I am a primary care NP, working with 2 MDs and 2 other NPs. Recently, I had a 90 years old patient, who has post herpetic neuralgia, had shingles 2 years ago. She has h/o diabetes, dementia, sciatica and hypothyroidism. Pt had a fall a year ago, broke her left hip, hemiarthroplasty done. This patient was on oxycodone 5 mg tid prior to the fall for her sciatica, which was tapered off recently in September. After her shingles, she was started on gabapentin 300 mg hs. Patient came this time to the office with her aide, who is with her for 10 years, complaining of neuralgic pain on the left side of her body, more in lt mid back. Aide insisted that gabapentin is not working, patient needs oxycodone back and the patient's daughter is also insisting for oxycodone. I tried to explain the risks, aide would not listen to me. She threw a storm at me. Patient is demented, has no say. I increased the gabapentin to 300mg bid, lidoderm patch for the left mid back and asked her to follow up in a month to see the change. I called the patient's daughter and explained, which she understood. Later, the office manager told me that this aide was collecting patient's medications from the pharmacy, (reported by the pharmacist), who knows whether the patient was getting oxycodone in the past or the aide was using/abusing it? What would you do here?
Death from respiratory depression from oxycodone TID? Not likely unless she already has one foot in the grave and the other on a banana peel in which case she should be under hospice care. And 'high' on PO meds? Have not seen any patient get high on POs and you show your hand with that comment. I don't use anything more mood altering than coffee, I also do not take inventory of others. If said 90 year-old were looking for a buzz I'd think she'd have a bit of a history with ETOH; you know, that widely accepted drug which only purpose is to alter ones' mood and which many of the more self-righteous imbibe in freely. I pray I do not live to be 90 with providers basing most of their decisions on fear of the DEA rather than fear of the patient functioning.
I'll practice medicine the way I see fit and protect my license and livelihood based on my own assessment of the guidelines and practice environment. If patients seek care elsewhere because of it, I won't lose any sleep over it.
I am a primary care NP, working with 2 MDs and 2 other NPs. Recently, I had a 90 years old patient, who has post herpetic neuralgia, had shingles 2 years ago. She has h/o diabetes, dementia, sciatica and hypothyroidism. Pt had a fall a year ago, broke her left hip, hemiarthroplasty done. This patient was on oxycodone 5 mg tid prior to the fall for her sciatica, which was tapered off recently in September. After her shingles, she was started on gabapentin 300 mg hs. Patient came this time to the office with her aide, who is with her for 10 years, complaining of neuralgic pain on the left side of her body, more in lt mid back. Aide insisted that gabapentin is not working, patient needs oxycodone back and the patient's daughter is also insisting for oxycodone. I tried to explain the risks, aide would not listen to me. She threw a storm at me. Patient is demented, has no say. I increased the gabapentin to 300mg bid, lidoderm patch for the left mid back and asked her to follow up in a month to see the change. I called the patient's daughter and explained, which she understood. Later, the office manager told me that this aide was collecting patient's medications from the pharmacy, (reported by the pharmacist), who knows whether the patient was getting oxycodone in the past or the aide was using/abusing it? What would you do here?
300 mgs of Gabapentin HS for that pain; why not just go with a placebo? Seriously and no snark intended, having worked past in oncology to this day longer than any other speciality made me a patient advocate for treating pain, I have seen some horrible deaths. Most people fear dying in pain more than they fear dying and how much time can a 90 year-old have left.
As the 90 year-old would be tested for her Rx which I completely agree with given she cannot advocate for herself she'd be testing positive, if this were my mother I'd run to another clinic. It would be different if all of this were related to med side effects only but if that were they case there are a host of meds elderly patients would not be receiving. All blood thinners, all chemotherapeutic agents, a host of various anti-hypertensives and the Ibuprofen we hand out like candy on Halloween.
I'm not stating this is the case with you but in the general we are not treating pain for #1 primary reason being 'the war on drugs; part two', I remember part one in the 1980s wherein inner city kids were tossed in jail forever over crack cocaine while the well-heeled snorted same drug off of discotheque tables. As for the same inner city folks they've always had heroin addicts as well, they did not go anywhere and they still OD.
Yet every 'cautionary tale' involves white people so we had to declare a crisis. We even renamed it 'opiate use disorder' for them and push Suboxone like candy in spite of the fact it has an opiate.
I actually don't fault providers as their fear of the DEA is well-founded, providers make easy targets; they don't shoot back and keep good records but, as with most things when the pendulum swings it swings to polar opposite with every well-heeled parent of a white OD wanting a new law after lil white Bobby/Susie. We give massive doses of methadone to heroin addicts and hand out 5/325 mgs Norco to cancer patients. I do not see the equity in this and working in corrections the vast majority of inmate withdrawing from methadone/Suboxone also use heroin, they tell me it's quite easy as methadone clinics just test for opiate metabolites which they will have (they don't get methadone in jail; very few controlled drugs in jail due to contraband misuse.)
But I digress, the elderly frequently have the most chronic pain and are the most undertreated due to everyones' concern for side effects on this specific class of drugs. So...we make sure we treat that HTN and A-fib in the interest of extending everyones' life without regard to their quality of life.
You made the right call. We had a family member 'advocate' strongly for a very specific narcotic recently, she was just a little too insistent for the doctor's taste. The floor called security on her. I understand this specific issue much better than I used to and my thoughts as I was listening to her make her case for this narcotic that her loved one just HAD to have was, "do you have any idea how you sound?" It was pitiful.
I will add that if the patient is asking for this medication, that's another story. I had shingles this time last year and it was horrible. I took only Gabapentin and it worked the first dose and then didn't work at all. It was all I could do to not jump up off the couch and run down to the ER to beg for relief. Weirdest pain I've ever experienced. Haven't had post herpetic pain, although I do know others who have.
I'm honestly not trying to be snarky here, but are you an APRN? I am currently in 3/4 finished with school and one of the MANY things that I have learned is how much I DON'T know. Pharmacology is complicated, pathophysiology is complicated and caring for the elderly is really complicated. They metabolize and respond to illnesses differently. How familiar are you with the Beers criteria? (If you are an APRN I apologize for being pedantic).
You are right in advocating for the patients pain relief, but there is probably so much more to this story that we aren't aware of. There are reasons for wanting to avoid opiates in this population if possible. I am still working on figuring it all out myself, but the providers have to be very thoughtful in cases like this. Pain is complicated, and opiates aren't always the solution.
Like I stated previously, opioids are a last resort for chronic pain management. They are useful in certain conditions causing acute pain, and may be the right choice for long-term pain related to cancer and its treatments or, in rare cases, noncancer pain that hasn't responded to any other medications. But there are better, more efficacious treatments for neuropathic pain.
I'm honestly not trying to be snarky here, but are you an APRN? I am currently in 3/4 finished with school and one of the MANY things that I have learned is how much I DON'T know. Pharmacology is complicated, pathophysiology is complicated and caring for the elderly is really complicated. They metabolize and respond to illnesses differently. How familiar are you with the Beers criteria? (If you are an APRN I apologize for being pedantic).
You are right in advocating for the patients pain relief, but there is probably so much more to this story that we aren't aware of. There are reasons for wanting to avoid opiates in this population if possible. I am still working on figuring it all out myself, but the providers have to be very thoughtful in cases like this. Pain is complicated, and opiates aren't always the solution.
djmatte, ADN, MSN, RN, NP
1,248 Posts
I'll practice medicine the way I see fit and protect my license and livelihood based on my own assessment of the guidelines and practice environment. If patients seek care elsewhere because of it, I won't lose any sleep over it.