No pain meds in ER??

ShaneTeam · Apr 1, 2016

We have started using ketamine for analgesia. I have also had migraine patients experience relief using Ofirmev, which is IV acetaminophen. That stuff is legit!

Lord knows, I would love to try it. I get migraines bad.

ShaneTeam · Apr 1, 2016

Hmm, I wonder how effective IV Tylenol is vs suppository vs oral. Someone should do a study.
The hospital I work for hardly ever uses dilaudid unless the patient is allergic to morphine. We use a lot of IV Toradol and PO oxy/norco or ibuprofen/Tylenol. We have our drug seekers, but they are rare. They usually come in looking for benzodiazepines instead of narcs.

That's mainly what we use in ours. But most people here are looking for Norco's. I am just concerned it will make it more difficult to care for our patients who actually need the pain relief.

Editorial Team / Moderator · Apr 1, 2016

IV Tylenol is over $1000/dose. Insurance comanies decline to pay that price if there are less costly analgesics available.

There is the beauty of working in a military ER â€” my patients don't get a bill, their price is their freedom. 'Merica!

Editorial Team / Moderator · Apr 1, 2016

Hmm, I wonder how effective IV Tylenol is vs suppository vs oral. Someone should do a study.

It's been done: Medscape: Medscape Access

canigraduate · Apr 1, 2016

It's been done: Medscape: Medscape Access

Sweet, ask and ye shall receive!

nuangel1, BSN, RN · Apr 1, 2016

The tide is turning on pain control. From giving everybody who asks for an opiate, an opiate, to withholding serious pain meds to those who really need it.
Just as the prior system aided the seeker, the new one hurts the patient who actually has intractable pain.
There is no middle ground.

I agree as a nurse there should be a decrease in opiate prescriptions and use .like all Ed i have seen too many OD in my time .We give a fair amount of iv dilaudid,morphine ,fentanylt and ativan,etc.for c/o pain .We traditionally also gave small 2-3 days worth in a script.Finally in last year the scripts for narcotics and or benzos are almost gone except in case of fractures.Pts are given Referrals.Pts not happy.I still believe the true c/o pain should be treated as we are in my ED .this is a compromise that should continue.I hope my ED Drs,NP, and Pa-s agree.

This NJ plan of no narcotics at all scares me if this becomes a National Trend because as a RN and a chronic and acute pain sufferer I want my pain treated with non narcotics preferably .But there have been and are times i have needed shorterm narcotics.I dont enjoy suffering and being unable to work.

nuangel1, BSN, RN · Apr 1, 2016

ERs (and hospitals in general) are funny places. Sometimes you have to fight to not be given a narcotic, because you don't think you need it. Sometimes you get no pain meds (not even Tylenol) when you are reporting a pain of 9.
I've been a patient in the ER when I was experiencing the worst pain I have ever had and when asked my pain level reported an 8 or 9. I was given nothing not even Tylenol the entire 8 hours I was in the ER. I was admitted for surgery. After the surgery, the surgeon told me that based on what he found during surgery, he was surprised I hadn't been in excruciating pain prior to surgery. I told him I was. He was surprised. Apparently they had been documenting my self-reported pain of 8 or 9 and documenting their assessment of "NAD."
Another time I was in for multiple broken bones. I kept telling them it was uncomfortable but I did not need anything for the pain. They insisted on giving me a narcotic.
The first example was 1000 times more painful than the broken bones, but they could see the breaks. They couldn't see the pain, and I didn't act like I was in pain. I didn't act like I was in pain, because I was raised to "use your words" and "just because you feel bad does not mean you have to put on a show."
My mother swears that narcotics make her pain worse and that Tylenol is a wonder drug for pain. As her POA I have a battle keeping people from giving her narcotics. I'm seen as the mean, neglectful family member for insisting on Tylenol instead of a narcotic. I'm told I don't know what I am talking about when I say narcotics make her pain worse.
For me Tylenol and Tramadol have as much effect as a witch doctor chanting over me, but ibuprofen works wonders. For severe pain, a low dose of hydrocodone works great, but never, ever, ever give me dilaudid again! Once was enough.
Until there is an objective test to determine pain level and what pain med is effective for that individual, I don't know what the answer is. I don't want to encourage a narcotic addiction, but I do want pain managed.

Very well said and I agree with you

ArrowRN, BSN, RN · Apr 2, 2016

So, how does everyone feel about the New Jersey hospital that decided to pull pain meds out of their ED?

All patients will do is go to another hospital. All they did is place a band-aid on a rupture aneurysm, it won't fix the source of the problem. Why not create a dependency program within the community?

ShaneTeam · Apr 2, 2016

I agree as a nurse there should be a decrease in opiate prescriptions and use .like all Ed i have seen too many OD in my time .We give a fair amount of iv dilaudid,morphine ,fentanylt and ativan,etc.for c/o pain .We traditionally also gave small 2-3 days worth in a script.Finally in last year the scripts for narcotics and or benzos are almost gone except in case of fractures.Pts are given Referrals.Pts not happy.I still believe the true c/o pain should be treated as we are in my ED .this is a compromise that should continue.I hope my ED Drs,NP, and Pa-s agree.
This NJ plan of no narcotics at all scares me if this becomes a National Trend because as a RN and a chronic and acute pain sufferer I want my pain treated with non narcotics preferably .But there have been and are times i have needed shorterm narcotics.I dont enjoy suffering and being unable to work.

That was my concern when I first heard the story. I can see NJ letting this one hospital do this, then make the decision to make it statewide. Two to three years later, nationwide. I might be a little overreacting to it, but sillier things have happened. So what will happen to the patient who uses the ED as their PCP?

NurseDiane · Apr 2, 2016

This news story leaves a lot to be desired, probably with good reason. Stressing that they are not going to use opioids as first-line treatment for pain discourages addicts from going there. If they stated what conditions would warrant opioid administration, there would be a whole lot of addicts with chief complaints of exactly what they said would get them some opioids.

I would have to think that if someone showed up with a compound fracture, feeling like their chest is being crushed by a tractor trailer, a dehiscing wound, or other obviously painful condition, opioid pain management wouldn't be a problem. But, the headaches, belly aches, muscle pain, etc. etc. etc. are not going to get opioids unless there is a verifiable reason for their pain like kidney stones, gall stones, appendicitis, ruptured Achilles tendon, etc.

While I hear about the "pain pills causes heroin addiction" every day of the week, it seems, I have to wonder what ulterior motive all of this serves. I know plenty of people who have received prescriptions for percocet and vicodin, for various reasons such as spinal stenosis, post op knee replacement or colon resection, who have 3/4 of a bottle of pills left because they took what they needed and no more. I can't help but think that the numbers they speak of who have gone from pills to heroin are a very small percentage of the total number of prescriptions for opioids that have been written. What never ceases to amaze me is that alcohol is the #1 killer of all "mind altering substances" out there, and NOTHING is done about it. The government has not stepped in to restrict the number of bottles of vodka or scotch or gin one can buy in a month, or limit how much beer a person can purchase in a supermarket at one time. We never hear numbers for the deaths from alcohol or cases of liver cirrhosis per year caused by excessive alcohol consumption. Why is that? Far more people die from alcohol abuse than from opioid abuse every year.

Maybe it's just my cynical mind at work. Targeting prescription opioids rather than cracking down on heroin entering the country seems like the wrong way to go about it. In New York, you can walk into a pharmacy and purchase syringes without a prescription, no questions asked. The pharmacist I know said it was done to try to control sharing contaminated needles to combat AIDS and hepatitis. So, the government is encouraging IV heroin use, isn't it? You can also buy beer at the same pharmacy, along with your needles. Somehow, this doesn't seem like the right way to address the heroin epidemic.

christamcf · Apr 2, 2016

I believe there definitely needs to be changes in how the medical field is prescribing opiates but as an addiction nurse the real changes need to be in our drug policy. The United States is the second largest country world wide to have the highest incarceration rate with those being nonviolent offenders related to drug offenses. People that are addicted are going to find the drug whether or not hospital ERs stop prescribing opiates all together or use as a second line of treatment. What we really need to be doing is looking at how other countries are tackling the increase in opiate dependence as use that as a model because these countries are having success in not only the decrease in opiate dependence but also everything that comes along with it being crime, infectious disease and even high rates of incarceration. This is a great article to read on what other countries are doing with their drug policies. From cannabis cafes to death row: drugs laws around the world

NurseDiane · Apr 2, 2016

ERs (and hospitals in general) are funny places. Sometimes you have to fight to not be given a narcotic, because you don't think you need it. Sometimes you get no pain meds (not even Tylenol) when you are reporting a pain of 9.
I've been a patient in the ER when I was experiencing the worst pain I have ever had and when asked my pain level reported an 8 or 9. I was given nothing not even Tylenol the entire 8 hours I was in the ER. I was admitted for surgery. After the surgery, the surgeon told me that based on what he found during surgery, he was surprised I hadn't been in excruciating pain prior to surgery. I told him I was. He was surprised. Apparently they had been documenting my self-reported pain of 8 or 9 and documenting their assessment of "NAD."
Another time I was in for multiple broken bones. I kept telling them it was uncomfortable but I did not need anything for the pain. They insisted on giving me a narcotic.
The first example was 1000 times more painful than the broken bones, but they could see the breaks. They couldn't see the pain, and I didn't act like I was in pain. I didn't act like I was in pain, because I was raised to "use your words" and "just because you feel bad does not mean you have to put on a show."
My mother swears that narcotics make her pain worse and that Tylenol is a wonder drug for pain. As her POA I have a battle keeping people from giving her narcotics. I'm seen as the mean, neglectful family member for insisting on Tylenol instead of a narcotic. I'm told I don't know what I am talking about when I say narcotics make her pain worse.
For me Tylenol and Tramadol have as much effect as a witch doctor chanting over me, but ibuprofen works wonders. For severe pain, a low dose of hydrocodone works great, but never, ever, ever give me dilaudid again! Once was enough.
Until there is an objective test to determine pain level and what pain med is effective for that individual, I don't know what the answer is. I don't want to encourage a narcotic addiction, but I do want pain managed.

I agree. I have been in ER's for various things---perforated gallbladder from salmonella infection w/ peritonitis (that one was a 100 pain level---I felt like someone was shoving a butcher knife into my abdomen----surgeon didn't want to give me any pain meds because it would "mask the symptoms", but the ER attending [who was a good friend of mine] knew me & knew that I was in excruciating pain, and wrote for some narcotics to control the pain---I seriously thought I was going to die, I rubbed the skin off my elbows from writhing on the stretcher); numerous kidney stones (one of which was 12 mm and blocking my ureter); torn ACL, MCL and medial meniscus in my knee; after being hit by a tractor trailer on I-95; a submissive saddle pulmonary embolism. Thankfully, I was never denied pain meds, but those ER visits were quite some time ago, except for the PE which was 2 years ago & I didn't need pain meds for that. But I cannot imagine not getting anything for the pain or something that is nowhere near strong enough to reduce the pain to a tolerable level. And YES----pain is a subjective thing. People have different levels of pain tolerance---what is a 10 to one is a 2 to another. We all know that. But since the government, who knows nothing about pain or pain management, got involved, they think everybody can tolerate pain the same way. They don't consider that patients get kicked out of the hospital 2 days after a bilateral knee replacement or sent home with kidney stones after receiving a couple liters of IV fluid to pass the stone at home or sent out of the ER to "follow up" with a specialist for whatever condition they came in with. They are very focused with their "tunnel vision" on the "pills to heroin" thing, and the are leaving a lot of collateral problems in their wake that they don't want to address, because they DON'T KNOW HOW to address it. It's easier for them to apply a blanket policy and put all cases under the same umbrella because it is easier, and because it makes them look like they are doing something. Because of Medicare/insurance company rules on discharge, most patients are discharged far too early & are not ready to go home---they have no idea how they will take care of themselves or how much pain they will be in. Pretty soon, hospitals will have conveyer belts put in where you walk into the ER, lay down on the conveyer belt, and it runs you through triage, admitting, to an RN for blood draw/IV insertion, radiology, the lab, and back into a "waiting area" to see the doctor for a diagnosis. You wait there, and then you can leave. That's pretty much what health care has come to.