Fed Up with Pain Management

[mountainaireNP]

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!

[BrnEyedGirl, BSN, MSN, RN, APRN]

BostonFNP you bring up some interesting points. I am currently in an FNP program and have spent the last 10 yrs in the ED. The concept of chronic pain is fascinating to me.

While we all know there are those patients who have no pain and are either wanting the high, or using the sell of narcotics as a form of income, there are those patients with pain, who have no legitimate diagnosis for their pain. It is these patients that intrigue me. This concept of a pain clinic is relatively new to medicine. I'm not sure I understand the concept to be honest.

If a patient has uncontrolled pain, that is an expected sequelae of his/her disease process, ie cancer, that pain is controlled by the provider treating the underlying disease. The patient with chronic migraines is treated by his or her neurologists. Orthopaedic injuries are treated or surgically repaired by the orthopaedic specialist. The oncologist treats cancer pain. Where did this concept come from to send patients to a "pain clinic" to just treat pain, without treating the underlying cause? How did it become in the patients best interest for a provider to decide that because he/she is unable to find a pathological explanation for the patients chronic, unrelenting pain, that the best solution is to send the patient to a new provider who will prescribe narcotic medications to be taken 24/7 for eternity? Better yet,.how did a provider decide that it would be good patient care to provide narcotics 24/7 to a patient without pathology to explain their pain, and without any treatment to heal the pathology?

I have researched the concept of "opioid induced hyperalgesia" , and while the data is limited, it appears we may be doing our patients a disservice by continuing to feed into this vicious circle of "'pain is what the patient says it is". I think there is more to this idea of chronic pain and that many if not most of the patients would benefit from counseling, physical/occupational therapy, antidepressants, and general life coping skills. While I would never want to leave a patient in pain unnecessarily, I would also hate to perpetuate this cycle of continued pain and poor coping that appears so prevalent in this patient population.

[elkpark]

BostonFNP you bring up some interesting points. I am currently in an FNP program and have spent the last 10 yrs in the ED. The concept of chronic pain is fascinating to me.

While we all know there are those patients who have no pain and are either wanting the high, or using the sell of narcotics as a form of income, there are those patients with pain, who have no legitimate diagnosis for their pain. It is these patients that intrigue me. This concept of a pain clinic is relatively new to medicine. I'm not sure I understand the concept to be honest.

If a patient has uncontrolled pain, that is an expected sequelae of his/her disease process, ie cancer, that pain is controlled by the provider treating the underlying disease. The patient with chronic migraines is treated by his or her neurologists. Orthopaedic injuries are treated or surgically repaired by the orthopaedic specialist. The oncologist treats cancer pain. Where did this concept come from to send patients to a "pain clinic" to just treat pain, without treating the underlying cause? How did it become in the patients best interest for a provider to decide that because he/she is unable to find a pathological explanation for the patients chronic, unrelenting pain, that the best solution is to send the patient to a new provider who will prescribe narcotic medications to be taken 24/7 for eternity? Better yet,.how did a provider decide that it would be good patient care to provide narcotics 24/7 to a patient without pathology to explain their pain, and without any treatment to heal the pathology?

I have researched the concept of "opioid induced hyperalgesia" , and while the data is limited, it appears we may be doing our patients a disservice by continuing to feed into this vicious circle of "'pain is what the patient says it is". I think there is more to this idea of chronic pain and that many if not most of the patients would benefit from counseling, physical/occupational therapy, antidepressants, and general life coping skills. While I would never want to leave a patient in pain unnecessarily, I would also hate to perpetuate this cycle of continued pain and poor coping that appears so prevalent in this patient population.

Pain management clinics and services aren't that new. My father was an anethesiologist and I remember him talking 40 years ago about colleagues of his who were doing sophisticated, multimodal, multidisciplinary pain management in outpatient clinics or inpatient consulting services. All the academic medical centers I've worked in over the years have had good multimodal pain services available.

What is a more recent development is that, unfortunately, we have to clarify, when talking about a "pain clinic," whether we mean a legitimate, multimodal specialty pain management practice or a quasi-legitimate opiate dealing operation. We all know there are lots of so-called "pain clinics" around that are little more than fronts for dealing opioids. You go in, say you have back pain, and, 20 minutes later, no exam, no imaging, no nothing, you walk out with the scrip(s) of your choice (there was one notorious one in my home state that got busted by the authorities -- the office was, literally, a one-room shack in the middle of nowhere, surrounded by farmland. The physician had no specialty training or certification in pain management. The office/shack had no exam table or imaging equipment, or even a thermometer or stethoscope; it didn't even have running water. Just a desk and a few chairs, and he just sat there all day and wrote scrips for opioids for money). The legitimate pain services don't "prescribe narcotic medications to be taken 24/7 for eternity," they (try to) educate people that there are better options for their chronic pain than long-term narcotic use, and do provide (or refer to) all the other interventions you list. As someone who has worked in psychiatric consultation/liaison nursing for a number of years in a couple different settings, I have worked closely with the pain services in those facilities (because it is recognized in these facilities that there is a big overlap between psych and pain, so it's common for both services to get consulted on cases, or the pain service consults us after they've seen the indiviidual) and have personally witnessed the pain service people knocking themselves out with individuals with chronic pain to get them to try other modalities besides just opioids.

A big part of the problem is that people like opioids. By the time they get referred to a specialty pain service/clinic, they've gotten used to the idea of taking the pill and feeling better. Most of them don't want to hear about other, non-narcotic interventions (inc. other medications) that are going to require some effort and patience on their part, and aren't going to provide quick (if short-lived) relief.

[BritFNP]

This is a huge issue in the rural clinic I work in too. The meth use is insane out here. Over 50% of people seem to be hooked on pain pills or benzos. It is disheartening. I had one patient come in, on the job a pipe had hit him in the rib cage, negative rib series...treated him acutely with Norco (back when we could rx), flexeril, and some prednisone. He returned 3 weeks later still in pain. I told him he would be sore for a bit - maybe costochondritis - and to take OTC antiinflammatories. He decided to leave me and see one of the doctors in my office who did no further diagnostic testing and rewrote his Norco. Now the patient comes in monthly for a prescription. Many times we do this to the patients ourselves. It is a sad reality.

[BostonFNP, APRN]

Happens all the time Brit, it's sad. Many providers would rather write a script than argue.

Sent from my iPhone.

[MedievalNurse]

I currently have a position working for a clinic owned and operated by a physician where the demands for benzos/pain medication is rampant. I find it very frustrating on a daily basis to have to deal with the people who have become addicted to their benzos or their pain medication and just want refills. If you truly want help for your anxiety or your pain, and are open to trying various options in addition to or in lieu of controlled substances, I want to help you. If you need a short course of benzos for a particularly rough time in your life, cool, let's talk. If you come in to my office telling me you NEED Xanax because clonazepam makes you sick, I don't want to hear it.

I am switching to a job where controlled substances are not an option. I have to say that it is one of the most attractive parts of the new job. I am ready to stop feeling like the gatekeeper of controlled substances, determining who is "worthy".