Pain Management

I had my first encounter with a potentially drug seeking patient today and reflecting on it, I realized that pain management is very different here, in part due to the population and in part due to the culture.  When I work up my patients, a lot of them have documented pain scores of 0.  Whether this is because the nurses don't document properly or the patients are trying to put up a tough front I'm not sure, but when I round, many of the patients in fact do not complain about pain.  Or anxiety for that matter.  In the 1 & 1/2 weeks I've been here, I think I've only seen lorazepam once and that was for insomnia, not anxiety.  Morphine I've only seen twice and that was at much lower doses than I have previously seen in the US hospitals I've rotated at.  Like only 0.5 mg/hr PRN.  It seems for the most part everyone does ok on "panadol" aka paracetamol aka acetaminophen.  Here we've still been using 4 g a day and it seems that's a standard order for the hospital.  I asked a resident here why that was and his partial explanation makes sense.  Many of the studies back in the US were done on Caucasians and the population here is, in general, smaller in size (height and weight) as well as more sensitive to opiates (pharmacogenomics).  Part of it is also cultural as some patients here fear the side effects so they would prefer not to take the drugs and tough it out.  I have yet to see fentanyl or methadone as I would have expected for cancer patients but with almost 4 weeks left, it should happen sooner or later.