Fed Up with Pain Management

allnurses Guide · Nov 18, 2014

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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allnurses Guide · Nov 18, 2014

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 · Nov 19, 2014

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.

allnurses Guide · Nov 19, 2014

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 · Nov 19, 2014

I don't know how you all do it.

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

NursesKnow · Nov 19, 2014

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 · Nov 19, 2014

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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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 · Nov 19, 2014

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.)

allnurses Guide · Nov 25, 2014

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 · Nov 25, 2014

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.

allnurses Guide · Nov 25, 2014

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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