The title says it all - has the pendulum swung the opposite way? Are we providing adequate pain relief for our patients or holding back for fear of addiction?
Recently I had a patient who fractured her femur, mid-shaft. She was unable to have it repaired due to multiple co-morbids. So, she was given a brace and told it would have to heal in time. She developed some wounds from the brace and it had to be removed. She goes to the wound clinic once per week, dialysis three times per week and each time she is transferred by a Hoyer lift into her wheelchair, transferred to the nursing home van and then, at least at dialysis is then transferred again via Hoyer to the dialysis chair. XRays done recently showed nonunion of this fracture which can be attributed to several factors: malnutrition, hyperphosphatemia, osteoporosis.
For pain, she has been Rx'd with: fentanyl 62.5mcg patch changed every 72 hours, percocet 10/325 one orally every 8 hours as needed and tylenol 650mg every 8 hours as needed. Prior to her femur fracture, she had been on a fentanyl 50mcg patch changed every 72 hours as well as Percocet 5/325 every 8 hours as needed due to severe osteoarthritis - made worse by end stage renal disease.
She comes to the dialysis unit crying in pain due to the 10 mile ride from the nursing home to the dialysis unit. There is no medication to give her at the dialysis unit except tylenol. Her pain is not controlled well - she continually rates her pain 8-10/10. She is physically addicted to opioids due to several years of chronic pain meds for her multiple disease processes. When I spoke to the nursing home staff, I was told "we can't continue to contribute to her addiction."
Another incident - a friend (fellow APRN) underwent major abdominal surgery recently. She was opioid naive and prior to her surgery, took no medication. She was healthy and had NKDA. Post-operatively she was given Norco 5/325 one every 8 hours as needed as well as ibuprofen 600mg every 8 hours. However, she rated her pain in the first 24 hours consistently 8/10. One nurse made the comment that she (the nurse) was sorry but the doctor "didn't want her to become addicted."
Two recent incidents, different patients, different reasons for pain yet both were denied adequate pain relief.
Have we gone too far in the opposite direction?
Are we letting our patients suffer in the name of patient safety?
"The National Institutes of Health (NIH) estimate that in the United States, 25.3 million adults have chronic pain." What are we supposed to do? As providers we want to provide adequate pain control for both our chronic pain patients as well as for those with acute pain. "A team of researchers at Wake Forest University and the University of Bath in the U.K. is exploring a new kind of opioid that could relieve pain without affecting breathing or raising the chance for abuse. The new drug, only called by its chemical compound name BU08028, relieved pain in rhesus macaque monkeys. When they had the opportunity to take as much of the drug as they wanted, they didn't abuse it. When taken off the drug, they didn't show signs of painful withdrawal." Perhaps this will be a new medication for both chronic and acute pain.
Some other suggestions:
Non-steroidal anti-inflammatory medication such as ibuprofen - can be used either alone or as an adjunct
Ketamine is now being used for acute pain. Recently the journal AACN Advanced Critical Care included a Drug Update about the use of ketamine in the ICU.
So, what to do? Are we helping to prevent opioid addiction or are we letting our patients suffer needlessly? What are your thoughts?
Several years ago, a big deal was made of asking patients about the "6th vital sign...Pain" at every visit. This was to be assessed to ensure that this 'vital sign" was addressed. Now, because heroin deaths have been lumped in as opioid od's, the government has made providers afraid to prescribe anything resembling an opioid. The 6th vital sign is being ignored, on the verge of neglect & malpractice! Patients with chronic pain whose pain is not being adequately alleviated are falling into deep depression followed by suicidal ideation, especially in the elderly. I have heard these same sentiments voiced in my own family, which both saddens & angers me. As patient advocates, what are we, including providers, to do? Some people cannot take NSAIDS or Acetaminophen for medical reasons. Choices become even more limited then. ??
Several years ago, a big deal was made of asking patients about the "6th vital sign...Pain" at every visit. This was to be assessed to ensure that this 'vital sign" was addressed. Now, because heroin deaths have been lumped in as opioid od's, the government has made providers afraid to prescribe anything resembling an opioid. The 6th vital sign is being ignored, on the verge of neglect & malpractice! Patients with chronic pain whose pain is not being adequately alleviated are falling into deep depression followed by suicidal ideation, especially in the elderly. I have heard these same sentiments voiced in my own family, which both saddens & angers me. As patient advocates, what are we, including providers, to do? Some people cannot take NSAIDS or Acetaminophen for medical reasons. Choices become even more limited then. ??
I still have an old copy of state guidelines for the "6th vital sign - Pain."
This is just my opinion. The health care industry has huge political clout. It has a huge amount of input into government decisions that affect their businesses. I think it's convenient for some to let the government shoulder the responsibility for the way the opiate "crisis" is being dealt with. As I see it, the need is for responsible prescribing and for careful individualized monitoring of patients including monitoring of opiate prescriptions. That takes time and effort, and resources, and face to face patient time. I don't see this as being a popular solution on the part of the health care industry.
Additionally, practically speaking, it is difficult for some patients to even get primary care appointments. I think part of the opiate problem is due often to a lack of real relationships between patient and health care provider, even due to a breakdown of the relationship between health care providers/prescribers and patients. We are looking at the end results. It's a form of disintegration. I don't see the will on the part of the health care industry (in general) to change how providers relate with patients; listening to patients, taking time to hear what they have to say and to understand them and be responsive to their individual needs.
The health care industry (in general) is about making as much money as possible as quickly as possible. As I see it, that's why we now have this situation. I think this situation could be undone if there was the will, but it would require an industry change that would reduce profits.
Several years ago, a big deal was made of asking patients about the "6th vital sign...Pain" at every visit. This was to be assessed to ensure that this 'vital sign" was addressed. Now, because heroin deaths have been lumped in as opioid od's, the government has made providers afraid to prescribe anything resembling an opioid. The 6th vital sign is being ignored, on the verge of neglect & malpractice! Patients with chronic pain whose pain is not being adequately alleviated are falling into deep depression followed by suicidal ideation, especially in the elderly. I have heard these same sentiments voiced in my own family, which both saddens & angers me. As patient advocates, what are we, including providers, to do? Some people cannot take NSAIDS or Acetaminophen for medical reasons. Choices become even more limited then. ??
A few thoughts.
By definition, pain is neither vital, nor is it a sign. "Vital" meaning necessary to maintain life, and a sign is objective, while pain is subjective. From my perspective as an ER nurse, calling it a "vital sign" has always been a mistake, and has not helped manage the symptom of pain. I am not downplaying the critical nature of pain and our responsibility to deal with it. But as a nurse, it is reasonable that my job is to keep your MAP above 60. Expecting me to keep your report of pain below 6 is an entirely different proposition.
You are correct that heroin deaths have been lumped in as opioid od's. That is because they are opioid ODs. The relationship between prescribed narcotics and heroin is well established. In fact, if I was selling heroin right now, I would be pretty psyched about the crack down on prescription opioids. Regardless of any laws passed by congress, the laws of supply and demand are immutable, and profits should be going up now that supply is going down.
You mention that some people can't take Tylenol or NSAIDS. This is absolutely true. But, any ER nurse can tell you about the number of patients with listed allergies to all OTC pain meds, as well as toradol, tramadol, and milder narcotics. My ER is no different than most. Until recently, we regularly gave narcotics to people we know have a history of abuse, as well as a history of lying to obtain narcotics, and that is not a good thing for us to be doing.
I agree that the pendulum is swinging too far, and that people will suffer. But, I also think we have to look at where we were to understand where we should be. It is terrible that some will be caught in the crossfire, so to speak, as we try to get this right.
This is just my opinion. The health care industry has huge political clout. It has a huge amount of input into government decisions that affect their businesses. I think it's convenient for some to let the government shoulder the responsibility for the way the opiate "crisis" is being dealt with. As I see it, the need is for responsible prescribing and for careful individualized monitoring of patients including monitoring of opiate prescriptions. That takes time and effort, and resources, and face to face patient time. I don't see this as being a popular solution on the part of the health care industry.
Additionally, practically speaking, it is difficult for some patients to even get primary care appointments. I think part of the opiate problem is due often to a lack of real relationships between patient and health care provider, even due to a breakdown of the relationship between health care providers/prescribers and patients. We are looking at the end results. It's a form of disintegration. I don't see the will on the part of the health care industry (in general) to change how providers relate with patients; listening to patients, taking time to hear what they have to say and to understand them and be responsive to their individual needs.
The health care industry (in general) is about making as much money as possible as quickly as possible. As I see it, that's why we now have this situation. I think this situation could be undone if there was the will, but it would require an industry change that would reduce profits.
You bring up some very interesting points. Providers in my state are now required to check the website to see who has received controlled substances (not just opiates) prior to Rx'ing for the first time.
" Beginning January 1, 2018, Public Act 100-0564 requires all prescribers with an Illinois controlled substance license to enroll in the Illinois Prescription Monitoring Program (PMP) Welcome to the Illinois Prescription Monitoring Program through the Illinois Department of Human Services (IDHS).
Prescribers are additionally required to attempt to check the PMP prior to writing an initial prescription of a Schedule II narcotics, such as opioids. That attempt must be documented in the patient's medical record."
Specializes in Critical Care; Cardiac; Professional Development.
It has definitely swung too far, but with a family member who has a prescription opioid issue, I feel torn. This individual doesn't take their meds as prescribed. Their reason for needing them in the first place is sketchy. They make up additional health problems with the goal of getting more meds for themselves (ie: an area of callous on their foot was represented to a physician as being a piece of glass that was working its way out of the foot from a broken item about 8 years ago. Needless to say, it wasn't - it was just a callous). This person takes meds from their elderly mother, finds reasons to take said elderly mother for care in hopes of getting more meds. Asks me regularly if I personally have any meds that I would be willing to "share" while they are visiting. Etc etc. The manipulation is both obvious and devastating. They live in one of the strictest states in the nation and recently got kicked out of their pain management program for violating the terms of their contract - they peed hot on a UDS. Of course, that was also an accident, they had some "edibles" from Colorado that they didn't think would cause them to be positive. Etc.
I get truly torn. No way do I think people should have unquestioned access to these medications. But no way should people be left to suffer as some of the previously described situations indicate. People ARE dying and it isn't just from street heroin/Fentanyl. Deaths are up from prescription drugs as well, especially benzos combined with narcs.
I don't know what the answer is, but the question depresses me mightily.
I believe more resources need to be dedicated at a primary care level to managing patients with chronic pain and especially opiate prescriptions. I think that inadequate pain management at a primary care level is often part of why these patients present to the ED. Opiate withdrawal and opiate dependence are not problems that patients can manage by themselves without medical supervision.
I also think that while pain isn't a vital sign by itself, it is still very important that it is recognized timely by health care providers and that it's cause is determined timely, and that pain medication is given timely and is effective. To do otherwise is inhumane. Also, pain, even significant pain, very often goes unrecognized and untreated by health care providers, and since pain (especially acute severe pain) also affects vital signs (tachcardia, hypertension, tachypnea) and skin signs (diaphoresis), shaking, etc., it can easily mask other symptoms and/or be mistakenly attributed to another medical problem.
I work in a PCP role serving area that is one of the regions leading the nation in opioid deaths; there is scarcely a day that I don't deal with the issue on one side or the other. In my state I am limited to 7 days of medication for new scripts, a MME/equivalency limit, must verify with the state prescribers' database each time prior to prescribing a CSII, complete opioid CMEs each renewal, document risk assessments prior to prescribing, etc.
I think it is very hard to get to a black and white answer about the pendulum swing because this issue has so many moving parts. Here are some of my thoughts on the issue:
Poor Prescribing Practices: In many ways the opioid problem is nothing more than a symptom of the larger illness of poor and inappropriate prescribing practice. The "pill for every problem" mentality in our country has joined forces with the increasing emphasis on patient satisfaction in a setting of (most) prescribers being afforded less and less time with each patient to create a perfect storm for poor prescribing. We prescribe far too much. I think we are all at times guilty of this but overall we are sliding quickly downhill. We needs to stand up to patients and do what is right for them regardless of whether that conflicts with their opinion of what is best for them, and we need to all do it together. The opioid crisis is a headline example because it trickles down from pills to heroin and results in fatalities. Antibiotics don't have the same trickle own effects and are rarely associated with fatality thus we don't have to jump though 50 hoops of public outrage to prescribe them; so we do and we do it inappropriately far more often than with opioids. We do know that the more hoops we put in front of opioid prescriptions the more likely we are to decrease the inappropriate prescribing (and probably some of the appropriate as well). I think the data is favorable that these measure can and will reduce the opioid problem, however, they do nothing for the weak-kneed prescribing practices that are plaguing our system.
Poor Healthcare Education on (and Stigma of) Opioids: We see posts about this on AN all the time, the rouge bedside RN saving the world from addiction by denying their POD1 patient narcotics or the tough as nails doctor that refuses to order any opioids for their patient passing a kidney stone because they used cocaine once 10 years ago. The underlying truth to these dramatic stories is that many HCPs are really quite ignorant when it comes to addiction and as such react with a knee jerk reaction and in doing so spread false information and probably harm some patients. This needs to stop. Prescribers need to keep themselves educated and if nurses are going to be giving advice on opioids they should be educated too.
Chronic Heavy Opioid Users: My state now has a MME/equivalency requirement of 180mg/day. There are lots of patients that are over this level, most are chronic opioid users. We know from research that doses over this level are not likely to covey any benefit and are more likely to result in serious ADRs. Clinically I see no reason why these patients shouldn't be slowly tapered down to safe-effective doses, but the devil is in the details: these patients 1. don't want to be tapered down and 2. are often times having the rug pulled out from underneath them with abrupt changes. Clinically these patients normally have pain at their current dosing but if tapered down slowly they will still have the same pain at lower doses just with less medication; the conversation is hard and I think that PCPs are best suited for this role, as a provider they have a long relationship with and trust, though sadly, many chronic pain patients bounce around. I do think needs to be done but done in a safe way for all.
New and Temporary Opioid Use: My state limits this to 7 days; overall I think this is a good thing, though I am not sure why they limited days supply rather than MME if they are using that as a requirement for chronic opioid use. This means more phone calls to me but to be honest I would rather that my patients not get 200 Percocets from their orthopod with no instructions on how or when to stop them; plus we all know these pills get horded in medicine cabs and then get stolen or used as non-prescription use. This also puts the power in my hands to make sure they are not taking opioids for longer then 8-12 weeks for a temporary issue; again PCPs should be able to talk to the patient and let them know when it's time to stop or ween.
Specializes in Critical Care; Cardiac; Professional Development.
I work in a PCP role serving area that is one of the regions leading the nation in opioid deaths; there is scarcely a day that I don't deal with the issue on one side or the other. In my state I am limited to 7 days of medication for new scripts, a MME/equivalency limit, must verify with the state prescribers' database each time prior to prescribing a CSII, complete opioid CMEs each renewal, document risk assessments prior to prescribing, etc.
I think it is very hard to get to a black and white answer about the pendulum swing because this issue has so many moving parts. Here are some of my thoughts on the issue:
Poor Prescribing Practices: In many ways the opioid problem is nothing more than a symptom of the larger illness of poor and inappropriate prescribing practice. The "pill for every problem" mentality in our country has joined forces with the increasing emphasis on patient satisfaction in a setting of (most) prescribers being afforded less and less time with each patient to create a perfect storm for poor prescribing. We prescribe far too much. I think we are all at times guilty of this but overall we are sliding quickly downhill. We needs to stand up to patients and do what is right for them regardless of whether that conflicts with their opinion of what is best for them, and we need to all do it together. The opioid crisis is a headline example because it trickles down from pills to heroin and results in fatalities. Antibiotics don't have the same trickle own effects and are rarely associated with fatality thus we don't have to jump though 50 hoops of public outrage to prescribe them; so we do and we do it inappropriately far more often than with opioids. We do know that the more hoops we put in front of opioid prescriptions the more likely we are to decrease the inappropriate prescribing (and probably some of the appropriate as well). I think the data is favorable that these measure can and will reduce the opioid problem, however, they do nothing for the weak-kneed prescribing practices that are plaguing our system.
Poor Healthcare Education on (and Stigma of) Opioids: We see posts about this on AN all the time, the rouge bedside RN saving the world from addiction by denying their POD1 patient narcotics or the tough as nails doctor that refuses to order any opioids for their patient passing a kidney stone because they used cocaine once 10 years ago. The underlying truth to these dramatic stories is that many HCPs are really quite ignorant when it comes to addiction and as such react with a knee jerk reaction and in doing so spread false information and probably harm some patients. This needs to stop. Prescribers need to keep themselves educated and if nurses are going to be giving advice on opioids they should be educated too.
Chronic Heavy Opioid Users: My state now has a MME/equivalency requirement of 180mg/day. There are lots of patients that are over this level, most are chronic opioid users. We know from research that doses over this level are not likely to covey any benefit and are more likely to result in serious ADRs. Clinically I see no reason why these patients shouldn't be slowly tapered down to safe-effective doses, but the devil is in the details: these patients 1. don't want to be tapered down and 2. are often times having the rug pulled out from underneath them with abrupt changes. Clinically these patients normally have pain at their current dosing but if tapered down slowly they will still have the same pain at lower doses just with less medication; the conversation is hard and I think that PCPs are best suited for this role, as a provider they have a long relationship with and trust, though sadly, many chronic pain patients bounce around. I do think needs to be done but done in a safe way for all.
New and Temporary Opioid Use: My state limits this to 7 days; overall I think this is a good thing, though I am not sure why they limited days supply rather than MME if they are using that as a requirement for chronic opioid use. This means more phone calls to me but to be honest I would rather that my patients not get 200 Percocets from their orthopod with no instructions on how or when to stop them; plus we all know these pills get horded in medicine cabs and then get stolen or used as non-prescription use. This also puts the power in my hands to make sure they are not taking opioids for longer then 8-12 weeks for a temporary issue; again PCPs should be able to talk to the patient and let them know when it's time to stop or ween.
I just cannot like this reply enough.
So how do you, as a PCP, handle it when your patient insists that you just do not understand how bad their pain is, that they DO need those doses, etc?
So how do you, as a PCP, handle it when your patient insists that you just do not understand how bad their pain is, that they DO need those doses, etc?
Honestly, by building trust. Its much harder to do with patients you don't have a good/established relationship with.
I readily admit that I don't have any idea how bad their pain is; but "I do have experience treating other people with pain and most often I find this approach works".
There are times I make deal with patients to get their buy-in and help establish trust or I let them know I won't leave them high-and-dry. There are times I will draw the line with patients and tell them I am concerned about them or that I want to avoid a situation where their medication has to be suddenly stopped. There are times I tell them that at the end of the day I need to do what is best for them and that may not always be what they think is best. There are times I just say I can't risk my license and livelihood to do something I feel is inappropriate.
I also have very clear boundries that I explain are to protect both of us and that all patients sign and agree to and I am very direct and honest with them and expect the same.
It has definitely swung too far, but with a family member who has a prescription opioid issue, I feel torn. This individual doesn't take their meds as prescribed. Their reason for needing them in the first place is sketchy. They make up additional health problems with the goal of getting more meds for themselves (ie: an area of callous on their foot was represented to a physician as being a piece of glass that was working its way out of the foot from a broken item about 8 years ago. Needless to say, it wasn't - it was just a callous). This person takes meds from their elderly mother, finds reasons to take said elderly mother for care in hopes of getting more meds. Asks me regularly if I personally have any meds that I would be willing to "share" while they are visiting. Etc etc. The manipulation is both obvious and devastating. They live in one of the strictest states in the nation and recently got kicked out of their pain management program for violating the terms of their contract - they peed hot on a UDS. Of course, that was also an accident, they had some "edibles" from Colorado that they didn't think would cause them to be positive. Etc.
I get truly torn. No way do I think people should have unquestioned access to these medications. But no way should people be left to suffer as some of the previously described situations indicate. People ARE dying and it isn't just from street heroin/Fentanyl. Deaths are up from prescription drugs as well, especially benzos combined with narcs.
I don't know what the answer is, but the question depresses me mightily.
I understand your conflicted thoughts. If we look at addiction as a disease process that can be treated, does that help to differentiate between opioid use and opioid abuse?
DeathzAngel2
9 Posts
Several years ago, a big deal was made of asking patients about the "6th vital sign...Pain" at every visit. This was to be assessed to ensure that this 'vital sign" was addressed. Now, because heroin deaths have been lumped in as opioid od's, the government has made providers afraid to prescribe anything resembling an opioid. The 6th vital sign is being ignored, on the verge of neglect & malpractice! Patients with chronic pain whose pain is not being adequately alleviated are falling into deep depression followed by suicidal ideation, especially in the elderly. I have heard these same sentiments voiced in my own family, which both saddens & angers me. As patient advocates, what are we, including providers, to do? Some people cannot take NSAIDS or Acetaminophen for medical reasons. Choices become even more limited then. ??