What can a friend do to get adequate pain meds for a short term injury?
June 9, 2015 8:33 AM   Subscribe

A friend has a very painful foot injury and needs enough painkillers to sleep and work. The doctor will not provide any. This is interfering with employment, not to mention with getting better. What can we do?

The foot injury is basically a big sprain that happened last week - my friend has been evaluated at the ER and then seen by their primary care doctor. It is so painful that my friend can't sleep well and cannot work, even though work involves sitting down. This is imperiling my friend's job. The ER provided a couple of doses of something strong whose name escapes me, but the primary care doctor will not continue the dose.

I think that what's going on is that because my friend is fat, the doctor is assuming that somehow my friend's weight is causing the pain; I see the same doctor and once walked out with a prescription for opiates as a migraine-med-of-last-resort based on my request, so I know this doctor is willing to prescribe strong painkillers at request to some patients.

At this point, my friend needs to be pain-free enough to sleep and walk around the house, and ideally would be pain-free enough to concentrate on work at work. My friend does not get a lot of sick time and has used it all up on this. The doctor wrote a doctor's note for work, but that doesn't really do any good if you don't have sick time.

What can we do to get some better meds? Go back to the ER? Call the primary care doctor again? Go to urgent care?
posted by Frowner to Health & Fitness (25 answers total)
I suggest your friend get a second opinion, because that doesn't sound like a regular sprain to me. Your friend might get a more careful examination from a sports med doc, even if the injury isn't sport-related; IME they not only have better knowledge of MSK issues than general doctors, but are placed to route people to appropriate care regardless of treatment philosophy, plus they can order imaging, unlike physiotherapists (who can also be great diagnosticians based on clinical evaluations, but can't get the images afaik).
posted by cotton dress sock at 8:46 AM on June 9, 2015 [4 favorites]

Back to doc or to another doc or to a podiatrist depending on how insurance will cover various sorts of visits. "I've given it a few days and still can no longer sleep" Sprains should be improving over time. If this is not improving, that is concerning. The magic words for painkillers are usually that the pain is interfering with your daily activities and that regular pain relievers do not do anything. Honestly it does not matter if your friend is fat, or what the doctor may think about that, that level of pain is unacceptable. If your friend can not sleep or work because of the pain, that is a problem that needs to be addressed. Also make sure they have already been trying the standard 800 mg of Advil every six hours just so your friend can tell the doc what has already been tried.
posted by jessamyn at 8:50 AM on June 9, 2015 [1 favorite]

I'm so sorry to hear this!

When I've had these types of injuries, pain relief from pills is just one of the components of treatment. Unless your friend has been told otherwise, he/she needs to be elevating the foot, icing it on a regular basis, and compressing it with an ace bandage or similar device. Just getting the foot elevated should help a great deal. You can do this with another chair, an ottoman, or a table; at night, in bed, the foot can be elevated by placing it on a pillow or two.

Most adults can safely take a maximum dose of 4000 mg of acetaminophen every day, and/or (I think) 3200 mg of ibuprofen. A good strategy is alternating acetaminophen with ibuprofen. Calling a pharmacist would be a good idea here, especially if your friend has other medical issues.

Pain that interrupts sleep is a major concern. After trying these ideas, and your friend still cannot rest--OR if you have already, that would be my cue to see another physician, maybe even an orthopedist, in case the pain is persisting from a tear or fracture. (ERs are great, but mistakes can be made, and another set of eyes on an X-ray never hurts.)
posted by FergieBelle at 8:50 AM on June 9, 2015

Response by poster: Friend is elevating and icing foot and wearing an ace bandage (and taking acetominaphen - can't take Advil), plus using crutches. There was an X-ray at the ER.

How can we get in to see another doctor fast? I don't even know how to find a doctor - I've been seeing my primary care doctor for years and they were the first one I saw when I moved here.
posted by Frowner at 8:54 AM on June 9, 2015

I don't know about the US; here, you could go to a sports medicine clinic (check Yelp, maybe?) that should have on its staff at least one sports medicine specialist (not a chiro).
posted by cotton dress sock at 8:57 AM on June 9, 2015

There should be a 'provider lookup' type feature on your friend's insurance plan website. Alternatively, if they have a nurse line associated with their insurance plan, call it and they can refer you to someone in your network.
posted by bookdragoness at 8:58 AM on June 9, 2015 [1 favorite]

naproxen (alleve/generic), diclofenac (rx) are both anti-inflamatory and pain killers that aren't opiates.

I think any/all docs are kinda spooked when someone is in begging for painkillers.

(And as one doc told me - opiates don't kill/end the pain, they just make you not care..)
posted by k5.user at 9:16 AM on June 9, 2015

Have the ankle and foot been x-rayed? I sprained my ankle once and after a couple of days of agony and swelling it turned out that I had broken a small bone in my foot.

Could it also be that your friend is on some other medications and the doc is preventing bad interactions between those and pain meds?
posted by mareli at 9:25 AM on June 9, 2015

Response by poster: I know I'm threadsitting a bit, but - the foot has been X-rayed. Friend has been taking naproxen. Med interactions aren't at issue here.

Again, I have begged this exact doctor for painkillers and got a quite large bottle of opiates out of it. (Which I ended up not taking, just for the record.) I feel bad because I recommended this doctor to my friend based on my experience and I feel like my friend has gotten the run-around several times from him. I also feel very strongly that this is based on my friend's weight. I'm not saying the doctor is doing it consciously, but we know that doctors are biased against significantly fat patients, tend to see them as non-compliant, etc.
posted by Frowner at 9:39 AM on June 9, 2015

It is so painful that my friend can't sleep well and cannot work, even though work involves sitting down.

I have sprained my ankles a lot and have had a combination buckle fracture and sprain and have never felt pain bad enough to prevent sleeping. In my experience, this level of pain is not normal for a sprain, even a bad one. If you're friend has already gone back to the doctor and they didn't offer any further help or referral to a podiatrist then your friend needs a second opinion and possibly another x-ray. If your friend's insurance company doesn't have an in-network doctor search ZocDoc or a similar service might be able to help you find someone who can see them same day. It's possible the original X-Ray was done wrong or missed something slight or just that the continued inflammation is affecting other things in the foot.
posted by edbles at 9:54 AM on June 9, 2015 [1 favorite]

Google 'sports medicine YOUR_CITY' or 'orthopedist YOUR_CITY'. Or check through friend's insurance carrier (usually there is an online doc lookup tool). Call them and tell them it's urgent, a sprain that has not resolved or even lessened, and ask if they can put you on a cancellation list.

I wouldn't go back to ER or Urgent Care; if friend did get a different doc, they will mostly just give you a few days of meds. Also, friend might get put on a list of frequent ER users, and get flagged for drug seeking.

The x-rays may not have been wonderful, or read wonderfully. Often the ER is looking for life-threatening issues, not subtle but still very painful breaks.
posted by Dashy at 9:58 AM on June 9, 2015

ps - put a pillow or other prop next to the injured foot, to keep the covers off it at night (but seek treatment!)
posted by Dashy at 9:59 AM on June 9, 2015

Seconding it's not normal for a sprain to hurt so badly you can't sleep or work at a seated job.

Your friend needs to see another doctor. If his insurance card has a consulting nurse hotline, try calling that. I've always found an empathetic ear, good advice and they can connect you to someone else to see him.

I've broken my foot and my leg and sprained my ankles a few times and been able to sleep okay with OTC painkillers. The suggestion for propping covers off the foot is a good one.
posted by purple_bird at 10:22 AM on June 9, 2015

My assumption with bad foot/ankle sprains that are way more painful that usual is that there's a stress fracture in there somewhere. Definitely find an orthopedic or sports med second opinion and let them take their own xrays. In general I find that ERs are not so great for injuries of this kind.
posted by poffin boffin at 10:23 AM on June 9, 2015 [2 favorites]

This does sound totally abnormal for even a bad sprain (speaking from personal experience as an overweight person with a history of bad sprains.) I think a second opinion would be good.

Which dovetails nicely with the fact that even if I did not think this sounded abnormal, I would still say that trying to get pain meds out of your doctor who does not want to prescribe them seems an exercise in frustration. I would suggest starting with an urgent care, both to help check for anything glaring that your doctor overlooked, and because in my experience they're more likely to be liberal with the meds than a regular family physician. Once you hopefully have the immediate pain under control, start trying to get into see a sports med doctor, pronto.

I don't think you're going to get anywhere with the ER or the regular doctor, either from a "second opinion" standpoint or a "just give me some damn meds" standpoint. Start looking elsewhere.
posted by Stacey at 10:28 AM on June 9, 2015 [1 favorite]

(Rounds down to) no doctors in the US will take on a walk-in patient for the purpose of upping the patient's pain treatment from non-narcotic to narcotic. Even seeking a second opinion on a diagnosis if the major implication of the new DX is to justify a narcotic RX is extremely problematic.

Your friend should go back to her PCP and say that her symptoms are obstructing her ordinary life functions, and ask for a referral to an orthopedist for a second opinion. No mention of a hope for narcotics should be made. The orthopedist, in turn, after a couple of visits might be open to a second referral onward to a pain specialist or write a narcotic scrip if he or she makes a diagnosis consistent with the reported levels of pain, to parallel whatever therapy for the condition is appropriate to treat it.

These days, both generalists and many non-pain specialists are unwilling to prescribe narcotics other than for people who are dying from cancer or in immediate recovery from open surgery or a gross bodily trauma. Legitimate pain specialists have the reputation and relationships with the DEA and state medical boards that can endure the scrutiny that high levels of opiate RXs create.
posted by MattD at 10:54 AM on June 9, 2015 [2 favorites]

Response by poster: Update - friend made an appointment at an orthopedic clinic for Friday. Do you think it would be worthwhile to go to an urgent care in the hope of better painkillers?

Honestly, I don't even know what my friend had the first time - I only know that the ER provided a small number of pills that mostly worked, and the primary provided some pills that don't cut the pain.

My understanding is that what is being sought is not A Large Prescription For Something Dubious, just a couple of days' worth of something strong enough to let my friend sleep - or some other way of reducing the pain to that point. I can't imagine that lack of sleep and the additional stress of being in serious pain all the time are helping the injury any. And at this point, my friend is so far from ahead of the pain that naproxen, etc can't keep up.
posted by Frowner at 11:06 AM on June 9, 2015

Pain specialists are for chronic issues - this seems to be an acute injury.

If it's that bad, she could ask to get on a waiting list at the orthopedic clinic to get in before Friday, and call every morning at 9 am just to check.

Robaxacet has helped me (for sprains, mind). It's an OTC drug (other brand names: Robaxin, Robaxin-750, Carbacot, Skelex) - acetominophen and methocarbamol are the things to look for.

(Re images - X-rays only capture calcifications in the case of soft tissue injuries, or small pieces of bone, or a narrowing of space; MRI or diagnostic ultrasound are called for with tendon and ligament injuries. And, X-ray interpretation is as much art as science; and, what radiologists see depends on the views ordered [e.g. weight-bearing or not, etc].)
posted by cotton dress sock at 11:56 AM on June 9, 2015

My sister is an ER nurse and I would avoid going to the ER or urgent care as much as you can because they will flag you and they'll give you as little medication as possible. It's unfortunate for people who have legitimate pain but they see tons of drug seekers. If your friend does go, make sure not to ask for a specific drug. Just describe the pain and explain how much it is interfering with daily life.
posted by desjardins at 11:57 AM on June 9, 2015

I admit I haven't read all your updates but it isn't clear to me if your friend has had an additional follow up with the primary doc after the initial one in which conservative management was pursued. It is very common for patients to come back to a doctor to try another method of treatment when the first does not work.

I would recommend another appointment or phone call to say "I tried the conservative approach but it is not sufficiently addressing my pain. What else can be done as I cannot sleep and my work is suffering."
posted by teamnap at 11:59 AM on June 9, 2015 [1 favorite]

Also, "my pain is 10/10" or "this is the worst pain I've ever had in my life" usually induces eye-rolling among the nurses unless you've been shot or disemboweled.
posted by desjardins at 12:00 PM on June 9, 2015

I'm afraid I can't help with the meds question (although it could help to use Aleve PM as the last evening dose of naproxen--not that it would give more pain relief, but maybe some much-needed sleep without mixing meds).

What I can tell you is that an orthopedist examined x-rays of my foot and could not see the stress fracture that showed up on the MRI he also ordered. The pain had been waking me up repeatedly through the nights, and getting an MRI was annoying, time consuming, expensive (even after insurance), etc., but it did confirm the fracture.

If I were your friend, I would not go in asking for pain killers or an MRI, because many doctors like to be in control and don't appreciate suggestions; but if the MRI doesn't come up, I wouldn't leave without asking about one "in light of a friend's experience" or some such phrasing.

I really hope your friend gets an accurate diagnosis and relief from the pain. Good luck!
posted by whoiam at 12:01 PM on June 9, 2015 [2 favorites]

In terms of what to do about pain killers until the doctors figure out what's causing the severe pain, I'd talk to friends and family. Everyone and their aunt Vicky has a bottle of Vicodin or Codeine left over from a wisdom teeth surgery or broken arm. With combination narcotic/NSAIDS it's easy and extremely deadly to overdose on acetaminophen, so pay attention to the dose. Heck, with the amount of pain your friend is in now, I'd be checking to see they weren't overdoing the Tylenol!
posted by congen at 1:37 PM on June 9, 2015 [1 favorite]

Oops, wasn't finished.

It's not actually legal to share prescription drugs, so I'd be delicate and discerning in my asking around. I can buy codeine without a prescription, so I don't feel like I'm advocating for something particularly dangerous here.
posted by congen at 1:45 PM on June 9, 2015

Would you be willing to call the primary care doctor's office and talk to his nurse about this. It's frustrating but doctors take someone else saying there's a serious problem more than they will a patients sometimes.

Don't ask for prescription pain killers, just ask for advice on what would help...specialist, OTC pain medicine combos or anything else they can think of. Give concrete examples of how this is causing problems and ask them to leave a message with the doctor. It might be enough of a push for the doctor to take it seriously and phone a script in.
posted by stray thoughts at 10:23 PM on June 9, 2015 [1 favorite]

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