful condition is to be discharged in a pain-free state while also being awake, alert, and able to ambulate without assistance. Just like a normal person, in other words.
4) Some patients are not able to obtain relief of pain and still meet the criteria in #3, so compromises are often required in one or more of the endpoints. The preferences of the physician and the patient regarding the ideal balancing of these compromises (and the risks involved) do not always agree.
5) Some patients do not want to achieve the optimum endpoint in #3, instead desiring the euphoric side effects of the narcotics whether or not their pain is relieved. In fact, their desired endpoint is not exclusively pain relief but rather the state of narcosis. These patients refuse non-narcotic medications that are often superior pain relievers because pain relief is not their only goal (and occasionally not even their primary goal).
6) A patient's expectations regarding pain relief and the setting in which it is provided greatly affect the outcome and success of the visit.
7) A patient who comes in to the ER asking for a specific dose of a narcotic and gets it without an argument is likely to ask for another dose before discharge. A patient who asks for a specific dose of narcotic and gets only half of that dose (and is informed of that fact) is certain to ask for the other half 30 minutes later, but they usually won't ask for a third dose before discharge. Thus their total narcotic dose is minimized, and is therefore more optimal.
8) A patient who agrees to take whatever medications that my years of experience have taught me will relieve their pain will sometimes require no narcotics at all. But if they do require narcotics, the total amount will nearly always be less than the dose that they thought would be necessary, as long as they trust me and accept my promise that when they leave they will be comfortable. These patients will also be much closer to the optimum endpoint stated in #3 than any other group.
9) If a patient refuses that reasonable approach and still insists on getting "their usual shot," then they are probably a drug-seeker and will be treated with suspicion.