Opiates Are Not for All Pain

  1. Hi all,
    I am a primary care NP, working with 2 MDs and 2 other NPs. Recently, I had a 90 years old patient, who has post herpetic neuralgia, had shingles 2 years ago. She has h/o diabetes, dementia, sciatica and hypothyroidism. Pt had a fall a year ago, broke her left hip, hemiarthroplasty done. This patient was on oxycodone 5 mg tid prior to the fall for her sciatica, which was tapered off recently in September. After her shingles, she was started on gabapentin 300 mg hs. Patient came this time to the office with her aide, who is with her for 10 years, complaining of neuralgic pain on the left side of her body, more in lt mid back. Aide insisted that gabapentin is not working, patient needs oxycodone back and the patient's daughter is also insisting for oxycodone. I tried to explain the risks, aide would not listen to me. She threw a storm at me. Patient is demented, has no say. I increased the gabapentin to 300mg bid, lidoderm patch for the left mid back and asked her to follow up in a month to see the change. I called the patient's daughter and explained, which she understood. Later, the office manager told me that this aide was collecting patient's medications from the pharmacy, (reported by the pharmacist), who knows whether the patient was getting oxycodone in the past or the aide was using/abusing it? What would you do here?
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    About soliantony

    Joined: Nov '18; Posts: 1; Likes: 4

    41 Comments

  3. by   Dodongo
    If you don't want to prescribe a narcotic, don't. No one can force you. The aide isn't even related so who cares what s/he says. Does the patient appear in moderate - severe pain when you examine her? She has a history of falls and dementia so the last thing you want to do is dope her up.

    You can increase the dose of gabapentin for the neuropathic pain. In a patient with normal renal function, the minimum effective dose is typically 600 mg 3 times a day. So I would titrate her up on that first. Even this medication has the potential for abuse, though. And side effects. Can she tolerate PT?
    Last edit by Dodongo on Nov 16
  4. by   anewsns
    The aide has no say what- so - ever !
  5. by   djmatte
    Quote from Dodongo
    If you don't want to prescribe a narcotic, don't. No one can force you. The aide isn't even related so who cares what s/he says. Does the patient appear in moderate - severe pain when you examine her? She has a history of falls and dementia so the last thing you want to do is dope her up.

    You can increase the dose of gabapentin for the neuropathic pain. In a patient with normal renal function, the minimum effective dose is typically 600 mg 3 times a day. So I would titrate her up on that first. Even this medication has the potential for abuse, though. And side effects. Can she tolerate PT?
    Quoting for posterity. Prescribe what you're comfortable with and what you feel your license can risk. 90 is pushing it for opiate therapy and I'd argue gabapentin may be tough as well. How she isn't in skilled nursing facility given the recent fracture and dementia history is quite amazing and something I'm seeing far too often.
  6. by   Jules A
    My first thought was who really wants the oxy?
  7. by   Oldmahubbard
    The aide is suspiciously over invested in the pt getting narcotics. Can you share the concerns of the pharmacist with the daughter?

    More diversion goes on than we usually know
  8. by   mtmkjr
    Quote from djmatte
    How she isn't in skilled nursing facility given the recent fracture and dementia history is quite amazing and something I'm seeing far too often.
    If there is adequate support and resources it is is a good thing to keep elderly at home, is it not?
    In fact, I would state the opposite, that we put our elderly in skilled care far too often...
  9. by   djmatte
    Quote from mtmkjr
    If there is adequate support and resources it is is a good thing to keep elderly at home, is it not?
    In fact, I would state the opposite, that we put our elderly in skilled care far too often...
    A topic worthy of its own discussion I'm sure.
  10. by   traumaRUs
    Hmmm...The aide is an employee and though she too is a patient advocate, she seems to have overstepped her bounds. I agree 90 is pushing the age where I would prescribe narcotics although at 90 I would strongly suspect that she has some degree of renal impairment and gabapentin 600mg three times per day is pushing the envelope too IMHO.
  11. by   Dodongo
    I qualified my statement concerning renal failure. Like I said, titrate her up over time and stop before she has side effects.
  12. by   traumaRUs
    From UpToDate:

    NORMAL AGING VERSUS CHRONIC DISEASE - Aging is a natural and inevitable biological process that results in structural and functional changes in many organ systems. The kidney systematically loses function (eg, glomerular filtration rate [GFR]) and undergoes anatomical changes (senescence) with age. In addition to specific kidney diseases that are common in older adults, such as diabetic nephropathy, physiological senescence of the kidney occurs, even with healthy aging

    To be honest at 90 I would not consider gabapentin or lyrica due to the increased fall risk. Pain control in the elderly is dicey at best. My chronically ill pts hurt and while I try to relieve some pain, I'm honest and upfront with them and tell them that we are not going to make their pain 0/10 and then we discuss what they could live with. I also encourage nonpharmacologic pain relievers for my super elderly patients, including warm water swimming, topicals as the OP indicates they've tried, massage, PT/OT to improve balance and mobiity. Sometimes a low dose anti-depressant can help too.
  13. by   SobreRN
    Quote from traumaRUs
    Hmmm...The aide is an employee and though she too is a patient advocate, she seems to have overstepped her bounds. I agree 90 is pushing the age where I would prescribe narcotics although at 90 I would strongly suspect that she has some degree of renal impairment and gabapentin 600mg three times per day is pushing the envelope too IMHO.
    I do not get this philosophy of being very elderly is pushing it on narcotic pain relief. Yes, I understand where concerns come in as in it could mask some dementia s/s, increase fall risk etc...but if someone is going to be in pain for the rest of their lives they should not have to spend whatever time they have left in constant pain which they likely will more due to the 'War on drugs' part two rather than side effects. Heck, lets talk about the side effects of everything else. Warfarin, the active ingredient in rat poison comes to mind as do anti-hypertensives but when it comes to narcotic pain meds or benzodiazepines doctors begin not treating conditions which will not improve.
    As to posters who mentioned the elderly woman's' aide being overly interested in Rx the 90 year-old would have to pee in a cup and have that UA be + for what she is prescribed. While I despise the government intrusion inserting itself into Dr: Pt relationships I think it is a good idea to obtain a urine sample from those who cannot verbalize not receiving their pain medication.
    We have gone off the deep end in nit treating pain. My mom had advanced dementia and I respected her wishes in no tube feeds etc...I did ask doc to keep fentanyl patch on in event she had pain she could not verbalize but this was @ 12 years ago, well before the pendulum swung toward not treating anyone.
  14. by   Dodongo
    I mean, I'll agree that I think we sometimes under treat the elderly because we're afraid of over treating them. But I can't tell you how many patients, young and old alike, that I admit a week with OD symptoms from lyrica, neurontin, etc. But IMO, just being elderly doesn't completely r/o any treatment necessarily. If you need to control pain, then you do what you have to do. That doesn't mean they will be completely pain free, but if I can take their pain from an 8 to a 4, then I think we've improved their QOL.

    And opioids are a last resort for chronic pain management. They are useful in certain conditions causing acute pain, and may be the right choice for long-term pain related to cancer and its treatments or, in rare cases, noncancer pain that hasn't responded to any other medications. But there are better, more efficacious treatments for neuropathic pain. Further, narcotic contracts and urine testing haven't proven to be effective in controlling diversion. The aide could just give the patient one the day prior to an appointment.

    I'd consider a NSAID or Cox-2 inhibitor (again, taking age and renal function into account here). This would be useful if she had an arthritic component to her pain. SNRIs are also an option as Traumarus indicated.

    Ultimately, you need to use your clinical assessment skills and judgement to decide what treatment option suits the patient best. We can only offer you so much here.

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