“How are they ‘really’ treating you?”

In “The#1 question to ask inpatients” (Pearls, Current Psychiatry, October 2007), Dr. Kenneth Lakritz encouraged clinicians to ask patients about the quality of their treatment in the hospital. If the patient’s response is negative, the clinician could consider various personality disorders, including borderline personality disorder, when a patient describes “hospital staff split into idealized and rejected components.”

Before exploring characterologic issues, determine if the patient has a valid concern about the quality of care, perhaps in regard to select staff only. Relying solely on the approach described in this article could worsen the therapeutic relationship.

Robert Barris, MD
Flushing, NY

Dr. Lakritz’s article regarding the diagnostic helpfulness of a hospitalized patient’s response to the question, “How are they treating you here at the hospital?” was interesting and useful. However, I would like to clarify a sentence regarding patients with substance abuse disorders.

The article states, “Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.” The same response could be given by a patient whose pain is undertreated, which often happens with short-acting opioids. Hydrocodone, oxycodone, or codeine often don’t ease pain for as long as assumed. Actual pain relief may be 2 to 3 hours at most, when the typical order is for 4 to 6 hours “as needed for pain.”

Because a patient might be in significant pain after 2 to 3 hours and the next dose isn’t due for another 1 to 4 hours, he or she understandably might be preoccupied with the timing and dose of pain medications. This behavior could make these patients appear to be substance abusers.

The difference between these 2 groups is evident when the pain is adequately treated and the demanding behavior disappears. In patients abusing opiates, the dose always needs to be a little higher. This phenomenon is known as pseudoaddiction. I realize that Dr. Lakritz had limited space to make his point. However, in recent years considerable time and effort has been expended to improve pain treatment.

Michael Newberry, MD
Vail, CO

Dr. Lakritz Responds

I agree with the points made by Drs. Barris and Newberry: neglectful or abusive hospital staff and undertreated pain are all too common, as is the tendency to label unhappy patients as “difficult” or character disordered. Perhaps I should have emphasized that a “positive” answer to my favorite question doesn’t establish a diagnosis, but rather should guide a more thorough investigation of the patient’s circumstances.

Kenneth Lakritz, MD
Lahey Clinic Medical Center
Burlington, MA

In “The#1 question to ask inpatients” (Pearls, Current Psychiatry, October 2007), Dr. Kenneth Lakritz encouraged clinicians to ask patients about the quality of their treatment in the hospital. If the patient’s response is negative, the clinician could consider various personality disorders, including borderline personality disorder, when a patient describes “hospital staff split into idealized and rejected components.”

Before exploring characterologic issues, determine if the patient has a valid concern about the quality of care, perhaps in regard to select staff only. Relying solely on the approach described in this article could worsen the therapeutic relationship.

Robert Barris, MD
Flushing, NY

Dr. Lakritz’s article regarding the diagnostic helpfulness of a hospitalized patient’s response to the question, “How are they treating you here at the hospital?” was interesting and useful. However, I would like to clarify a sentence regarding patients with substance abuse disorders.

The article states, “Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.” The same response could be given by a patient whose pain is undertreated, which often happens with short-acting opioids. Hydrocodone, oxycodone, or codeine often don’t ease pain for as long as assumed. Actual pain relief may be 2 to 3 hours at most, when the typical order is for 4 to 6 hours “as needed for pain.”

Because a patient might be in significant pain after 2 to 3 hours and the next dose isn’t due for another 1 to 4 hours, he or she understandably might be preoccupied with the timing and dose of pain medications. This behavior could make these patients appear to be substance abusers.

The difference between these 2 groups is evident when the pain is adequately treated and the demanding behavior disappears. In patients abusing opiates, the dose always needs to be a little higher. This phenomenon is known as pseudoaddiction. I realize that Dr. Lakritz had limited space to make his point. However, in recent years considerable time and effort has been expended to improve pain treatment.

Michael Newberry, MD
Vail, CO

Dr. Lakritz Responds

I agree with the points made by Drs. Barris and Newberry: neglectful or abusive hospital staff and undertreated pain are all too common, as is the tendency to label unhappy patients as “difficult” or character disordered. Perhaps I should have emphasized that a “positive” answer to my favorite question doesn’t establish a diagnosis, but rather should guide a more thorough investigation of the patient’s circumstances.

Kenneth Lakritz, MD
Lahey Clinic Medical Center
Burlington, MA

In “The#1 question to ask inpatients” (Pearls, Current Psychiatry, October 2007), Dr. Kenneth Lakritz encouraged clinicians to ask patients about the quality of their treatment in the hospital. If the patient’s response is negative, the clinician could consider various personality disorders, including borderline personality disorder, when a patient describes “hospital staff split into idealized and rejected components.”

Before exploring characterologic issues, determine if the patient has a valid concern about the quality of care, perhaps in regard to select staff only. Relying solely on the approach described in this article could worsen the therapeutic relationship.

Robert Barris, MD
Flushing, NY

Dr. Lakritz’s article regarding the diagnostic helpfulness of a hospitalized patient’s response to the question, “How are they treating you here at the hospital?” was interesting and useful. However, I would like to clarify a sentence regarding patients with substance abuse disorders.

The article states, “Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.” The same response could be given by a patient whose pain is undertreated, which often happens with short-acting opioids. Hydrocodone, oxycodone, or codeine often don’t ease pain for as long as assumed. Actual pain relief may be 2 to 3 hours at most, when the typical order is for 4 to 6 hours “as needed for pain.”

Because a patient might be in significant pain after 2 to 3 hours and the next dose isn’t due for another 1 to 4 hours, he or she understandably might be preoccupied with the timing and dose of pain medications. This behavior could make these patients appear to be substance abusers.

The difference between these 2 groups is evident when the pain is adequately treated and the demanding behavior disappears. In patients abusing opiates, the dose always needs to be a little higher. This phenomenon is known as pseudoaddiction. I realize that Dr. Lakritz had limited space to make his point. However, in recent years considerable time and effort has been expended to improve pain treatment.

Michael Newberry, MD
Vail, CO

Dr. Lakritz Responds

I agree with the points made by Drs. Barris and Newberry: neglectful or abusive hospital staff and undertreated pain are all too common, as is the tendency to label unhappy patients as “difficult” or character disordered. Perhaps I should have emphasized that a “positive” answer to my favorite question doesn’t establish a diagnosis, but rather should guide a more thorough investigation of the patient’s circumstances.

Kenneth Lakritz, MD
Lahey Clinic Medical Center
Burlington, MA