I treated a guy a few days ago for the "worst lower back pain of his life". This is a surprisingly common occurrence for emergency doctors, and I must admit that I immediately wrote him off. Mohawk, neonazi tattoos, bad teeth, nasty attitude.
I went through the song and dance, pretending to care about his "back pain after twisting it the wrong way". I've heard this story so many times, from so many drug seekers, that is has competely lost its luster. Immediately I informed him that I was not comfortable prescribing narcotic medications.
"But I'm allergic to tylenol, aspirin, and advil!" he decried, "Please, doctor, it hurts so bad. Can't you give me something else? Nobody can help me but you..."
Even a couple of years into hearing these complaints I still cringe a little on the inside while I put on the hard, callous exterior. "I'm not going to prescribe you any narcotics today, sir."
But what if I'm wrong? What if he's truly in pain and I'm just being stubborn? He was barely able to sit up from the bed without wincing in pain when I examined him. Every small touch sent him into paroxysms of agony. I discharged him with an anti-inflammatory I hoped he wouldn't recognize the name of.
Two days later I was walking back from the cafeteria and saw him strutting down the hall towards the urgent care with a heavy backpack on, no evidence of the "extreme pain" he had 2 days earlier. The doctor covering urgent care called me when he came in 10 minutes later for an inability to walk.
Nobody likes to be made a fool of, which I suspect is part of the reason Emergency Physicians undertreat pain. I follow up many of my patients in the hospital (did my suspected heart attack actually have one?), but I never follow up on suspected drug seekers. Why? Because I don't want to turn cynical earlier than I have to.