Are We Letting Our Patients Suffer?

  1. 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?

    Are We Letting Our Patients Suffer?

    Recently I had a patient who fractured her femur, mid-shaft. She was unable to have it repaired due to multiple co-morbids. So, she was given a brace and told it would have to heal in time. She developed some wounds from the brace and it had to be removed. She goes to the wound clinic once per week, dialysis three times per week and each time she is transferred by a Hoyer lift into her wheelchair, transferred to the nursing home van and then, at least at dialysis is then transferred again via Hoyer to the dialysis chair. XRays done recently showed nonunion of this fracture which can be attributed to several factors: malnutrition, hyperphosphatemia, osteoporosis.

    For pain, she has been Rx'd with: fentanyl 62.5mcg patch changed every 72 hours, percocet 10/325 one orally every 8 hours as needed and tylenol 650mg every 8 hours as needed. Prior to her femur fracture, she had been on a fentanyl 50mcg patch changed every 72 hours as well as Percocet 5/325 every 8 hours as needed due to severe osteoarthritis - made worse by end stage renal disease.

    She comes to the dialysis unit crying in pain due to the 10 mile ride from the nursing home to the dialysis unit. There is no medication to give her at the dialysis unit except tylenol. Her pain is not controlled well - she continually rates her pain 8-10/10. She is physically addicted to opioids due to several years of chronic pain meds for her multiple disease processes. When I spoke to the nursing home staff, I was told "we can't continue to contribute to her addiction."

    Another incident - a friend (fellow APRN) underwent major abdominal surgery recently. She was opioid naive and prior to her surgery, took no medication. She was healthy and had NKDA. Post-operatively she was given Norco 5/325 one every 8 hours as needed as well as ibuprofen 600mg every 8 hours. However, she rated her pain in the first 24 hours consistently 8/10. One nurse made the comment that she (the nurse) was sorry but the doctor "didn't want her to become addicted."

    Two recent incidents, different patients, different reasons for pain yet both were denied adequate pain relief.

    Have we gone too far in the opposite direction?

    Are we letting our patients suffer in the name of patient safety?

    "The National Institutes of Health (NIH) estimate that in the United States, 25.3 million adults have chronic pain." What are we supposed to do? As providers we want to provide adequate pain control for both our chronic pain patients as well as for those with acute pain. "A team of researchers at Wake Forest University and the University of Bath in the U.K. is exploring a new kind of opioid that could relieve pain without affecting breathing or raising the chance for abuse. The new drug, only called by its chemical compound name BU08028, relieved pain in rhesus macaque monkeys. When they had the opportunity to take as much of the drug as they wanted, they didn't abuse it. When taken off the drug, they didn't show signs of painful withdrawal." Perhaps this will be a new medication for both chronic and acute pain.

    Some other suggestions:

    • Non-steroidal anti-inflammatory medication such as ibuprofen - can be used either alone or as an adjunct
    • Cognitive behavioral therapy has been used successfully for acute worker's compensation injuries
    • Ketamine is now being used for acute pain. Recently the journal AACN Advanced Critical Care included a Drug Update about the use of ketamine in the ICU.

    So, what to do? Are we helping to prevent opioid addiction or are we letting our patients suffer needlessly? What are your thoughts?
    Last edit by tnbutterfly on Sep 14
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    71 Comments

  3. by   Mudpinesredneck
    Trauma, great article. But I'm sure you already knew

    There are also deeper issues

    1. If you have anxiety, all pain to the doctor is psychosomatic. If SSRIs almost did some major damage, as it did me, you're out of luck for relief. Benzodiazepines do not exist in rural areas, unless bought at a smoke shop (kinda, think Phenibut) or a drug dealer's house. Even if benzodiazepines work wonders for you. It'd be a shame if you become Benzo addicted rather than have your heart explode on Paxil!

    2. ER's have an attitude of "Rule out major stuff and discharge"
    I've been to the ER 5 times for neuro symptoms (Facial tingling/numbness, dizziness, extreme migraines and headaches) since February when I was beat badly and took a secondary impact.
    As long as you are not having a stroke, you are just another drug seeking, attention seeking, good for nothing with no pain tolerance.
    The one time a doctor wanted to give me something for pain (And boy, with the migraine I had, I was CRYIN for pain meds), it was a choice of Tylenol or Dilaudid. I mean, is there ANY middle ground betwen that I can have, please?

    What ever happened to the days when my grandmother was a midwife, and rotated to ER when busy? When my grandmother took the time to relieve pain, and get down to the bottom of things?

    3. Doctors unavailable or booked months out, forcing patients to use the ER when they've had a migraine for 3 days with no relief. You can only go so many times before you're treated like the incarceritis or dilauid seeker next door to you. Even if you are an upstanding citizen with no hx of drug usage

    4. Like point 3, doctors make a blanket assumption that EVERYONE is drug seeking. There is no person in the world in enough pain to deserve anything more than Zoloft and Tylenol (Sorry if I reiterated you on that one)

    Just my 2 cents on this "Opioid crisis"

    Does an opioid crisis exist? Do bears poop neatly in dumpsters, in a city?

    The DEA was losing numbers over the decline in other drug usage. They needed to find something to keep their numbers up.

    Perhaps this "Opioid" and medication crisis in general, has been caused by our own government, skewing statistics around.

    Also, heroin contributes to many of those opioid deaths.
    Last edit by Mudpinesredneck on Sep 14
  4. by   brownbook
    It's not that complicated.

    In your first example, (a generally debilitated chronically sick patient), the nurse and or the patient's doctor was wrong to think a patient in chronic pain who has been on opioids for several weeks, or months, could or should have her opioids reduced. A big DUH to them.

    In your second example a "new " patient in the hospital status post surgery is not going to become an opioid addict when given as much opioid pain relief as is necessary for the first few days or week after surgery. Another big DUH!

    However intelligent educated health care providers are learning from evidenced based studies that opioids are not helpful, and may be harmful, for long term pain. As you mentioned new drugs, and non opioid alternatives, have been found to be as effective.

    Pain relief needs to be tailored to each patient. There is no one size fits all.
  5. by   LovingLife123
    The problem comes down to, we have no medical educated people trying to make medical decisions.

    I have said this before, little Bobby buys Oxys on the street, crushes them, snorts them, then dies. Parents want someone to blame because Bobby is such a "good kid". They blame the doctors for prescribing this evil and allowing it to get to the street. They want Bobby's Law made so they go to our legislators about all the evils of pills, instead of accepting that Bobby was perhaps a stupid teenager. They scream all over the news about the evils of narcotics.

    It has snowballed to where we are now. I have debilitating chronic pain. I actually got some relief from low dose norcos. Now, I can't get them because Im labeled an addict for simply having chronic pain. Never mind the fact I've never experienced cravings or any type of withdrawal ever from narcotics. I responsibly used my meds.

    I never question pain with my patients. I'm right there too. I cry almost every day from my pain.

    It sucks to be sentenced to a life of pain. It's like you are in the deep hole of hell and there is no escape.

    I hate how everything has to be a knee jerk reaction in this country.
  6. by   traumaRUs
    Quote from Mudpinesredneck
    Trauma, great article. But I'm sure you already knew

    There are also deeper issues

    1. If you have anxiety, all pain to the doctor is psychosomatic. If SSRIs almost did some major damage, as it did me, you're out of luck for relief. Benzodiazepines do not exist in rural areas, unless bought at a smoke shop (kinda, think Phenibut) or a drug dealer's house. Even if benzodiazepines work wonders for you. It'd be a shame if you become Benzo addicted rather than have your heart explode on Paxil!

    2. ER's have an attitude of "Rule out major stuff and discharge"
    I've been to the ER 5 times for neuro symptoms (Facial tingling/numbness, dizziness, extreme migraines and headaches) since February when I was beat badly and took a secondary impact.
    As long as you are not having a stroke, you are just another drug seeking, attention seeking, good for nothing with no pain tolerance.
    The one time a doctor wanted to give me something for pain (And boy, with the migraine I had, I was CRYIN for pain meds), it was a choice of Tylenol or Dilaudid. I mean, is there ANY middle ground betwen that I can have, please?

    What ever happened to the days when my grandmother was a midwife, and rotated to ER when busy? When my grandmother took the time to relieve pain, and get down to the bottom of things?

    3. Doctors unavailable or booked months out, forcing patients to use the ER when they've had a migraine for 3 days with no relief. You can only go so many times before you're treated like the incarceritis or dilauid seeker next door to you. Even if you are an upstanding citizen with no hx of drug usage

    4. Like point 3, doctors make a blanket assumption that EVERYONE is drug seeking. There is no person in the world in enough pain to deserve anything more than Zoloft and Tylenol (Sorry if I reiterated you on that one)

    Just my 2 cents on this "Opioid crisis"

    Does an opioid crisis exist? Do bears poop neatly in dumpsters, in a city?

    The DEA was losing numbers over the decline in other drug usage. They needed to find something to keep their numbers up.

    Perhaps this "Opioid" and medication crisis in general, has been caused by our own government, skewing statistics around.

    Also, heroin contributes to many of those opioid deaths.
    Thanks for sharing - I'm sorry you have gone thru this.
  7. by   traumaRUs
    Quote from LovingLife123
    The problem comes down to, we have no medical educated people trying to make medical decisions.

    I have said this before, little Bobby buys Oxys on the street, crushes them, snorts them, then dies. Parents want someone to blame because Bobby is such a "good kid". They blame the doctors for prescribing this evil and allowing it to get to the street. They want Bobby's Law made so they go to our legislators about all the evils of pills, instead of accepting that Bobby was perhaps a stupid teenager. They scream all over the news about the evils of narcotics.

    It has snowballed to where we are now. I have debilitating chronic pain. I actually got some relief from low dose norcos. Now, I can't get them because Im labeled an addict for simply having chronic pain. Never mind the fact I've never experienced cravings or any type of withdrawal ever from narcotics. I responsibly used my meds.

    I never question pain with my patients. I'm right there too. I cry almost every day from my pain.

    It sucks to be sentenced to a life of pain. It's like you are in the deep hole of hell and there is no escape.

    I hate how everything has to be a knee jerk reaction in this country.
    Another example: I had a pt recently who had a dental abscess. I Rx'd him with an antibiotic and Norco 5/325 #30 with directions one orally every 8 hours as needed for pain. Our local Walmart wouldn't fill the script because it was for more then a 7 day supply.

    This occurred in a very small town and the dentist who accepted state Medicaid didn't have an opening for 2 weeks.

    Totally agree that non-medical people are making medical decisions. One of the reasons I asked has the pendulum swung too far in the oppositie direction where providers aren't allowed to Rx needed meds. Thanks for your comments
  8. by   traumaRUs
    Quote from brownbook
    It's not that complicated.

    In your first example, (a generally debilitated chronically sick patient), the nurse and or the patient's doctor was wrong to think a patient in chronic pain who has been on opioids for several weeks, or months, could or should have her opioids reduced. A big DUH to them.

    In your second example a "new " patient in the hospital status post surgery is not going to become an opioid addict when given as much opioid pain relief as is necessary for the first few days or week after surgery. Another big DUH!

    However intelligent educated health care providers are learning from evidenced based studies that opioids are not helpful, and may be harmful, for long term pain. As you mentioned new drugs, and non opioid alternatives, have been found to be as effective.

    Pain relief needs to be tailored to each patient. There is no one size fits all.
    I agree with everything you said - however, we as providers are sometimes not being allowed to treat our patients' pain as should be treated
  9. by   Susie2310
    Quote from traumaRUs
    Another example: I had a pt recently who had a dental abscess. I Rx'd him with an antibiotic and Norco 5/325 #30 with directions one orally every 8 hours as needed for pain. Our local Walmart wouldn't fill the script because it was for more then a 7 day supply.

    This occurred in a very small town and the dentist who accepted state Medicaid didn't have an opening for 2 weeks.

    Totally agree that non-medical people are making medical decisions. One of the reasons I asked has the pendulum swung too far in the oppositie direction where providers aren't allowed to Rx needed meds. Thanks for your comments
    With respect, my first thought was: "only Norco 5/325 one tablet orally every 8 hours as needed." My knowledge/experience (including personal experience) is that dental abscesses cause severe unremitting pain. I have been literally shaking and diaphoretic with 10/10 unbearable pain every time I have had an abscessed tooth (which has happened several times), with the dentist on call the last time telling me to take large amounts of Ibuprofen at regular intervals until I could get an appointment with my own dentist, who when I saw him/her apologized that they weren't allowed to prescribe anything stronger. I'm pretty sure Norco 5/325 one tablet orally every 8 hours (which I have taken before at 6 hourly intervals for another problem) wouldn't have touched the severe pain from my abscessed tooth. What was your assessment of your patient's pain?
    Last edit by Susie2310 on Sep 14
  10. by   Chrispy11
    Quote from traumaRUs
    Totally agree that non-medical people are making medical decisions. One of the reasons I asked has the pendulum swung too far in the oppositie direction where providers aren't allowed to Rx needed meds. Thanks for your comments
    So true. Early last year, my State's lawmakers put through legislation based on some rock star`s daughter`s overdose. I had arranged for an orthopedic surgery, the surgeon had a three month wait list, and I had my maximum prescriptions for tramadol as per the new state laws. I had two choices. Go to a pain management doctor, since I was not considered under the care of my surgeon until I had the surgery or take Celebrex. Two issues. Celebrex cost over $1300, generic cheaper but still up there. Soonest appointment with pain management was the day before my surgery. I was in serious pain, with no relief for over a month. I even thought of a marijuana scrip out of desperation, but my illness was not listed as an allowable condition. I was pretty miffed at the time that I was put into a no win situation by politicians that had no in depth knowledge of how this would affect actual people who had a medical need for these prescriptions. I wouldn't wish my experience on anyone. Thankfully I had the surgery, but I had the entire week before off NSAIDs. This is a situation I'd avoid if it ever comes up again.
  11. by   Sparki77
    It's nice to know that I'm not alone in this type of thinking. What a great disservice to those that truly need the med. I might be going out on a limb here but I think the "clueless shot callers" have inadvertently contributed to the current crisis by forcing some people to buy meds illegally & when those run out, well there's always heroin.

    What a horrible situation this is and I agree, it was a total knee jerk reaction to satisfy the parents of the little Bobbys of the world.
  12. by   applewhitern
    I had a horrible dental abcess, but the dentist refused to give me any kind of narcotic. Told me to take ibuprophen or acetaminophen! It was the worse pain I've ever felt. I had to keep chipped ice in my mouth to deaden the pain some. To me, 30 Norco tabs sounds heavenly.
  13. by   applewhitern
    @Mudpinesredneck: What are talking about, the paxil comment and heart exploding? Please explain what you meant. I've been on 40mg paxil for YEARS and now you have me worried. Does Paxil affect the heart??
  14. by   traumaRUs
    Quote from Susie2310
    With respect, my first thought was: "only Norco 5/325 one tablet orally every 8 hours as needed." My knowledge/experience (including personal experience) is that dental abscesses cause severe unremitting pain. I have been literally shaking and diaphoretic with 10/10 unbearable pain every time I have had an abscessed tooth (which has happened several times), with the dentist on call the last time telling me to take large amounts of Ibuprofen at regular intervals until I could get an appointment with my own dentist, who when I saw him/her apologized that they weren't allowed to prescribe anything stronger. I'm pretty sure Norco 5/325 one tablet orally every 8 hours (which I have taken before at 6 hourly intervals for another problem) wouldn't have touched the severe pain from my abscessed tooth. What was your assessment of your patient's pain?
    I should have clarified: this is a hemodialysis patient who weighs 50kg. This is the appropriate dose for this pt. I also added ibuprofen (the pt is anuric) 400mg twice per day.

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