chronic pancreatitis

I had a patient come to ED last night complaining of abdominal pain with nausea and vomiting. This 32 year/old female claimed to be suffering from chronic pancreatitis that was so severe that she could not work and was subsequently collecting disability. In case you don’t know, the pancreas is responsible for producing many of the digestive enzymes that are released into the gastrointestinal tract to help breakdown food. Inflammation of the pancreas, pancreatitis, is most commonly caused by gallstones or excessive alcohol consumption which creates a condition were the digestive enzymes are released into the pancreas itself inducing a state of auto-digestion of the pancreas which can vary in severity and symptoms and usually include severe abdominal pain with nausea and vomiting. There are other much less common causes of pancreatitis including scorpion stings and “cryptogenic pancreatitis” (can’t figure out what caused it). This patient denied a history of gallstones and alcohol and told me her doctors had been unable to find a cause. As I reviewed her records I confirmed that she had been to our hospital on many occasions for abdominal pain with several admissions for pain control. The discharge summaries described unremarkable work-ups with only occasional mild elevations in the patient’s measurable pancreatic enzymes. However, the summaries were remarkable in their descriptions of this patient’s demands for very specific pain and anti-nausea medications. The patients insisted on the medications that are known to induce euphoria (get you high) and she demanded they be given intravenously (for a better high). At the same time she refused traditional interventions for pancreatitis such as a nasogastric tube which is placed through the nose to decompress the stomach. She also refused anti-nausea suppositories which are very affective medications placed in the rectum when a patient cannot tolerate oral medications. Now refusing to have things shoved up your nose and bottom may not sound too unreasonable, but typically patients that are suffering from a case of pancreatitis that is severe enough to warrant hospitalization are usually so miserable that they will try anything to feel better. Not this patient. When she arrived in my ED she was accompanied by her mother, and she appeared quite distressed. She was intermittently writhing in pain, stopping occasionally to retch but was unable to vomit. The mother informed me that she too suffered from a chronic pain syndrome and went to the same pain management clinic as her daughter (great- now chronic pain is genetic?!?). I ordered a panel of labs to elicit the cause of the patient’s pain and assured her I would give her medications for her pain and nausea. Of course the patient wanted to know which medications I would be giving her, and I told her “strong pain medications”. However the pain medications I ordered were not narcotics and had no euphoria or sedative qualities. When the lab reports returned they were stone cold normal with no evidence of pancreatitis. This absence of findings did not surprise me, nor was I surprised when the nurse reported that when he went to administer the patient’s pain medication and she found out it was not a narcotic she stated “it’s not going to work” even before getting the medication. The patient continued to carry on with her writhing and retching. Actually she only writhed and retched when she had an audience (especially when her father was at bedside), but when a nurse or I entered the room unexpectedly she was always resting comfortably for the seconds until she realized she was no longer alone and then she would be wracked by paroxysms of pain. Her performance was good enough to get an Oscar nod, and her poor father was certainly distressed by her theatrics. After I reported the unremarkable results of her studies and prepared to discharge the patient I offered her a dose of the medication she so desperately wanted. As I confronted her with the evidence of a benign work-up I pointed out that her behavior in the ER was concerning for drug-seeking. After I let her yell at me for 2 minutes I calmly pointed out to her father that when she was distracted her seemingly intractable nausea and retching completely disappeared. The patient really didn’t like this statement and told me “as soon as you leave I’m gonna start puking again!” and she immediately returned to her non-productive retching. OK- she just had her Oscar nod revoked.
Who knows how many ER visits, hospitalizations, CT scans, and procedures this patient underwent for her “chronic pancreatitis”. I learned that the pain management doctor she and mother visited was arrested for prescription drug-trafficking. Warning- big red flag. And somehow this patient had been put on disability so that her drug addiction, her entire life, is being supported by taxpayers’ money. What a great system. In addition to her frequent hospital visits for what is largely a fictitious disorder, taxpayers are also paying for her to go to pain clinic and get large amounts of drugs which ensures she will stay addicted to drugs and continue her lifestyle for what will probably be 3-4 decades. Her and probably 10’s of thousands of others…