what do you think of this pain med schedule?

jnrsmommy · Jun 13, 2010

Not knowing this pt's history, I would say that this order could be ok. That being said, I've learned, if your gut is questioning it, follow-up/clarify it.

dthfytr, ADN, LPN, RN, EMT-B, EMT-I · Jun 13, 2010

I'd check the chart first to see how long the patient's been on these meds. If the patient has been on them long term for chronic pain, it may be his/her normal regimen, even though it would be fatal to you or me.

If there's no pertinent hx to justify the meds, by all means question it.

Ms.RN · Jun 13, 2010

lets say this patient is really sick. but when i called doctor he questioned me why he ran out of ms and i felt little offended by it and felt like i had to defend myself. what would you do if this happened to you? i left a note to don explaining why he ran out of ms but now i'm regretting it.

CNL2B · Jun 13, 2010

That's a lot of drug. I am assuming this patient has chronic pain. I've seen regimens like this before. I guess the only question I would have is this -- patient is on one sustained release pain medication and two immediate release (oral plus IV.) Is he supposed to be getting both of the immediate release ones on a schedule, or is one supposed to be PRN? Just something to consider. Either way, that schedule could be correct.

You would definitely need to monitor closely for respiratory depression and other side effects of narcotics if giving large doses of two different immediate release pain medications at the same time, especially if the patient had not been on this regimen longstanding.

NotFlo · Jun 13, 2010

i work in ltc and we dont give pain meds every 2 hours like hospitals do. we usually see pain meds scheduled tid or qid and prn. yesterday i had a patient and this patient and he was scheduled with two different doses of morphine surfate plus dilaudid. his schedule is like ms 70mg tid, oramorph 80mg tid then dilaudid 7mg q4 hrs. all at different times. does this make sense to you or should i question this and clarify with doctor?

i've seen people with pain regimens like this plenty of times. there's never anything wrong with asking the doctor if you are questioning the meds, but it could very well be that this is the regimen pt. is supposed to be on.

i guess i'm confused about what running out of a medication has to do with your original question.

SunnyAndrsn · Jun 13, 2010

i'd call the pharmacy that the ltc uses when i used the last dose and request it be sent out stat. i agree that, depending on the pt's history and dxs, that this routine may be acceptable. is the pt showing s/s of pain on this regimen? also, when was the last time the md reviewed the meds? is a fentanyl patch an option for the pt to replace some of the oral meds?

lets say this patient is really sick. but when i called doctor he questioned me why he ran out of ms and i felt little offended by it and felt like i had to defend myself. what would you do if this happened to you? i left a note to don explaining why he ran out of ms but now i'm regretting it.

FLArn · Jun 13, 2010

I agree to monitor the respirations but if this patient has cancer or other life-limiting illnesses that are associated with significant pain levels don't get overly focused on the resp. rate. The amount of pain the patient experiences will be significant and these patients often live a very long time with rates we would consider very low but the comfort level MUST be the primary consideration. Studies have shown that terminal patients on the whole fear a painful death more than actually dying itself.

morte, LPN, LVN · Jun 13, 2010

the sustained action med should be spread out as close to Q8 hours as possible, i am surprised to see that much MS, one would think that the oramorph needs an increase perhaps? and the dliaudid is for break thru?

FLArn · Jun 13, 2010

These would be high doses for patients with acute disease; however, they are fairly routine doses for patients with chronic pain or terminal diagnoses. Actually I've given significantly higher doses routinely to patients who were then still able to do all their own ADL's including cooking, shopping and driving! The pain somehow "uses" up the meds and the patients remain alert, oriented and totally functional. Amazing the first few times you see it.!

tewdles, RN · Jun 13, 2010

i work in ltc and we dont give pain meds every 2 hours like hospitals do. we usually see pain meds scheduled tid or qid and prn. yesterday i had a patient and this patient and he was scheduled with two different doses of morphine surfate plus dilaudid. his schedule is like ms 70mg tid, oramorph 80mg tid then dilaudid 7mg q4 hrs. all at different times. does this make sense to you or should i question this and clarify with doctor?

you really didn't give me information that allows me to say if this seems appropriate for this patient.

people experience "constellations" or clusters of pain symptoms...mixed bags of suffering if you will...that, more often than not, require some basic polypharmacy. in my region and experience the morphine combination in this case is somewhat unusual, but the practice of mixing in and transitioning to other agents is reasonably common. i have had patients taking a long acting and short acting morphine, vicodin, gabapentin, and other symptom managment meds in significant dosages.

the bottom line is that i cannot make sense of it, really, without knowing the patient...but you can. do a good comprehensive pain assessment. talk to the doctor about the patient pain management plan of care...particularly if the patient seems to be uncomfortable between doses. speak to the patient and family and try to determine their goals for care...is this a terminal patient? is this patient on hospice or palliative services?

i would be interested if you would care to update on your ongoing experience with this patient...

scoochy · Jun 14, 2010

Medication regimes such as the one you refer to are common in LTC setting. That being said, however, it is important the MD reviews this regime frequently. Easy to say, but often difficult to get the MD to do in LTC. I care for a resident who was receiving a similar regime of narcotics. One evening while making my rounds, I found the resident with slurred speech, hypotensive, tachycardic, pin-point pupils, and 02 sat 82%. The resident spent the night in an acute care hospital. Narcan was administered there. Resident returned the next day; MD tapered the regime with resident's full consent. I was concerned as to how the resident would do from a physiological and psychological standpoint. Happy to report the resident is doing well overall. There has been a more concentrated effort to use alternative therapy with the resident for pain control. The resident has a terminal diagnosis, but is now able to be more independent d/t medication reduction. The resident was receiving too much narcotic, but because the resident was admitted to the facility having been on this regime for quite some time, it was accepted as such.

My wish for this resident, as well as others, would be to have a consulting pain management specialist involved in their care.