Order that says "Don't call MD for pain meds"?

[Summers3]

Hello!

I recently took care of a pt with a foot fracture and he only had Tylenol for pain. I don't have any experience yet but I feel that this does nothing for pain of a foot fracture. And the pt is complaining that Tylenol does nothing for his pain...... However, there is an order that specifically states "Do not call the on-call MD for pain meds"...... Why? So the MD is aware of the pt's pain.... but does not want to give any other pain meds?

Sorry but I don't understand this situation... why not?

Thanks!

[KatieMI, BSN, MSN, RN]

Excellent idea and to avoid those dreaded middle of the night calls I plan to add this statement to the admissions template on my psych unit. Just kidding folks.

Actually, writing down who is doing what under which circumstances (within limits of common sense) AND making it all known and followed that way is the one kind of policy which is really useful.

I kind of feel for providers who do not want to get into each other's business (a BIG professional no-no in medical world, among other things); but, in this case, please let me know whom I should contact, AND make sure this person knows about it.

[KatieMI, BSN, MSN, RN]

Acetaminophen (Tylenol) works by different mechanism which has nothing to do with suppressing inflammation. It is even not considered to be NSAID, actually.

And it is way easier to correct "high risk factors" (exercise, PT/OT, massage, nutrition, calcium, magnesium, protein, sulfur-containing amino acids, Vit D, vit C, zinc, copper, etc) than to wean off OxyContin+ fentanyl patch and all their trimmings and sequelas yet another junkie produced by "excellent pain management" which started with those Norcos 5 PRN for a minor fracture.

[LovingLife123]

This. If nothing else, they can order some ibuprofen or toradol (unless contraindicated, of course) if they're not going to order opioids.

Actually, NSAIDs inhibit the healing process according to the latest research.

Look, just because Tylenol has worked for certain people on here with a fracture dies not mean it works for everyone. We are not to judge people's pain.

There is a reason that order was written. Just call and clarify who you are supposed to call. No big deal. Why is it assumed they are a drug seeker or doctor shopper? There could be numerous reasons.

[Kooky Korky, BSN, RN]

Doctor-shopping is a common strategy for many drug abusers. Typically, when hospitalized, they will wait until "after hours" to insist on calling the md in the hopes that a substitute unfamiliar with their behaviors will give them what they want.

This is why pain specialists insist that their patients get pain prescriptions exclusively from their practice. It's part of the contract they sign and is intended to control drug-seeking and manipulative behaviors. If your patient is known to abuse pain medication, the order is a reasonable one.

Seems like you are assuming a lot, Heron.

This patient has a foot fracture.

The pain needs to be assessed and treated properly.

And even abusers might be having real pain - the foot is fractured, for crying out loud. Don't know if you have ever had a fracture, but I can tell you from personal experience that there is real pain involved.

So sick of all the people who don't actually have pain telling people on the front lines how to not treat it. People in their ivory towers, their statistics lab, their newsroom, their legislative halls wish to scare doctors on the front lines, threaten them with "DEA is watching your every move".

Then it's the nurses who have to deal with the patient for hours.

I hope everyone who is causing patients to suffer needlessly gets some very painful disease/surgery/trauma and gets only Tylenol for it - for weeks and months on end. And their loved ones should have pain, too, so the idiots making these insane rules can endure the suffering of their loved ones. That's the only thing that will open their eyes to the agonies they force upon others.

This pain frenzy we are now having is just the latest fad. We go through these every now and again.

OP - call the doctor, call your supervisor, get the appropriate order. Also, neurovascular checks, elevation of the foot, positioning, distraction must all be done.

[Kooky Korky, BSN, RN]

Acetaminophen (Tylenol) works by different mechanism which has nothing to do with suppressing inflammation. It is even not considered to be NSAID, actually.

And it is way easier to correct "high risk factors" (exercise, PT/OT, massage, nutrition, calcium, magnesium, protein, sulfur-containing amino acids, Vit D, vit C, zinc, copper, etc) than to wean off OxyContin+ fentanyl patch and all their trimmings and sequelas yet another junkie produced by "excellent pain management" which started with those Norcos 5 PRN for a minor fracture.

Like minor surgery, the only minor fracture is the one somebody else has.

[Kooky Korky, BSN, RN]

My first instinct is to say this patient probably has a history of "doctor shopping" hoping a provider that is either not familiar with them or is too busy at an ED to look too closely at prescribing history will write an order for narcotic pain meds.

I actually have a resident in LTC that has a long history of med seeking with an order that all pain medication orders are to be approved by the PCP and all psychotropic meds are to be managed by her psych NP so I guess I don't find this kind of order unusual or inappropropriate at all.

Is OP's patient in LTC or where?

[Jules A, MSN]

I wish this and a few other topics didn't always have to turn into a histrionic debate of the extremes. Just like we can't judge from where we sit whether the patient is drug seeking we also can't determine whether or not the order is inappropriate.

[SHGR, MSN, RN, CNS]

Acetaminophen (Tylenol) works by different mechanism which has nothing to do with suppressing inflammation. It is even not considered to be NSAID, actually.

You are correct that APAP is not an NSAID, I was just making a point why specifically APAP would have been ordered and not NSAIDS.

[Here.I.Stand, BSN, RN]

Actually, NSAIDs inhibit the healing process according to the latest research.

Look, just because Tylenol has worked for certain people on here with a fracture dies not mean it works for everyone. We are not to judge people's pain.

There is a reason that order was written. Just call and clarify who you are supposed to call. No big deal. Why is it assumed they are a drug seeker or doctor shopper? There could be numerous reasons.

Interesting. Most of my patients have fentanyl drips and we don't typically give NSAIDs, so I wasn't aware. Thanks!

[Boomer MS, RN]

Acetaminophen (Tylenol) works by different mechanism which has nothing to do with suppressing inflammation. It is even not considered to be NSAID, actually.

Very true.

Not to talk down to anyone here:

Tylenol has two properties: anti-pyretic and analgesic

Nsaids have three: anti-inflammatory, anti-pyretic. and analgesic

Also true about not using nsaids after some surgeries for fractures. Interferes with bone healing.

[JBudd, MSN]

There was an interesting article a year or so ago in the JEN about the efficacy of one gram IV acetaminophen; on the analgesia scale pts reported the same amount of relief as 2 mg of morphine, with placebo way below. Large scale study. My only problem using it in the ER is that you have to infuse it over an hour.

Long time ago at a pain management seminar, 650 mg of po tylenol was rated as equivalent to 30 mg of po codeine.

People just don't want it because it is OTC so it must not be "as strong as I need".

[Teresag_CNS]

Acetaminophen has been shown to be little better than placebo for musculoskeletal pain. Since nurses spend the bulk of the time at the bedside, we deserve a rationale for such an order. Fractures hurt.

Several people here have speculated, but you need to know the reason. A past history of addiction does not justify inflicting unnecessary pain.