Withdrawal

    I am shaking, sweating and a bit nauseated as I write this.  I can not concentrate.  No, we have not been anywhere near the earthquake devastation that has recently happened on the South Island in Christchurch.  Our thoughts and prayers are with the people affected by that tragedy.  Instead my shaking, sweating and nausea comes from the fact that it has been over 10 months since I last wrote a prescription for those desperately sought after pain medications of Vicodin, Lortab, Oxycontin and Dilaudid. 
    What is it with these Kiwis?  Why do they not need massive amounts of pain medication?  In ten months I have seen only one bonafide drug seeker.  What the heck.  I am missing being told I do not know anything about pain.  I miss the threats of being sued for misdiagnosing the chronic abdominal pain that has had three CT scans,  2 ultrasounds, 14 xrays, and multiple non diagnostic specialist consults in the greater Central Oregon hospital service area within the past year.  Definitely signs of craving as I go through withdrawal.
    So imagine my joy when I had a twenty something year old male in the office a few weeks ago complaining of dental pain.  I sat back and enjoyed watching the 5th year medical student from Auckland work his way through the patients history, waiting for my chance to discuss the difficulties of assessing a patients pain level and need for medication.  Especially in the setting of dental pain where some relatively benign exam findings can be very painful and severe dentition can be painless.  As the medical student finished his exam, I shifted to the computer to search Pharmac (subsidized medications from the public health care pharmacy schedule and not to be confused with Big Pharma in the US) to find an appropriate narcotic containing pain medication for this patient who had a very painful looking dental infection with a fractured tooth.  I felt a euphoric rush as the patient stated " Can I get something else for the pain?  I have been taking Panadol (Tylenol) and it has not helped."

    Relief in site?  I will possibly be writing my twentieth narcotic pain medication prescription (the other nineteen were for incarcerated patients on methadone withdrawal programs or hospice patients, no chance for misusing the drug) since I have been in New Zealand.  A minuscule fraction of what would be expected of me in practice in the US.  I am conditioned to know what is coming next by all the similar patient encounters in the US.  I can hear it, almost music to my ears... "Doc, can I get some of that uh Vik..uh Viku..uh...Vikudin stuff?"  Yes, say it.....But wait, this is a Kiwi patient.  "Can I get some of that stronger pain medication called Brufen?"  Aye?  Brufen is ibuprofen.  Mate, that looks painful, are you sure?  Lots of guys in your demographic in the US  claim they are allergic to brufen or it does not work to relieve pain.  "Brufen works really well for me, thanks doc."
    Bugger!  My withdrawal from patients demanding high strength pain medications will continue.  What is it that makes these Kiwi patients have a different perception of pain.  Pain results when our body suffers physiologic damage to tissue which releases inflammatory chemicals and neurotransmitters to stimulate pain fibers in the nervous system.  Our perception of pain is then modulated by the brain and is influenced by many factors including previous experience with pain and socially accepted expressions of pain.  Socially acceptable such as the difference between a Hmong woman delivering her child and placenta without a whiff of noise and a Caucasian diva screaming for an epidural the minute her uterus thinks about having a contraction.   Time to do a little research...

Ouch

    After exhaustive research, (exhausting work goes better with a cup of coffee and newspaper to start the day) I realized I had to look no further than the Monday morning sports page (get your pain right here)!  What makes Kiwis different from Americans in their demand for pain medication?  Look no further than the national sport and pride of New Zealand:  Rugby.  Not by coincidence I started my research on the weekend that coincided with Super Bowl weekend in the US.  What better way to contrast the social understanding of pain than to see how the gladiator heroes of a country respond to their injuries and pain. (Biased research disclaimer:  I tend to prefer sports stories like the 2010 Crook County High girls volleyball team who washed cars, had bake sales, and carpooled to games to overcome school budget cuts to go on and win their fourth straight Oregon state volleyball title as opposed to hearing about how much money Brett Favre will earn to lead the Vikings to another mediocre season).
    Luckily on Super Bowl weekend, the research project came to us. (Any Big Pharma out there want to sponsor my next project?)  Self funded research only provided tickets and transportation for my research assistants and I to the Kerikeri Domain where the final preseason test of the Auckland Blues and the Wellington Hurricanes would take place.

    The Hurricanes and Blues field 14 present or former AllBlack national team members, so bonafide heroes for the nation.  Pain is definitely part of rugby as it basically involves guys the size and fitness of football middle linebackers and free safeties pummeling each other without padding, colliding at high speed, (occasionally getting their heads squeezed between the sweaty bums of two front line players, but I'll save that detail for the scrum) until the ball is advanced over the try line.  It took until the middle of the second half to find the subject for my research, when not one, but two rugby players lay injured on the pitch.

     Observation One:  If you are hurting, the game still goes on.  Both players went down after tackles within an approximate one minute time span, leaving them writhing on the field in pain.  Yet the game did not stop.  Play continued around them, risking further injury to the players, but on the other hand an acceptance of needing a quick resolve to get beyond the pain and get out of the way.   Contrast that with professional football's game stoppage (commercial time) and speculation from the announcers regarding the nature of the injury (dwell on the pain).

Medic One

     Observation Two:  All bleeding stops, eventually.  Not to ignore the risk of the spread of infectious disease through contaminated body fluid exposure, but there is a little less focus on removal of blood stained jerseys and universal precautions during the game than there is in the US (not a lot of rubber gloves on the sidelines).  A good compression dressing around those torn earlobes and you are good to go again, mate.

Water boy/medic two

     Observation Three:  You are long way from complex medical care, so you might have that pain for awhile.  Note the orange medic clad individual on the lower right observing the pitch, and in the second picture the green shirted water boy/medic two.  These two fellows are your primary responders in this test.  This game is taking place with the nearest complex medical care nearly an hour away.  There is a volunteer ambulance crew stationed nearby, but no doctor scheduled for sideline care.  The volunteer ambulance crew has a limited amount of ability to administer pain medication.  Knowing that your national hero could be suffering through a long ambulance ride in pain from a broken leg certainly sets the socially accepted level of complaining about pain a little higher.  Contrast that with in training room xray machines and sideline physicians all the way down to the high school level in the US.  The US wins this one with the ability to provide immediate care for the pain, but it shows how the New Zealand psyche has a different tolerance for pain.
    Both players were able to be assisted off the pitch under their own power.  Applause for their recovery as the game continued.  I contemplated the following headline (click on it to read the fine print)



as I drew up conclusions to my research project.  I am thrilled that the Oregon legislature enacted the Web-based computer monitoring program so that physicians can have ready access to determine if a patient has recently been prescribed narcotic pain medications.  It is not an invasion of privacy for a physician to have access to this data.  It is data that can mean the difference between life and death from a drug overdose for a patient.  For those 18 to 25 year old who show up begging narcotics from their dentist or doctor, instead of being coerced into prescribing to them the conclusion of my research shows that the medical provider should take them outside for a good game of rugby! (Now who in the FDA do I need to buy in order to sell my billion dollar medical solution?)
    Addendum:  Watching New Zealand respond to the crisis in Christchurch has been amazing.  Calls were put out for assistance from all professions including medicine.  Within one day, the Cantebury GP service coordinators had to tell physicians from throughout the country to slow down on sending in the volunteer forms.   They were overwhelmed by the response and had enough volunteers to cover over a month of relief.  Just another way in which New Zealand deals with the pain.  Pick up your mates, and help them move on.
    Kia Kaha = Stay Strong.