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Are We Letting Our Patients Suffer?

Nurses Article   (20,005 Views 74 Comments 668 Words)

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

492 Likes; 14 Followers; 127 Articles; 184,914 Visitors; 20,501 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 6 of Are We Letting Our Patients Suffer?. If you want to start from the beginning Go to First Page.

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

492 Likes; 14 Followers; 127 Articles; 184,914 Visitors; 20,501 Posts

Here is my current situation and I'm sorry for going on about this. I have a torn left rotator cuff. I also have C4-C7 bulging and prolapsed docs causing nerve root compression of several nerves.

The shoulder doctor pulls up my narcotic history. I have taken no narcotics since November 2017. I had a csection in August of 2017, subsequent infection in my uterus at the surgical site, had a gallbladder attack in October of 2017, then gallbladder removal in November. I had to defend those narcotic scripts from 12-15 months ago.

I've been refused pain meds the past 2 months. I can't even lift my child. I haven't slept more than 4 hours a night due to the pain.

Tomorrow, I get epidural injections. I'm not allowed ibuprofen for the last 5 days leading up to the injection. Ibuprofen was all I had. Today I had a root canal. Can't take even ibuprofen.

How is this right? I've been told it can up to 2 weeks for these injections to work. I'm the grumpiest, most hateful person right now.

So very sorry. I agree that this is abuse of the ability to Rx appropriate pain meds.

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BostonFNP works as a Primary Care NP.

18 Likes; 1 Follower; 3 Articles; 54,183 Visitors; 5,223 Posts

Here is my current situation and I'm sorry for going on about this. I have a torn left rotator cuff. I also have C4-C7 bulging and prolapsed docs causing nerve root compression of several nerves.

The shoulder doctor pulls up my narcotic history. I have taken no narcotics since November 2017. I had a csection in August of 2017, subsequent infection in my uterus at the surgical site, had a gallbladder attack in October of 2017, then gallbladder removal in November. I had to defend those narcotic scripts from 12-15 months ago.

I've been refused pain meds the past 2 months. I can't even lift my child. I haven't slept more than 4 hours a night due to the pain.

Tomorrow, I get epidural injections. I'm not allowed ibuprofen for the last 5 days leading up to the injection. Ibuprofen was all I had. Today I had a root canal. Can't take even ibuprofen.

How is this right? I've been told it can up to 2 weeks for these injections to work. I'm the grumpiest, most hateful person right now.

Prescribing opioids is difficult to navigate at times, both ethically and legally, and unfortunately there are clearly areas where the water is very murky. None (by this I mean the vast majority) of us want someone like you to suffer, especially given the bad 12-15 months you are having (though with the miracle of having a child in there too). But I would suspect most of us, without knowing you, would also have concerns about that prescription history (multiple scripts from multiple providers in the past year). You are a case, probably through no fault of your own, of the water being murky. To complicate matters, if you try and advocate for yourself, it makes prescribers dig in their heels.

These are the cases where clinicians need to be able to use clinical judgement. From the other side of the desk, so you can maybe have some insight into what the thought process is here, this is what I would be considering in making a clinical decision: it boils down to a choice about the risks to you vs the risks to me.

First off, do I have an objective clinical rationale for you requiring opioids (imaging demonstrating stenosis correlated with clinical evidence of radiculopathy combined with a clear failure of non-narcotic management).

Second off, can I safely prescribe you the medication. For me this is a question both about you (safely start and stop the medication) and about me (assume acceptable risk both to you and to my license); every script we write is a risk to both of us. I start with the opioid risk tool (score of 8 or more it is an automatic no for me, between 4-7 then the water is murky, and less than 4 is safe) and a review of your medical/surgical/prescriptive history. Are there other adjuncts that could be used more safely and effectively? I then consider the timetable of both the progression of symptoms and the overall course/prognosis.

Finally, is the overall clinical picture consistent with the risk assumption and the clinical evidence. For example, if you score a 0 on the screening tool but when I look at your history you've had 10 different prescribers in the past 12 months red flags go up; this is especially concerning with "soft" diagnoses - ones without objective clinical evidence or with clinical presentations that seem to be non-consistent with the objective evidence).

I don't want you to live in pain but I also don't want 1. you to end up in a worse place or 2. to put my license and practice at risk. The water is murky and clinical decisions become important: these are being biased by increased regulation and risk to the provider.

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7 Likes; 1 Follower; 32,046 Visitors; 6,945 Posts

I am so sorry for your loss.

thank you

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128 Likes; 1 Follower; 31,452 Visitors; 1,719 Posts

Prescribing opioids is difficult to navigate at times, both ethically and legally, and unfortunately there are clearly areas where the water is very murky. None (by this I mean the vast majority) of us want someone like you to suffer, especially given the bad 12-15 months you are having (though with the miracle of having a child in there too). But I would suspect most of us, without knowing you, would also have concerns about that prescription history (multiple scripts from multiple providers in the past year). You are a case, probably through no fault of your own, of the water being murky. To complicate matters, if you try and advocate for yourself, it makes prescribers dig in their heels.

Re the poster's prescription history; multiple scripts from multiple prescribers in a period of one year is not evidence by itself that abuse of opioids is taking place, although it can be a red flag. The poster specified a number of medical conditions (that are known to be painful) for which he/she received prescriptions, and these medical conditions should be able to be verified via his/her medical record.

Edited by Susie2310

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BostonFNP works as a Primary Care NP.

18 Likes; 1 Follower; 3 Articles; 54,183 Visitors; 5,223 Posts

Re the poster's prescription history; multiple scripts from multiple prescribers in a period of one year is not evidence by itself that abuse of opioids is taking place, although it can be a red flag. The poster specified a number of medical conditions (that are known to be painful) for which he/she received prescriptions, and these medical conditions should be able to be verified via his/her medical record.

Multiple scripts from multiple providers is a red flag giving prescribers concerns, as stated. It can absolutely be benign but that can be a difficult thing to verify: the orthopod likely does not have access to the entire medical record, prescription monitoring does not track the reason a script was written, and (perhaps sadly) I doubt he's going to spend the time to call around and verify.

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

492 Likes; 14 Followers; 127 Articles; 184,914 Visitors; 20,501 Posts

I wouldn't have any issue prescribing narcotics for an ACUTE issue even if a pt receives narcotics from other providers. I document very well with a thorough exam, evaluate xrays, test results, physical exam and look at the IL Prescription Monitoring Program which provides info on several surrounding states even if a pt pays cash and chooses not to utilize insurance.

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Prescribing opioids is difficult to navigate at times, both ethically and legally, and unfortunately there are clearly areas where the water is very murky. None (by this I mean the vast majority) of us want someone like you to suffer, especially given the bad 12-15 months you are having (though with the miracle of having a child in there too). But I would suspect most of us, without knowing you, would also have concerns about that prescription history (multiple scripts from multiple providers in the past year). You are a case, probably through no fault of your own, of the water being murky. To complicate matters, if you try and advocate for yourself, it makes prescribers dig in their heels.

These are the cases where clinicians need to be able to use clinical judgement. From the other side of the desk, so you can maybe have some insight into what the thought process is here, this is what I would be considering in making a clinical decision: it boils down to a choice about the risks to you vs the risks to me.

First off, do I have an objective clinical rationale for you requiring opioids (imaging demonstrating stenosis correlated with clinical evidence of radiculopathy combined with a clear failure of non-narcotic management).

Second off, can I safely prescribe you the medication. For me this is a question both about you (safely start and stop the medication) and about me (assume acceptable risk both to you and to my license); every script we write is a risk to both of us. I start with the opioid risk tool (score of 8 or more it is an automatic no for me, between 4-7 then the water is murky, and less than 4 is safe) and a review of your medical/surgical/prescriptive history. Are there other adjuncts that could be used more safely and effectively? I then consider the timetable of both the progression of symptoms and the overall course/prognosis.

Finally, is the overall clinical picture consistent with the risk assumption and the clinical evidence. For example, if you score a 0 on the screening tool but when I look at your history you've had 10 different prescribers in the past 12 months red flags go up; this is especially concerning with "soft" diagnoses - ones without objective clinical evidence or with clinical presentations that seem to be non-consistent with the objective evidence).

I don't want you to live in pain but I also don't want 1. you to end up in a worse place or 2. to put my license and practice at risk. The water is murky and clinical decisions become important: these are being biased by increased regulation and risk to the provider.

Here's the thing. I have not taken an opioid in a year. A year. Yes, I had several in a short period of time. 2 of those scripts coming from the same practice. One my actual OB, the other coming from an NP. I couldn't walk and had a fever when I had the infection in my uterus. The NP was my only option that day. I walked bent over almost in a fetal position.

With my first gallbladder attack, I thought I was having a heart attack. At first I thought I had severe indigestion. Took a bunch of tums. The pain radiated to my back and was excruciating. I could pick up my 10 week old who was screaming to be fed and I'm laying on my bathroom floor vomiting constantly. We went directly to the ER. The ER found the gall stones blocking the duct. The prescribed the whole 10 norco. 10. Which was fine with me. I made then last the 10 days until my surgery could take place. I ate virtually no fat for 10 days. Any little bit of fat was causing an attack. Then the surgery occurred. Absolutely no narcotics since then.

I personally don't feel the meds I took 12-15 months ago should have been held against me at this time. I'm miserable and hateful right now. My marriage is taking a huge hit because A, I can't do my normal load of the household work, and it's basketball season where I normally step up and take over the house. It's been 2 months and my family is frustrated with my grumpiness as much as I am. I find myself lashing out constantly. That's not me. I'm normally a happy, go lucky, positive person.

If I had numerous scripts in the last year and I was visiting numerous practices, and poly-pharmacies I would get it. But that wasn't even the case 12 months ago. I go to the same pharmacy every time. I went to my OBs office for my pregnancy and postpartum issues. I then visited the ER and a surgeon. That should make total sense to a physician. With this situation on my shoulder and arm, I'm at the same facility. But the way there faculty works, I've seen 3 different providers. That's no different than 12 months ago.

So no, I don't get it. The fear that providers have these days over prescribing a 5mg Norco is insane. People don't get addicted to a 5mg norco. They get addicted when the 5mg diexht work anymore so the provider goes straight to the heavy duty stuff. 5mg is pretty much nothing.

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And I've been rating my pain at a 7-8. I'm sure it's my lack of sleep and grumpiness making me continue to argue. I apologize for that. I have the normal every, day life stressors on top of my mind-numbing pain.

As an extrovert, I'm having a really hard time being at home by myself, every day. It makes me focus more on the pain with no distractions. There's only so many Friends and The Office reruns I can watch. I can't hold my child so he's in daycare, and I can't even run the vacuum cleaner. I miss going to the gym, my friends at work, and interacting with my baby. My husband coaches basketball and my oldest son plays ball at a different school. I think if I at least had done pain control, I could function better.

Like I said, I'm sorry for continuing argue. I got my epidural injections today and I'm in more pain than I was before which I was told was expected for 3-5 days.

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nursej22 has 30 years experience as a MSN, RN and works as a royal pain in the tuchus.

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And I've been rating my pain at a 7-8. I'm sure it's my lack of sleep and grumpiness making me continue to argue. I apologize for that. I have the normal every, day life stressors on top of my mind-numbing pain.

As an extrovert, I'm having a really hard time being at home by myself, every day. It makes me focus more on the pain with no distractions. There's only so many Friends and The Office reruns I can watch. I can't hold my child so he's in daycare, and I can't even run the vacuum cleaner. I miss going to the gym, my friends at work, and interacting with my baby. My husband coaches basketball and my oldest son plays ball at a different school. I think if I at least had done pain control, I could function better.

Like I said, I'm sorry for continuing argue. I got my epidural injections today and I'm in more pain than I was before which I was told was expected for 3-5 days.

I am so sorry that you are going through this. This kind of treatment seems cruel. I hope your injection begins to work quickly. Is there a plan going forward?

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BostonFNP works as a Primary Care NP.

18 Likes; 1 Follower; 3 Articles; 54,183 Visitors; 5,223 Posts

Here's the thing. I have not taken an opioid in a year. A year. Yes, I had several in a short period of time. 2 of those scripts coming from the same practice. One my actual OB, the other coming from an NP. I couldn't walk and had a fever when I had the infection in my uterus. The NP was my only option that day. I walked bent over almost in a fetal position.

With my first gallbladder attack, I thought I was having a heart attack. At first I thought I had severe indigestion. Took a bunch of tums. The pain radiated to my back and was excruciating. I could pick up my 10 week old who was screaming to be fed and I'm laying on my bathroom floor vomiting constantly. We went directly to the ER. The ER found the gall stones blocking the duct. The prescribed the whole 10 norco. 10. Which was fine with me. I made then last the 10 days until my surgery could take place. I ate virtually no fat for 10 days. Any little bit of fat was causing an attack. Then the surgery occurred. Absolutely no narcotics since then.

I personally don't feel the meds I took 12-15 months ago should have been held against me at this time. I'm miserable and hateful right now. My marriage is taking a huge hit because A, I can't do my normal load of the household work, and it's basketball season where I normally step up and take over the house. It's been 2 months and my family is frustrated with my grumpiness as much as I am. I find myself lashing out constantly. That's not me. I'm normally a happy, go lucky, positive person.

If I had numerous scripts in the last year and I was visiting numerous practices, and poly-pharmacies I would get it. But that wasn't even the case 12 months ago. I go to the same pharmacy every time. I went to my OBs office for my pregnancy and postpartum issues. I then visited the ER and a surgeon. That should make total sense to a physician. With this situation on my shoulder and arm, I'm at the same facility. But the way there faculty works, I've seen 3 different providers. That's no different than 12 months ago.

So no, I don't get it. The fear that providers have these days over prescribing a 5mg Norco is insane. People don't get addicted to a 5mg norco. They get addicted when the 5mg diexht work anymore so the provider goes straight to the heavy duty stuff. 5mg is pretty much nothing.

First off, in no way am I trying to defend or justify you not getting adequate pain relief. I would hope you could talk with your PCP about the issue. Your PCP knows you and knows your history. I don't want to see you (hear about you) being in pain and suffering, I'm sure that everyone here doesn't want to either! I am sorry that you have a front row seat for this issue.

I am very surprised to hear some of your timelines; it is really unacceptable you have a right to be upset. I have never in my career seen a patient with acute cholecystitis be given pain meds in the ED and sent home for 10 days before surgery!

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BostonFNP works as a Primary Care NP.

18 Likes; 1 Follower; 3 Articles; 54,183 Visitors; 5,223 Posts

And I've been rating my pain at a 7-8. I'm sure it's my lack of sleep and grumpiness making me continue to argue. I apologize for that. I have the normal every, day life stressors on top of my mind-numbing pain.

As an extrovert, I'm having a really hard time being at home by myself, every day. It makes me focus more on the pain with no distractions. There's only so many Friends and The Office reruns I can watch. I can't hold my child so he's in daycare, and I can't even run the vacuum cleaner. I miss going to the gym, my friends at work, and interacting with my baby. My husband coaches basketball and my oldest son plays ball at a different school. I think if I at least had done pain control, I could function better.

Like I said, I'm sorry for continuing argue. I got my epidural injections today and I'm in more pain than I was before which I was told was expected for 3-5 days.

I assume the interventional pain specialist did your injections? He also wouldn't give you anything short-term for pain?? Did you talk to your PCP?? You shouldn't have to suffer.

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

492 Likes; 14 Followers; 127 Articles; 184,914 Visitors; 20,501 Posts

First off, in no way am I trying to defend or justify you not getting adequate pain relief. I would hope you could talk with your PCP about the issue. Your PCP knows you and knows your history. I don't want to see you (hear about you) being in pain and suffering, I'm sure that everyone here doesn't want to either! I am sorry that you have a front row seat for this issue.

I am very surprised to hear some of your timelines; it is really unacceptable you have a right to be upset. I have never in my career seen a patient with acute cholecystitis be given pain meds in the ED and sent home for 10 days before surgery!

This is common in my rural area due to the lack of surgeons, hospitals.

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