IS IT REAL PAIN OR DRUG ADDICTION?

    The other day I was in the hospital and saw that the hospital was asking patients to answer a questionnaire, in which they were asked about the treatment that they got in the hospital . They were also asked to evaluate the doctor as far as communication, care, and if he answered their questions or concerns. I was surprised to see some of the 'good ' and 'caring ' doctors get lower grade . I made a comment , that may be they need to ask extra question, "did you need any pain medication ?" . I hear about pain seeking patients everyday . Fortunately I am not directly involved in taking care of these patients, but do know that these patients do exist and get angry when they do not get the pain medicines.Theses patients will not be happy with the doctors, who would not give them the pain medicines. It is very difficult sometimes to really know the difference between the 'real' pain and just drug seeking behaviour. It reminded me of this patient that I had seen many years ago.
     I saw this 71 years old male with complaint of coughing blood . He was coughing hard and brought up blood tinged sputum. He was given an antibiotic and a cough medicine and was asked to see me . He had X-ray done and it was OK , and so he came to me .On questioning , I came to know that he was ex smoker and had quit smoking 5 years ago .He was retired, and had some cough for last 6 months . He had history of high blood pressure and arthritis . His examination was unremarkable .On reviewing his medicines I saw that he was taking long acting morphine called Oxycontin . I asked him as to why he was taking it . He told that he had back pain and was treated by family doctor first and the when the pain continued , he was refereed to orthopedic doctor . He had some X-ray and was given physical therapy and when pain continued was given morphine . I looked at the chest X-ray and noted some abnormality on the left side . It was close to the heart border. I was not concerned about the hemoptysis, but I was surprised by the back pain in this 71years old who needed narcotics to control the pain . I ordered the CT scan of the chest and also the CT scan of the lower spine .
     I was not surprised when the radiologist called me with 'wet' reading . He had a tumour in the spine and it was pressing upon the spinal cord . He also had a tumour in the left lower lobe . ( He also had swelling of the leg and I had done a scan to rule out clot called phlebitis and it was positive for the clot ).The main concern was the tumour pressing on the spinal cord . I started him on blood thinner and called a radiation oncologist , the doctor who treats cancer with radiation . He agreed with me and saw patient same day and started the treatment without diagnosis of the cancer . Due to the clot in the leg I had to treat it first. ( if the clot is not treated then it can travel to lung , which could be fatal  ) So we decided to continue the radiation treatment and the blood thinner fof next 3 weeks , then do the biopsy of the lung mass . We got the diagnosis of the lung cancer , which had spread to the spine and had caused the severe back pain , which needed narcotic.
    The 'clue ' to the diagnosis of tumour was that he did not look like some one who was drug seeking and  had real bad pain , which needed the narcotic . I was glad that I could differentiate between the two behaviours.