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Joined Jun 28, '11 - from 'Virginia'. Palliative Care, DNP is a DNP, FNP. She has 'Since 2009' year(s) of experience and specializes in 'Family Nurse Practitioner'. Posts: 763 (55% Liked) Likes: 1,895

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  • Dec 9

    Quote from BostonFNP
    This is a huge issue in primary care, something I deal with every day.

    We are talking with all of our non-cancer chronic narcotic users and starting a dialogue based partially on CDC info, partially on our state changes, partially on insurance changes, and partially on having re-evaluated the extant data on the topic. We are encouraging (well in some cases mandating) that patients re-trial PT/OT, get evaluated by a pain specialist, try CAM modalities.

    If a patient has surgery scheduled that's one thing and I doubt I would spend much time dealing with it prior to surgery but i would have the conversation that after surgery there is a 6-week plan to be off the meds. More commonly I am seeing the people that are two or three years s/p THR that are still on the same amount of narctoics, or even more frequently, people that have very minimal disease and have not tried any other modalities or interventions. We are making dependent patients in those cases.

    I have some major concerns about chronic pain syndrome in which after the initial 6-12 weeks the pain is no longer associated with the initial insult: you can fix the underlying problem and the patient still is not able to tolerate life off of narcotics. I especially have issues with 18-30 year-olds that are on chronic non-cancer pain opiates and those patients taking more than 180mg/day of morphine equivalent.
    Pain management is complex in many cases and I agree that there are problems with chronic pain patients who do not have cancer. Not that long ago I talked to a pat who had an accident some years ago with spine injury, hip and leg. The patient was on more than 200 mg morphine equivalent a day for many years until his PCP retired and the new one was not willing to go that route. He did a controlled tapering over 3 months and got off narcotics. After half a year without narcotics the patient get re-admitted and low and behold now has 10/10 pain due to cancer. No narcotic helped and the patient got non responsive with still huge pain. Methadone was the way to go but the primary physician was not aware that methadone would be the best choice for pain and kept on telling the patient to make himself CMO instead so he could receive mega doses narcotics. He got switched to methadone with significant improvement after 3 days and continued to improve with pain.

    The other group that has problems with narcotic addiction are sickle cell patients with frequent crisis as they require high doses to control the pain. There is a good protocol now and those patients go home on methadone for a couple of days and are on no narcotics between crisis.

    There are patients who go to the pain clinic only to reject all non narcotic solutions and circle back to the ER...

  • Dec 9

    Lots of options between oxy and Tramadol. Our doc use a multi modal protocol: celebrex, lyrica, tylenol, and a narcotic. Tramadol is usually not used unless it is pt request or out very elderly pts. I would say that this pain management plan is not optimal. He almost should be on something long-acting like MSContin if he can't tolerate the oxy group. I would have him speak to the surgeon, not the PA. PAs tend to be a lot more conservative.

  • Dec 9

    Quote from HeySis
    I understand your friend is not a drug seeker... but that's not the important part here for me.

    And I also believe in teaching patients that to expect 0/10 is unrealistic, they need to understand post-op pain that rates 2-3 is well managed, but allowing pain to be 6/10 or greater without trying more interventions (medications as well as non-Pharm) is harmful.

    Pre-op and post-op is not the time to "fix" someone's narcotic use..... We will not cure/prevent addiction by allowing these patients to have extreme pain.

    What we will do is prevent them from getting up and around, from doing their deep breathing, from eating properly... all because the pain is not managed.
    You are so right.

    To add to your thoughts -

    You don't taper someone down before the surgery which will fix the condition causing the pain. You wait until after the surgery and after the period of acute pain caused by the surgery. Then you gradually wean them off the pain med.

    You don't "taper" someone down by suddenly cutting their pain medication in half. You decrease the medication gradually.

    This is not a patient who wants to be on narcotics indefinitely. He has surgery scheduled. He wants pain medication to allow him to function until the surgery can be done. That is a very appropriate use of pain meds.

    OP, yes. In some states providers are under extreme pressure to not prescribe pain meds.

    My state has passed a lot of laws the past few years to "fix" the narcotic abuse problem.

    The state flags the top 100 prescribers of schedule drugs. No provider wants to be on that list and to be subjected to the added scrutiny it entails.

    The state has classified tramadol as a schedule II drug even though the fed classifies it as schedule IV.

    Prescribers are limited to the total amount, to the number of doses a day, and to the length of time they can prescribe w/o being a pain specialist (i.e. fellowship trained in pain managment).

    It goes on and on.

    The good news is that the amount of scheduled drugs prescribed has decreased since these laws were passed. The bad news is that the use of illegal drugs (especially heroin) has increased at the same rate during that time period.

  • Dec 9

    I understand your friend is not a drug seeker... but that's not the important part here for me.

    And I also believe in teaching patients that to expect 0/10 is unrealistic, they need to understand post-op pain that rates 2-3 is well managed, but allowing pain to be 6/10 or greater without trying more interventions (medications as well as non-Pharm) is harmful.

    Pre-op and post-op is not the time to "fix" someone's narcotic use..... We will not cure/prevent addiction by allowing these patients to have extreme pain.

    What we will do is prevent them from getting up and around, from doing their deep breathing, from eating properly... all because the pain is not managed.

  • Dec 9

    I and my coworkers wonder a lot lately...
    Granted, I work in end-of-life care and there is a lot of symptom management related to terminal illness. There has always been the group of providers who are very hesitant to prescribe narcotics for symptom management pain and would not prescribe liquid morphine to deal with SOB unless the patient decided to be CMO.
    Pain management is not that easy to begin with if a person has more than the standard pain issues or prior substance use. When we see patients who have a prior narcotic history or are already on high doses they may do better with methadone but many prescribers do not have the experience and do not like to deal with it for example. I had a patient basically screaming out in severe pain because of cancer and the patient had a prior tolerance history with taking up to 200 mg of morphine a day. What can I say? methadone fixed the problem but it was an act to get there....
    I do think that providers need to be more educated about prescribing narcotics and also utilize other medications and methods.

  • Dec 9

    That preventative care is my passion and acute care is NOT for me. Now I am doing my best to get back into primary care and it's tough.

    That I am no longer the "nicey-nice" person I was before I started in healthcare and my patience for crap is dwindling.

    That you can say No to your employer. You can and must stand up for yourself and your patients. Just be prepared for the repercussions.

  • Dec 9

    My nursing school buddy was former Army. He summed it up simply, "People Are Stupid."

    3 years working ER, I can confirm this is truth.

  • Dec 9

    Education solely is not enough to change people's behavior.

  • Dec 9

    1. People are crazy. Like, ALL people are at one point or another some or other kind of crazy.
    2. I kind of like that about us.
    3. People do not really want to know the truth most of the time.
    4. We know a lot less about how to save people than nonmedical people believe and this dichotomy is very painful and shocking to them when it is discovered, often when CPR didn't work or there are no more treatments to be had or CHF has progressed to the point that it can't be adequately relieved.
    5. If we cured diabetes we would cure an awful lot of other things along with it. Sometimes I think it is the root of most modern day ailments.
    6. Obesity is the last internally justified prejudice among health care workers.
    7. I have a lot more in me than I ever realized.

  • Dec 9
  • Dec 9

    The Joint Commission has the magical ability to bring administrators out on the floor to help. When the JC leaves, the magic recedes, taking with it the extra support.

  • Dec 9

    Death is sometimes like a tidal wave that you can see coming but you can't stop. Death is also sometimes surprising and random.

    Be an organ donor. Enjoy every bite of dessert. Love your people deeply and fiercely.

    Also, the pleasantly confused old lady who thinks you look like an angel during the day will be the confused one trying to scratch your eyes out after dark. Be loving and compassionate to both.

  • Dec 9

    many people do not want to take responsibility for their health. They just want a pill/procedure to fix the mess they made.

  • Dec 9

    Sometimes the care that you want to provide for the patient is not possible. You will have to take a deep hard look at the resources you have and make the best decision possible with what you are given.

  • Dec 9

    I learned very, very quickly that you can't save patients from themselves. That, to me, was no big deal. The hardest thing? When the patient DOES want to save themselves, but there are literally no resources available to make them successful at it.


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