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Are We Letting Our Patients Suffer?

Nurses Article   (20,011 Views 74 Comments 668 Words)

traumaRUs has 25 years experience as a MSN, APRN and works as a Asst Community Manager @ allnurses.

498 Likes; 14 Followers; 127 Articles; 184,932 Visitors; 20,505 Posts

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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? You are reading page 4 of Are We Letting Our Patients Suffer?. If you want to start from the beginning Go to First Page.

T-Bird78 has 6 years experience.

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Yes, we are making some pts suffer. My state limits narcotics to a 7-day supply ONLY, regardless of the qty on the actual script. I'm in ENT, so we're talking some very painful surgeries (tonsillectomy, UPPP, sinus/septoplasty/turbinate reduction; head and neck cancers) and our adults who are 7-days postop tonsilletomy can't get any more norco when they're in the worst pain of their life. It's horrible.

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not.done.yet has 8 years experience as a MSN, RN and works as a Professional Development Specialist.

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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?

I definitely believe that addiction is a disease process. Where I get hung up is that, like any disease process, we can only treat a person who wants treatment and that denial of there actually BEING a disease is common, both in the patient and often in their families as well. I have a great deal of ethical stress about it. I want to treat pain. I have had pain myself. I have had undertreated pain. It was horrific. But I don't want to be a supplier to someone who is addicted or so tolerant that they no longer work but are resistant to trying to do other things. The madness has to stop somewhere but having it stop on the backs of people in genuine need is madness as well.

Edited by not.done.yet

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BostonFNP works as a Primary Care NP.

18 Likes; 1 Follower; 3 Articles; 54,184 Visitors; 5,223 Posts

Yes, we are making some pts suffer. My state limits narcotics to a 7-day supply ONLY, regardless of the qty on the actual script. I'm in ENT, so we're talking some very painful surgeries (tonsillectomy, UPPP, sinus/septoplasty/turbinate reduction; head and neck cancers) and our adults who are 7-days postop tonsilletomy can't get any more norco when they're in the worst pain of their life. It's horrible.

Why can they not get more? Are you saying that in your state patients can not get another script after the initial 7 days?

Our surgery teams here are disgruntled by the change because they get more phone calls for script refills and/or need to see patients in clinic 7-days post-op to refill their initial script, but they are not prevented from giving additional medication.

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BostonFNP works as a Primary Care NP.

18 Likes; 1 Follower; 3 Articles; 54,184 Visitors; 5,223 Posts

The madness has to stop somewhere. Having it stop on the backs of people in genuine need is madness.

I think we are placing too much emphasis on curtailing existing opioid prescriptions when the solution to the problem is to restrain new opioid prescriptions. The way I see it there are four types of patients:

1. Stable/appropriate chronic users: My approach is that there is little to be done to this population, they are not the problem. The only things we can/should do is inform patients about risks and screen for them, make attempts to taper to a lowest tolerated dose, and prevent drug interactions that increase risk.

2. Unstable/inappropriate chronic users: My approach here is that these users need to be transitioned to either appropriate users or be safely discontinued. If they are showing negative for prescribed drugs or they fit a clear pattern of abuse then I abruptly (in the case of the former) or rapidly discontinue them. If they are over the MME then I slowly work with the patient to transition them to a stable chronic user.

3. Appropriate acute users: My approach here is similar to the first case: screen for risks and discuss then treat their acute pain appropriately with the lowest tolerated dose for shortest time. There is nothing wrong with these scripts, and I don't see any reason to need more than 7 days at a time.

4. Inappropriate acute users: These patients need non-opioid options or extremely close monitoring or specialist referral. They are not safe candidates for opioids.

**Caveat: I am talking only about prescription drug use/abuse.

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128 Likes; 1 Follower; 31,453 Visitors; 1,719 Posts

I definitely believe that addiction is a disease process. Where I get hung up is that, like any disease process, we can only treat a person who wants treatment and that denial of there actually BEING a disease is common, both in the patient and often in their families as well. I have a great deal of ethical stress about it. I want to treat pain. I have had pain myself. I have had undertreated pain. It was horrific. But I don't want to be a supplier to someone who is addicted or so tolerant that they no longer work but are resistant to trying to do other things. The madness has to stop somewhere. Having it stop on the backs of people in genuine need is madness.

The denial is part of the disease, and family members are affected also. People who are addicted to opiods (or other drugs/alcohol), for whatever reason, whether they are rich or poor, employed, unemployed, or homeless, all deserve to receive medical care in order to help manage the effects of these strong medications. People cannot manage chronic/acute pain and/or opiate withdrawal/opiate dependence by themselves safely without medical supervision. It really is a matter of patient safety and treating people humanely.

I think we have to realize that we don't know the details of peoples lives, or the reasons that led to a person's addiction, and do our best to withhold our judgement about the few details we do know about the person, i.e. they aren't employed and don't seem to want to do anything to fix their problem, if we want to be of help. Much more could be done at a primary care level to help these patients, and this would decrease their need to use the ED for this purpose.

Edited by Susie2310

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SobreRN works as a RN.

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Yep, welcome to the 'war on drugs' part two. Part one we tossed inner city folks in jail forever while well-heeled white folks snorted cocaine off the tables at discotheques. Now that lil white Susie and Bobby OD we need to have a new law for each one and blame meds for which they never had a legit Rx.

And what happened to meth? It is still out there in abundance but the government isn't going to declare a crisis with a drug people can whip up at home when doctors make such nice targets; don't shoot back and have assets to seize. I saw this coming the moment the DEA decided Norco should be a schedule two; only thing this did was cause docs to fear treating pain at all. I hope this unfortunate patient is not anuric lest her RX is Dc'd for inability to pee in a cup.

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traumaRUs has 25 years experience as a MSN, APRN and works as a Asst Community Manager @ allnurses.

498 Likes; 14 Followers; 127 Articles; 184,932 Visitors; 20,505 Posts

Yes, we are making some pts suffer. My state limits narcotics to a 7-day supply ONLY, regardless of the qty on the actual script. I'm in ENT, so we're talking some very painful surgeries (tonsillectomy, UPPP, sinus/septoplasty/turbinate reduction; head and neck cancers) and our adults who are 7-days postop tonsilletomy can't get any more norco when they're in the worst pain of their life. It's horrible.

Is there no way around this? In IL, I can only Rx opioids for 7 days at Walmarts but there are ways around this: increase the frequency of meds, discuss this with the phamacist personally, encourage the pt to utilize a different pharmacy.

This is horrible

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traumaRUs has 25 years experience as a MSN, APRN and works as a Asst Community Manager @ allnurses.

498 Likes; 14 Followers; 127 Articles; 184,932 Visitors; 20,505 Posts

Why can they not get more? Are you saying that in your state patients can not get another script after the initial 7 days?

Our surgery teams here are disgruntled by the change because they get more phone calls for script refills and/or need to see patients in clinic 7-days post-op to refill their initial script, but they are not prevented from giving additional medication.

I live in a very rural area and travel 100-200 miles per day to see pts. I'm not always at their location when they need pain meds. I've on occasion driven extra to either drop a script off at a pharmacy. However, when you are talking rural America, there are more barriers to obtaining scripts of any kind: distance, limited pharmacies, limited pharmacy hours, inability to travel to the pharmacy to pick up a script.

So, yes, while I CAN write another script after the 7 day script is gone, its not always an easy task to accomplish.

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T-Bird78 has 6 years experience.

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Is there no way around this? In IL, I can only Rx opioids for 7 days at Walmarts but there are ways around this: increase the frequency of meds, discuss this with the phamacist personally, encourage the pt to utilize a different pharmacy.

This is horrible

The pharmacy reads the sig and dispenses quantity for 7 days worth only, regardless of the quantity written. If it's 1 tab q 4-6 PRN pain, #60, the pharmacy will give 42 (1 6 times a day x 7 days). When postop pts call to get additional narcotics, I'll call the pharmacy and verify if their insurance will allow it or not. There's some database that prescribers have to check before giving any additional narcotics, and if another provider has given a script then they can't give more, if there's no other script in a certain timeframe they can give more. It's fairly new so I'm still trying to figure out the methodology. I do check with the pharmacy every time, though. One told me it was acceptable because it was a continuation of an acute fill. It's crazy.

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BostonFNP works as a Primary Care NP.

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I live in a very rural area and travel 100-200 miles per day to see pts. I'm not always at their location when they need pain meds. I've on occasion driven extra to either drop a script off at a pharmacy. However, when you are talking rural America, there are more barriers to obtaining scripts of any kind: distance, limited pharmacies, limited pharmacy hours, inability to travel to the pharmacy to pick up a script.

So, yes, while I CAN write another script after the 7 day script is gone, its not always an easy task to accomplish.

That's an understandable concern. It's sad that having the ability to transmit scheduled substances electronically is something that EMR systems charge extra for. It would eliminate a number of logistical problems.

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BostonFNP works as a Primary Care NP.

18 Likes; 1 Follower; 3 Articles; 54,184 Visitors; 5,223 Posts

The pharmacy reads the sig and dispenses quantity for 7 days worth only, regardless of the quantity written. If it's 1 tab q 4-6 PRN pain, #60, the pharmacy will give 42 (1 6 times a day x 7 days). When postop pts call to get additional narcotics, I'll call the pharmacy and verify if their insurance will allow it or not. There's some database that prescribers have to check before giving any additional narcotics, and if another provider has given a script then they can't give more, if there's no other script in a certain timeframe they can give more. It's fairly new so I'm still trying to figure out the methodology. I do check with the pharmacy every time, though. One told me it was acceptable because it was a continuation of an acute fill. It's crazy.

Are you a prescriber?

How it works for me: Prior to writing any script for a schedule II, chronic or acute, I need to login to the Prescription Monitoring Program (which interconnects with 33 other states) and assess the prior CS history and document my assessment. I can then write a 7-day (acute initial) or 28-day script (acute additional or chronic) which needs to be on hard copy and hand-signed. That script can either be handed to the patient or mailed to the pharmacy. Patients can not fill another script until 2 days prior to the end of the previous script. If the pharmacist has concerns they will call. If the insurance company requires a prior authorization, then that needs to be done or the patient has to pay cash.

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not.done.yet has 8 years experience as a MSN, RN and works as a Professional Development Specialist.

297 Likes; 4 Followers; 42,888 Visitors; 5,171 Posts

I live in a very rural area and travel 100-200 miles per day to see pts. I'm not always at their location when they need pain meds. I've on occasion driven extra to either drop a script off at a pharmacy. However, when you are talking rural America, there are more barriers to obtaining scripts of any kind: distance, limited pharmacies, limited pharmacy hours, inability to travel to the pharmacy to pick up a script.

So, yes, while I CAN write another script after the 7 day script is gone, its not always an easy task to accomplish.

This is such incredibly valuable info to have and info that so many either do not realize or willfully overlook. There are vast areas of the country now without adequate resources for healthcare, from providers to pharmacies. I had not considered how these restrictions impact those areas.

I want to be very plain. I am PRO pain control. I just find myself in moral distress at times, particularly on a personal level due to said family member, because of the issue of abuse. I love BostonFNP's categorizations above. It makes something that can feel really murky far more distinguishable.

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