Chapter 4: Pain Management
“I go to the doctor to get dismissed,
‘Try losing weight, you’re just anxious’,
That’s fine, that’s cool, I’m not pissed,
Just wait ten years for a diagnosis.
‘Psychosomatic, you’re so dramatic,
Hysterical, emotional, hormonal, erratic,’
Heart disease, chronic fatigue, depression and anxiety,
‘Do you have pain? No you don’t.’
‘Cause we never really studied the female body.”
-Farideh, Female Body
Over the next couple weeks, Rita grows accustomed to the way the shop functions, including the ‘back room’. Those customers are easy to distinguish from the others. they walk straight up to the counter without looking around, and they’re slightly more taken aback by Rita’s presence, especially when she’s seemingly alone. She quickly masters the certain smile that somehow says ‘I know why you’re here and I’m cool with it.’ Usually there’s already a parcel in the small bin under the counter with the person’s first name marked on the small chalk label on the front of what Rita thinks of as the outbox.
The backroom customers always pay in cash that gets tucked away in its own slot in the cash register. They’re different than Rita expected, coming from every walk of life. They’re so… normal. Just people, like any others. People who just happen to have chronic conditions that respond well to marijuana.
The recreational customers are more what she’s expecting. Most are under 35 and give stereotypical burnout vibes, but not in a chill way. Rita is glad that Paolo deals with them. She would have a hard time maintain aa pleasant retail attitude if she had to talk to them one on one for more than five minutes. They make her feel uncomfortable for reasons she can’t quite put names to. The herbalist and her nephew are the opposite. Her first week, Angela makes a point of telling her that she can try some herb whenever she wants, but there’s no pressure either way.
They’re so much more neutral about the drug than most of the opinions she’s experienced. She’s heard so many things, both positive and negative about marijuana. The positives usually sound unbelievable, and the negatives have so much misinformation running through them that it’s hard to know what to believe.
It isn’t the first time Rita has been offered marijuana, but it is the first time she considers accepting. In the past, anyone who was for it usually made her feel guilty for not trying it sooner, given her chronic pain. It always makes her uncomfortable and, while not the only reason, is a large part of why she hasn’t tried it yet.
This particular Thursday morning, Rita sweeps a little too fast, her nerves not allowing her to sit still. She has her first pain management appointment today, and she somehow simultaneously has no idea what to expect, and can’t stop thinking of worst case scenarios. What if they drop her as a patient? What if they don’t believe her and she gets permanently red-flagged as hysterical in her medical records? What if they say there’s nothing they can do?
Rita’s anxiety thoughts are not helped by the conversation between the herbalist and a close friend of hers who comes in all the time. Not for the stuff behind the counter, just to talk to her friend. The woman is younger than Angela, Middle aged, probably. A heavyset white woman with long greying brown hair twisted into a knot, she uses a cobalt blue mobility scooter thanks to crippling joint pain. She’s usually dressed neatly in office wear, always seeming to have come from work. Rita mentally dubs her ‘The Engineer’ when she first meets her, after the job she talks a lot about. She has heard the woman’s real name but never remembers it.
“I tell them my pain has increased and they halve my prescription!” The Engineer rants. “What kind of pain management is that?”
“The same kind given by those who see criminals before patients and treat with suspicion before compassion,” the Herbalist responds. “Opioid overdoses must be up again.”
“Exactly! Every time this happens it’s some war on drugs bullshit. As if criminalizing chronic pain patients and our doctors is helping anyone. It’s bullshit, is what it is. Bat rastards.”
“Not all of them.”
“But enough,” the Engineer finishes Angela’s thought.
“You’re always welcome to try what I’ve got to offer.”
“Nah, you know how I feel about it. Can’t afford to lose any of those little grey cells.”
“And yet, you drink alcohol. Which actually kills nerve cells.”
“I know, I know.” The Engineer waves a hand.
“Suit yourself.” Rita gets the sense that this is a well-worn argument. The herbalist turns her lined brown face towards Rita, wise dark eyes fixing on her face. “Rita has her first pain management appointment today, isn’t that right, dear?” Rita nods jerkily, putting a hand on her aching back.
“My mom will be here in a few minutes to pick me up.”
“Not at cascade, hopefully,” the Engineer says.
“I think it’s called ortho-something,” Rita can’t remember the full name of the clinic.
“That’s good. I’ll have to come back next week and hear how it goes. I might want to get a referral there. Don’t give them any reason to think you might be drug-seeking. Or that you don’t take drugs seriously.”
“Well, I do take drugs seriously,” Rita says truthfully. “So that should be easy.”
“You would think so,” the Engineer says.
“You would think so,” The herbalist echoes, shaking her head.
“Good luck, kid.”
Feeling not at all comforted about her impending appointment, Rita’s stomach sinks as her mom’s car pulls up in front of the shop. Opening the front door, Rita sweeps the small pile of dust she’s collected out onto the sidewalk, then crosses to the cabinet behind the counter where she returns her broom and apron to their proper places. She stops short on the way out at the sight of Mamá and Angela standing it the doorway, chatting as the bells tinkle above their heads.
“Angela was just telling me how great you’re doing,” she says as Rita approaches stiffly, worlds colliding.
“It’s truly a blessing to have her here.” The herbalist smiles warmly up at her. Rita blushes, glancing around uneasily.
“I had a feeling she would be.” Mamá’s brown eyes sparkle as she holds the door open.
“Buena Suerte, amiga,” the Herbalist says, laying a warm, slightly tremoring hand on Rita’s forearm. Is luck more potent when it’s given in 2 languages? Rita wonders. Hopefully so.
“How are you feeling, Mija?” Rita stares out the car window, no idea how to respond.
“Alright enough, I guess,” she gives an equally vague answer.
“A little nervous?”
“Yeah,” she shrugs one shoulder.
“It’ll be fine,” Mamá reassures. But Rita, sadly, is beyond the age when she blindly believed her words. When she was small, her mother’s words were magic. Now they’re just words.
Sitting in the waiting room of the pain management clinic, Rita’s foot taps nervously against the floor. Jostling faint tinkles from the clipboard in her lap. Her hips and back quickly yell in protest to the motion, and she makes herself stop, starting again a few moments later when her attention shifts to the forms in front of her. The waiting room is nicely appointed and the receptionist is friendly and inviting, but the questions on the forms make her suppress a shudder.
In the past 30 days, how often have you run out of your pain medication?
Seems innocent enough, but they soon escalate.
In the past 30 days, how often have you stockpiled medication?
How often have you shared your medications with others,?
How often have you taken prescription medications for pain that were not prescribed to you?
It feels like navigating a minefield, any one of which might blow up her chances at getting any help. The Herbalist’s earlier conversation with the Engineer floats back to the front of her mind as she carefully answers the form’s questions. Two neighboring questions ask:
In the past 30 days, how often have you used alcohol to manage your pain or other symptoms?
And
How many units of alcohol do you consume per week?
Followed quickly by:
In the past 30 days, how often have you used street drugs to manage your pain?
And
Have you tried marijuana for the treatment of your pain?
Is that legal to ask in a state where it isn’t? Rita wonders.
On the back of the questionnaire , Rita has to suppress a groan at the all-toofamiliar sight of twin front and back anatomy figures with text above and below asking her to circle every region where she has pain and annotate the quality and intensity of the pain using an alphanumeric code detailed in a small key in the corner that Rita has to squint to read. By the time she’s done, most of the figure’s body parts are circled and annotated. It takes over fifteen minutes to answer all the form’s questions, including L and I questions that don’t apply to Rita, and functionality questions that are just depressing.
After she finishes the ‘Are you a drug-seeking criminal’ and ‘tell me every single detail of your pain’ forms, she moves on to the more standard privacy policy, medical history, and insurance forms. The forms have an optional spot for a preferred name and pronouns, which Rita considers a good sign. It definitely gets old hearing medical personnel call her Margarita when no one else does apart from her mother. She’s halfway through the forms when she’s called back by the medical assistant, flustered as she tries to balance the clipboard and pen and maintain her own balance on the way. Mamá grabs her purse and makes to follow but Rita gestures to her to stay.
The medical assistant takes her back to the room, wearing clean scrubs and a stethoscope. He introduces himself as Calvin and takes Rita’s vitals and pharmacy information. Rita is glad the scale is set to kilograms. She knows she’s gained weight in the past two years, but she’s not sure how much. In the past, weighing herself at home sent her into far too many anxiety spirals, so she gave up on it entirely. Bad enough to have to feel her stomach drop when she checks ‘yes’ to weight gain on the intake forms, she doesn’t need a number to obsess over. The medical assistant records her vitals then leaves her alone in the exam room. He says the doctor will be in soon, which could mean 20 minutes or 2, so she rushes through the forms in case it’s the latter. Of course, because she does, it turns out to be the former, and she’s left to try to untangle the spiraling mess of her thoughts and feelings in painful silence. She tries to answer the anxiety and depression screenings as honestly as she can, though they always make her uncomfortable. She’s grateful, in that moment, that Mamá hasn’t come back with her.
She gives up on trying to keep her leg from bouncing, biting her nails as she silently reviews everything she is and is not supposed to say. The appointment hasn’t even properly started yet and she’s already mentally exhausted.
Eventually, there’s a knock on the door and Rita hastily straightens her shirt, sitting up straighter in a way that immediately pains her back as the door opens and the doctor enters, crossing to the computer terminal opposite the door and sitting on the rolling stool in front of it. He’s probably in his forties or fifties and looks like a dictionary example of a doctor from the 1970s or ‘80s.
“Hello. How are we doing today?” The doctor wears a white lab coat and glasses. His graying brown hair and beard are neatly trimmed and his voice is gentle and soft. Still, Rita has enough experience with the medical system by now to keep her guard up.
“Not too bad, I guess.” Rita immediately chastises herself for reflexively minimizing her symptoms. She’ll never get the help she needs that way. But she can’t overexaggerate either, or she might be accused of faking.
“That’s good. So…” Rita can see the screen’s reflection in his glasses as he spends several painful minutes reading over her file and intake forms. She wonders if it’s reflected in her own glasses too, and wishes she could see well enough to read along. You never know what a provider night be writing about you in their notes until you read them after the fact. Rita has wondered before if part of the reason they use such dry, boring med speak in them is to deter patients from spending the time and energy to read them. “We’re looking at some pretty significant flank pain, looks like.” He looks at her, eyebrows raised.
“Yes,” Rita nods a little too vigorously and puts a hand to the growing knot of tension on the left side of her neck.
“And it looks like you’ve been worked up pretty thoroughly. I’m seeing a number of diagnoses in your file.”
“But none that can really explain my pain.” Rita nods again.
PCOS, Ulcerative Colitis, or something else that could cause kidney stranding, Crohn’s, Gallstones, Endometriosis, IBS… If it can possibly cause torso pain and isn’t easy to rule out, she’s probably been diagnosed with or investigated for it at some point. But none can really account for the severity and specific presentation of her symptoms. Much as she longs for one definitive answer, it gets more and more clear that she won’t find one.
“Uh-huh. And where’s your pain at present?” Rita takes the worst kind of inventory, focusing inward on all the pain in her body, which she usually avoids at all costs.
“There’s the usual pain in my side, or flank, I guess.” Rita motions over the area as she speaks. “And then there’s the pains in my legs and arms. And my neck hurts.”
“And on a scale from 1 to 10, how would you rate the severity of your pain right now.” It’s at least the third time she’s answered this question in the past half hour, and probably the thousandth in general. It doesn’t get much less irritating with the repetition. Alone, it hardly even gives any useful information. 10 is usually set as the worst pain the person answering has ever experienced. But that’s bound to vary wildly patient to patient. And how is one supposed to adequately scale pain when it is actively becoming the worst they’ve ever experienced?
“I would say, 8, I guess?” It comes out more as a question than an answer. “It gets worse, but it’s pretty bad right now.” Her hand comes up to rub at the knot of tension on the left side of her neck. Thankfully, the doctor asks follow-up questions. Unfortunately, he decides to poke and prod at her side as he does.
“That 8, that’s the flank pain?” he asks as his fingers find the sorest spot.
“Uh, yeah, I think so,” Rita gasps, wincing satisfactorily as the fingers poke deeper at a spot on her back an inch over.
“And what’s the arm and leg pain at?”
“Right now?”
“Yes.”
“Uh, maybe a 6?” The doctor nods, finally letting up. Rita lets out the breath she’s been holding and tries to maintain focus through the throbbing pain in her side.
“Would you describe the pain as shooting? Stabbing? Burning?” Rita takes a shaky breath, blinking through the lights flashing in her peripheral vision.
“Stabbing? I guess?” her voice sounds short of breath and her thoughts are slow and sluggish, as if her head is full of thick mud. “But deeper. Sometimes it’s less sharp and more like a really bad, really deep ache.” She can only hope her words are sufficient to convey her pain. They don’t feel sufficient. It’s difficult with so many missing. She isn’t fluent, but she understands enough Spanish to know it’s no different in her mother’s language. She supposes it makes sense. Most people are deeply uncomfortable talking about pain. Some even seemed to hold a superstitious fear of the subject, as if talking about it would let it come for them next. No wonder the vocabulary on the subject is stunted. “The pain in my arms is different. It moves around more. Sometimes it’s burning or searing, other times it’s like anything touching my skin hurts. Like, small itches or, say, a tag on my clothes becomes painful pretty quickly if I don’t do anything about it.”
“What makes it worse?”
“Moving. Sleeping on it wrong, bad weather.”
“Weather?”
“It hurt worse during the winter storms. And when it was really cold in January.”
“Is that the pain in your flank? Or elsewhere?”
“Both,” Rita shrugs a hand as she answers. “It hurt worse in my flank and in my arms and legs.” The doctor nods thoughtfully as a trickle of sweat runs down Rita’s side.
“You’ve been through quite a few specialties. It says here you did get physical therapy. How did that go?” Rita chooses her words carefully.
“Okay, at first, but after a few weeks it started to actively make my pain worse, so my PT said I should stop. That’s around when I got the injections.”
“And the ablation. I see that here.” He turns the screen a little farther away from her. Rita’s eyes dart nervously around the small room and she pulls her phone out of her pocket for something to look at while the doctor reads. She scrolls through the 3 notifications in the dropdown menu, then quickly shuts it off again and returns it to her pocket as the doctor clears his throat. “What were the results of the ablation?”
“It worked on a small section of my back, about 2 inches square, but did nothing for the surrounding pain. And the nerve pain when it came back was awful.”
“How long did the relief last?”
“About a month, I think.” The doctor makes a low, noncommittal noise in his throat.
“And you were on oxy for a little while?”
“Before it was chronic, yeah.”
“Tell me about that.”
“It helped a little, but only really took the edge off. My primary care doctor wasn’t comfortable prescribing it to me long-term with so little benefit.” The doctor nods again and Rita wishes she could see what he’s thinking.
“And this was how long after the accident?” Rita’s breath hitches in her throat but she forces it through enough to respond.
“About 6 months.”
“I see.” The doctor nods again. “Has anyone ever talked to you about Fibromyalgia?”
“Someone brought it up at some point, I think, but I don’t really know anything about it.”
“It used to be called Centralized Pain Syndrome, and it often develops following a trauma.”
“So it’s, a real thing, then?” Most of the references Rita’s heard to the condition are making jokes about it being fake.
“Most definitely. I see patients with it all the time. Pain often proliferates. When one part of your nervous system is sending constant pain signals, the rest of your nerves can become primed to send their own signals at any provocation.”
“So, you’re saying it’s my fault?”
“I’m saying it’s not unexpected, given what you’ve been dealing with for the past 2 years.”
“Is there a test for it?”
“No, it’s just diagnosed based on symptoms. And you have quite a few of them.”
“I do?”
“Yes.”
“Is there a cure for it?” She holds her breath awaiting the answer. It’s as cruel as it is short, when it comes.
“No. But it is treatable.” Rita looks down at the smooth tiled floor, trying to hide the disappointment that crushes her. The doctor continues. “I think there are a few things we can do to try to get you some relief. I’m going to put you back on Gabapentin, at a higher dose than you were on before. I’ll refill the muscle relaxers you’ve been taking. Any side effects with those?” It takes several moments for Rita to respond.
“Not really, no.” The doctor nods, typing. “A little drowsiness, but it doesn’t bother me much. If anything, it helps me sleep.”
“That’s good.” The doctor nods again, then turns to face Rita, their eyes locking through their lenses. “I also have a few more types of nerve blocks you haven’t had yet that I’d like to try, if you’re amenable.” Rita doesn’t know how to answer. The doctor goes on. “We can provide IV or oral sedation, if the actual procedure itself is the concern.” Rita nods, thinking. Sedated nerve blocks definitely sound better than unsedated nerve blocks, but they still don’t sound great. One of the ones she had before backfired so badly it put her in the ER with an acute flare. Probably the worst one yet. That was probably her 10, not that anyone ever asks. The doctor is waiting for her answer. She suppresses a shudder. She can’t afford to seem uncooperative.
“Okay,” she says reluctantly.
“I also think you may benefit from seeing our in-house pain psychologist.”
“A psychologist?”
“You show several symptoms of depression and anxiety. That stress could hypothetically be adding to your pain level. Talking to someone might help in the long run. And a pain psychologist only treats patients with severe pain, so they understand your circumstances better than a regular therapist will.”
“I’m not sure if my insurance covers it.”
“It should, but I’ll have my practice manager make sure.”
“Okay,” she agrees, a little less reluctantly. At least this one doesn’t involve needles in her spine.
“Excellent,” the doctor finishes whatever he’s typing on the computer, logging out to the same screensaver it was showing when Rita was brought back. “I’ll want to see you back for a follow-up in about 4 weeks. See how things are doing.” Rita nods. “You can schedule everything at the front desk on your way out. Any questions I haven’t addressed?” Rita can’t think of any in the moment, so she shakes her head, the motion catching on the knot in her neck. “Excellent. I’ll see you soon, then.” Rita nods as he sweeps out of the room, leaving her alone in the near silence.
“I have a 2:30 or a 4:45…” The receptionist pauses her typing, awaiting a response.
“2:30, I guess.” Rita thinks that the earlier appointment will give her less time to worry leading up to it.
“And for the Nerve block, I have a 2:00 next Tuesday.” That’s so soon. Rita feels like she shouldn’t be allowed to schedule a procedure she knows so little about. She forgot to even ask the doctor what the block he wants to try is called.
“I guess that works,” she answers, head aching and back spasming.
“And we’re doing the IV sedation for that, is that right?”
“Yes, please. Definitely.”
Alright, I’ve got you all booked up. Would you like a reminder card?”
“Sure.”
“And the doctor wants you to try filling out a pain log for the next few weeks.”
“Why?”
“it can help to identify triggers.”
“Okay.” It’ll just add to the pile of things on Rita’s desk, but maybe she’ll get some motivation to start using a calendar app again instead of vaguely holding her upcoming appointments in her head and relying on Mamá to remind her of the exact times.
“How did it go?” Mamá wants to know as the car pulls out of the clinic parking lot. Rita suppresses a sigh. She’s so fucking tired and drained and just plain ow.
“Not too bad. He has a couple things he wants to try,” Rita says in a tired, breathless voice.
“Oh yeah?” Mamá glances sideways, smiling. “Like what?”
“Nerve blocks, gabra something.” Rita yawns and shifts in her seat, unable to really get comfortable. “A couple other things. I’ll remember later.”
“You tired?” Stating the obvious.
“I don’t remember the last time I wasn’t.” Rita yawns through the last words.
“Wait until you have kids.” Rita makes a noncommittal noise. Who knows if she’ll ever be able to have kids. Like this, probably not. And she forgot to even ask what the doc thinks is causing her pain,. They went over her various diagnoses but it feels like the conversation isn’t finished. Like she didn’t say or ask the right things. Taking a deep breath, Rita reminds herself that this won’t be her last appointment with this provider and she can make a list of questions to ask him next time. Still, she blinks back tears at the thought that she might have failed herself.
For now, though, her day is done and she’s on her way home. In the end, as she returns from the pain management clinic for the first time, it’s with an air of Exhausted and Extremely-cautious Non-pessimism.