Fed Up with Pain Management

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I guess that's too bad for me, though, I can't afford to quit. The thing is, we do drug screens at each visit, and send the samples off for analysis. A large number of patients have no noroxycodone in their systems, which basically means they are selling their pills. The first time they are put on a 2 week program, the next time they are dismissed. They always want to argue the results, and insist they "don't do meth" or "they don't even know what suboxone is" and they will waste our time whining and arguing...I've gotten to where I don't listen to them. I hand them their test results and tell them to take it up with the drug testing company which they will own if they can prove that the results that test 96% positive for crystal meth are false.

Any of you veterans, how do you deal with these people and keep your sanity? I end up getting flustered and angry. I'm sick of them trying to take advantage of me. The pill heads really know how much the law will allow a pain clinic to prescribe and feel they should get the maximum allowed. We have a few good patients but most of them are just junkies. One was overheard on her cell phone saying I'll have some this afternoon...FOR REAL??? Yes, she was dismissed over her drug test results but the nerve of some of these people is outrageous.

One left sobbing today because not only was she nodding off and practically falling out of her chair in the waiting room but she failed for having absolutely no oxycodone or oxymorphone in her system but lots of crystal meth. She was so upset that we waited until she paid her money to send her away empty handed. Well, didn't she do it to herself? But we're the bad guys.

I have to review new patient requests and have learned to not only check the database for what they have already been getting but criminal records as well. The managers of the clinic want us to give people a chance but should we really take on patients with numerous drug charges for controlled substances, etc.? I'm coming across a lot of these and have been saying no, citing their criminal history as the main reason.

I'm losing faith in humanity. I started with the best of intentions but I was talking to the office manager and we both agreed this job is turning us into the "B" word...

If anyone has any tips please share!

BostonFNP, APRN

3 Articles; 5,581 Posts

Specializes in Adult Internal Medicine. Has 12 years experience.

It's a tough business. On the bright side at least in paint garment you have the resources and structure to deal with thaw folks. In primary care you often don't.

Addicts will tell you every sob story they can. They will get angry. They will threaten to sue.

The good ones with be convincing and complementary. It's tough.

If they come for pills and test negative for their script I am surprised you give them a warning. That's instant dismissal at my primary care practice. There is no excuse for that but selling.

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BCgradnurse, MSN, RN, NP

1 Article; 1,678 Posts

Specializes in allergy and asthma, urgent care. Has 14 years experience.

I agree with Boston FNP-this is a tough job. In fact, opioid and benzo abusers are what made me leave primary care for a specialty where controlled substances are not indicated. Does your practice deal solely with medications for pain, or do you offer other modalities like physical therapy? Medication only sounds suspiciously like a pill mill. It sounds like you do have some good policies in place, but I also disagree with the "warning". Any abuse, and they should be dismissed, IMHO.

How long have you been at this job? Maybe time to start looking for something else?

toomuchbaloney

9,771 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice. Has 44 years experience.

So I know of a pain center patient who was discharged because he was not using the morphine prescribed for him, but he used the pain killer prescribed by the DDS after his oral surgery. He had advised his pain specialist that the morphine caused him terrible nausea and vomiting but the provider would not prescribe an antiemtic at an earlier visit. Now the fellow has no provider to assist him with his pain control.

It is important to know that the patient had his essentially full compliment of MS in the original container with him at the appointment to demonstrate that while he didn't take the med, he continued to have it in his possession. He further indicated to them that he would be happy to take it if they would provide him with the antiemetic.

BostonFNP, APRN

3 Articles; 5,581 Posts

Specializes in Adult Internal Medicine. Has 12 years experience.
So I know of a pain center patient who was discharged because he was not using the morphine prescribed for him, but he used the pain killer prescribed by the DDS after his oral surgery. He had advised his pain specialist that the morphine caused him terrible nausea and vomiting but the provider would not prescribe an antiemtic at an earlier visit. Now the fellow has no provider to assist him with his pain control.

It is important to know that the patient had his essentially full compliment of MS in the original container with him at the appointment to demonstrate that while he didn't take the med, he continued to have it in his possession. He further indicated to them that he would be happy to take it if they would provide him with the antiemetic.

Perhaps unfortunate for this individual. I am willing I go out on a limb that this individual also signed a contract stating that the pain clinic is to be the sole prescriber of narcotics. If this individual got a script from another provider that's a breach of contract, and sadly in that business, no excuses are valid.

As far as the nausea. That is most often a transient side effect of the narcotic. If it persists there is another problem.

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Farawyn

12,646 Posts

Has 25 years experience.

I don't know how you all do it.

OP, why can't you quit and do something else?

NursesKnow

2 Posts

Hi- I do feel your "pain". That must be so frustrating! (You have to admit though how ironic it is to fail a drug test because there is none in you system! Sheesh what a world we live in today, huh?)

As a patient, I have had an opposite experience. I get migraines and prefer to deal with them with triptans which of course are non-narcotic. But there are times when it just doesn't work and I need to "be trusted" with a small supply of codeine. I've heard it is freely "handed out" in parts of the country, but I am so tired of feeling like I have to apologize and "convince" when I tell a doctor I need this.

I am always worried I won't have pain meds when I need them and also fret and ask for them as infrequently as possible. However, if I get on a migraine jag, a supply I have had on hand for maybe a couple of years I might go through in a few days and then there I am desperate, needing to be believed that I am not abusing the drugs. I had this experience last year and it was terrible.

I understand this is not the case with your patents. It's just weird how I guess in certain parts of the country it is apparently seems easy to get pain meds (not the places I go!) and in others you feel like people will assume you are an addict, or some healthcare professional will get all puritanical on you and expect you to "tough it out".

Sounds like you need another position where you can feel like you are really helping people with their health and not with their drug dealing.

toomuchbaloney

9,771 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice. Has 44 years experience.
Perhaps unfortunate for this individual. I am willing I go out on a limb that this individual also signed a contract stating that the pain clinic is to be the sole prescriber of narcotics. If this individual got a script from another provider that's a breach of contract, and sadly in that business, no excuses are valid.

As far as the nausea. That is most often a transient side effect of the narcotic. If it persists there is another problem.

Sent from my iPhone.

Yup, he signed a contract to follow the center's plan of care. He complained often that he didn't feel that it was "his" plan of care because he actually had no voice in it. The fact that he couldn't even get an Rx to address the nausea so that he could take the morphine was evidence of that. "His" plan failed to address his issues with constipation in spite of his repeated requests for help, as another example of how his needs were not addressed in the clinic's plan. It seems to me that the plan mostly addressed the needs and the concerns of the prescribing provider rather than addressing the concerns and needs of the patient.

Like so many pain patients the guy does have a mixed bag of health issues; insulin dependent DM, CHTN, pancreatitis, sciatica, bulging and painful discs, arthritis, failing dentition, bells palsy...I could probably go on and on.

I get the whole Morphine thing, I cannot take morphine without experiencing nausea and vomiting. Nor could my mother when she was on hospice. Nor could my sister or my brother when they required pain meds...we vomit, often, and repeatedly.

mountainaireNP

44 Posts

We dismissed a couple more today. So, we should dismiss them after the first offense of having no metabolites? This is a new pan clinic with new staff and a medical director who isn't as involved as he should be, and we're still trying to figure things out. I can't up and quit as I waited two years to even get on with this job (glut of NPs in the area) and on top of that I have to drive 80 miles one way to have it.

What do you do with them when a new patient comes in demanding "roxi 30'" because the 15's don't work (supposedly.)

BostonFNP, APRN

3 Articles; 5,581 Posts

Specializes in Adult Internal Medicine. Has 12 years experience.
Yup, he signed a contract to follow the center's plan of care. He complained often that he didn't feel that it was "his" plan of care because he actually had no voice in it. The fact that he couldn't even get an Rx to address the nausea so that he could take the morphine was evidence of that. "His" plan failed to address his issues with constipation in spite of his repeated requests for help, as another example of how his needs were not addressed in the clinic's plan. It seems to me that the plan mostly addressed the needs and the concerns of the prescribing provider rather than addressing the concerns and needs of the patient.

Like so many pain patients the guy does have a mixed bag of health issues; insulin dependent DM, CHTN, pancreatitis, sciatica, bulging and painful discs, arthritis, failing dentition, bells palsy...I could probably go on and on.

I get the whole Morphine thing, I cannot take morphine without experiencing nausea and vomiting. Nor could my mother when she was on hospice. Nor could my sister or my brother when they required pain meds...we vomit, often, and repeatedly.

I know it has been awhile but I wanted to come back to this and respond.

Any pain clinic (or any prescriber) that doesn't aggressively manage bowel regimens is bad medicine.

Prescribing antiemetics (in my opinion) is also not best practice as it it most often transient and promotes medication cascade.

As far as the "plan of care" it is developed in the best interest of the patient in the provider's opinion. I will work with patients inside the framework of what I think is best for the patient. This isn't always what the patient thinks is best for them. They are free to choose another provider.

Pain contracts have to be absolute. This is for the protection of both the patient and the provider. Unfortunately some "innocents" get screwed by this but you have to treat everyone the same.

Sounds like it wasn't a good match with this clinic. Hope he has moved on and is better controlled.

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toomuchbaloney

9,771 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice. Has 44 years experience.

He has moved on.

He gets that the provider's opinion was reflected in the POC, he would have preferred that his needs and opinions were also reflected there.

His pain is not better controlled by his physician.

He simply suffers, some days worse than others.

The fact that he has changed pain providers further labels him as a drug seeker and he is treated accordingly by the health "professionals" in that practice.

It is an interesting phenomenon to observe, sad but interesting.

It unfortunately reinforces my experiences as a home health nurse caring for people in the community with chronic pain issues which were inadequately addressed by providers who were reluctant to prescribe, reluctant to change dosage, and afraid to rotate medications. Those patients also suffered on a daily basis as their providers considered their own fears and emotions about opiates before they considered the needs of the patient.

BostonFNP, APRN

3 Articles; 5,581 Posts

Specializes in Adult Internal Medicine. Has 12 years experience.

It's a tough business for a provider, to be honest. I see it frequently and it always makes me pause and it (honestly) tugs at my heart strings at times. I see a new patient. They complain of chronic pain, I review their prescription monitoring program and they have often more than 75 scripts from more than 25 providers filled at many pharmacies under many addresses. It makes me think: is this person just in pain and unable to secure a provider to chronically treat them or are they abusing prescription medications. It's tough. Often these folks don t have much objective evidence of the etiology of their pain.

My "fear" in prescribing is not my own fear. It's the knowledge that the prescription medication abuse is responsible for the rampant heroin abuse and subsequent deaths running wild across our country. A country that uses 80% of the world's opioid supply with only 4.6% of the population.

I also (personally/professionally) believe much of this pain is not strictly physical pain and can/should be treated with other modalities (SNRIs, tricyclics, PT/OT, alternative med).

It's sad to see innocent people end up in pain because of dishonest people. In the end, in my experience, most of these types are not truly honest. They invest little in their own care. They refuse psych therapy. They refuse PT/OT. They have other distances in tox screens that they always have an excuse for.

It's hard. I hope I have no one that I miss that is truly in need but I am not naive enough to think that I don't occasionally err.

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