Pain control in pt. With hx of opiate abuse

[anewsns]

I noticed that some patients have this severe chronic pain with history of opiate abuse have a lot of trouble getting pain control in the hospital. Sometimes, I feel like physicians don't listen to them enough. I feel like doctors (including the pain team !) usually go with a pharmacological approach to pain control but once they have all these non opiate pain medicines on board, they get a teeny amount of opiate or none at all and then they are on their own. I even struggle trying to get consults for people sometimes and get responses like "well they broke their pain contract in the past." I think people with severe uncontrolled pain (and often psych comorbidities) are very likely to break pain contracts so they can go get illegal drugs to get some relief for a minute. The system is pretty unforgiving of those situations. If they don't get enough support they will likely go back to using again. It's a vicious cycle. I feel like we should try harder. I also hardly ever hear of alternative therapies such as accupuncture and we seem to forget to get psych or stress management involved. This is one of the few areas where I find myself having to really strongly advocate for people. Anyone else have this dilemma ? What more can I do for this population?

[Been there,done that, ASN, RN]

Please keep up your effort. My father had intense neuro pain due to a botched procedure. We tried acupuncture and all of the above. He went to pain clinics, methadone treatment and more. He died in pain despite my best efforts. He ended up requiring 80 mg/ of morphine an hour for pain control.( no ceiling on morphine)

The best answer I got was from an anesthesiologist. He told me there is a brain enzyme that blocks opiates.

If the pain team doesn't get it.. screw them, go straight to the anesthesiologist.

[psu_213, BSN, RN]

I even struggle trying to get consults for people sometimes and get responses like "well they broke their pain contract in the past." I think people with severe uncontrolled pain (and often psych comorbidities) are very likely to break pain contracts so they can go get illegal drugs to get some relief for a minute.

I totally agree with you that we do a very poor job of handling pain in someone who takes opioids already--either legally as an outpatient or illegally.

To address you above statement, in my state, the government is starting to suspend the medical licenses of non-pain clinic doctors who prescribe too many opioids. In addition, the state is really starting to tighten up on the pain clinics as well. As a result, the pain clinics are becoming more stringent, even for patient who do not break their contracts. Is it fair for pain clinics to not prescribe to people who may have broken their contracts once, especially if the person was just looking for some relief? No, generally not. However, with the opioid epidemic, and with how the government is "working" to fight it, these clinics cannot afford to take chances. Unfortunately, it hurts the most for the people who most need the help.

[Cari1030, RN]

Honestly, this seems to be a problem even for non-addicts. I'm not a nurse yet, so I can't comment on the issue as a whole, but as a person with a chronic issue (I have idiopathic intracranial hypertension/pseudotumor cerebri) who very, very rarely actually goes in for pain management (it's been probably close to 8 years before this), I found that last time I went in, I was treated like an addict/drug seaker. This despite my lack of history, my requesting caffeine as an attempt to get it under control, and my requesting something to just take the edge off. I usually handle my constant headaches ok, I'm used to it by now, but I had just switched to graveyard and I guess my body was being a brat. Anyway, I was denied pain meds and offered ibuprofen....

[blondy2061h, MSN, RN]

Honestly, this seems to be a problem even for non-addicts. I'm not a nurse yet, so I can't comment on the issue as a whole, but as a person with a chronic issue (I have idiopathic intracranial hypertension/pseudotumor cerebri) who very, very rarely actually goes in for pain management (it's been probably close to 8 years before this), I found that last time I went in, I was treated like an addict/drug seaker. This despite my lack of history, my requesting caffeine as an attempt to get it under control, and my requesting something to just take the edge off. I usually handle my constant headaches ok, I'm used to it by now, but I had just switched to graveyard and I guess my body was being a brat. Anyway, I was denied pain meds and offered ibuprofen....

I have idiopathic intracranial hypertension also and an NSAID allergy, so yeah, that's my life.

[anewsns]

I totally agree with you that we do a very poor job of handling pain in someone who takes opioids already--either legally as an outpatient or illegally.

To address you above statement, in my state, the government is starting to suspend the medical licenses of non-pain clinic doctors who prescribe too many opioids. In addition, the state is really starting to tighten up on the pain clinics as well. As a result, the pain clinics are becoming more stringent, even for patient who do not break their contracts. Is it fair for pain clinics to not prescribe to people who may have broken their contracts once, especially if the person was just looking for some relief? No, generally not. However, with the opioid epidemic, and with how the government is "working" to fight it, these clinics cannot afford to take chances. Unfortunately, it hurts the most for the people who most need the help.

I totally get that. I think the opioid epidemic is truly terrifying. A lot of people have psych problems too. I feel they are more vulnerable to addiction, wanting to kill the pain in more ways than one. But, are opiates the only solution? And, if someone who is in constant extreme pain, and they've broken pain contracts, is it helpful to let them go on their own with no control? I had a specific case recently that really touched my heart. Bad traumatic past and chronic pain due to "lupus " as the doctors keep telling her for years and years. She was starting to feel really helpless. I see a fair amount of this but her case particularly touched me. Some drug addicts can be manipulative, but some just need better help. Even if we can't do opiates we should keep trying new things and assessing / addressing the many issues of this population. They get ignored a lot.

[anewsns]

Honestly, this seems to be a problem even for non-addicts. I'm not a nurse yet, so I can't comment on the issue as a whole, but as a person with a chronic issue (I have idiopathic intracranial hypertension/pseudotumor cerebri) who very, very rarely actually goes in for pain management (it's been probably close to 8 years before this), I found that last time I went in, I was treated like an addict/drug seaker. This despite my lack of history, my requesting caffeine as an attempt to get it under control, and my requesting something to just take the edge off. I usually handle my constant headaches ok, I'm used to it by now, but I had just switched to graveyard and I guess my body was being a brat. Anyway, I was denied pain meds and offered ibuprofen....

That's so hard. People have to be crying and writhing on the ground or else they are considered a "drug seeker." I found that in my hospital if someone has major headaches (neuro floor) doctors keep on pushing for better plans, caffeine, compazine, decadron, etc.

But if an opiate abuser has a major headache from a real problem it's all *radio silence* like we suddenly forgot all our non opiate methods. (Given a lot of those patients are on other services such as gen med who may not be as used to treating headaches without opiates. )

[mmc51264, BSN, MSN, RN]

We have a separate Acute Pain Service to help with hard to manage pain issues. We use regional nerve blocks, try to maintain home doses of pain medication, ice, we also have alternative medications like Ketamine gtts and Lidocaine gtts, which can be extremely useful.

It is very difficult for people to get treatment for chronic pain. They do what they can, sometimes getting stuff on the street which does blow their pain contracts.

I have chronic pain and go to a pain clinic. I take it very seriously and follow my plan to a T. Even when I was in a car accident, I told them no narcotic pain meds because I had a pain contract. Toradol is a magnificent medication!!!.

I do my very best to help my chronic pain pts. I work orthopedics (no spines-which can be very difficult to pain manage) I don't judge and I know that I am not going to rehab them in the few days to a week that they are going to be under our care. One of our NPs was in pain management before she came to her current position, so she is a good resource.

My two cents from the primary care side:

I noticed that some patients have this severe chronic pain with history of opiate abuse have a lot of trouble getting pain control in the hospital.

There is no (good) excuse for anyone not getting adequate acute pain control in the inpatient setting, regardless of history. This is an controlled environment for an acute issue. The only was a prior history of opioid use should factor in is in determining the correct starting dose as these patients may need more than a standard dose if they are non-naive.

I even struggle trying to get consults for people sometimes and get responses like "well they broke their pain contract in the past." I think people with severe uncontrolled pain (and often psych comorbidities) are very likely to break pain contracts so they can go get illegal drugs to get some relief for a minute. The system is pretty unforgiving of those situations.

Again, for inpatient and acute issues, see above. Contracts are an outpatient thing: they are not designed to be punitive, rather, they exist such that controlled substances can be safely prescribed, for both the patient and the prescriber. If I have an outpatient that breaks my CS contract I will no prescribe them a CS as an outpatient because is has been demonstrated that I can not safely do it.

Illegal street drugs are not a solution to a pain problem: they are a solution to an addiction problem.

If they don't get enough support they will likely go back to using again. It's a vicious cycle. I feel like we should try harder. I also hardly ever hear of alternative therapies such as accupuncture and we seem to forget to get psych or stress management involved.

They do need support and they do need treatment, sadly, those resources are becoming more and more difficult to find and at times the patient's illness prevents them from following through with it even once they do get assistance. The support and treatment is not narcotics.

I think the opioid epidemic is truly terrifying. A lot of people have psych problems too. I feel they are more vulnerable to addiction, wanting to kill the pain in more ways than one.

More than 50% of prescription opioids go to adults with mental illness. Of those with mental illness 18% are prescribed opioids compared to 5% of the general population.

Some drug addicts can be manipulative, but some just need better help.

They (very nearly) all need better help, but they are also (very nearly) all manipulative. It is a difficult thing to balance in practice: how much emphasis can providers place on subjective history (normally >90% of the diagnosis) when dealing with a population that can not be trusted to provide an accurate history.

He ended up requiring 80 mg/ of morphine an hour for pain control.( no ceiling on morphine)

There is an effective ceiling on morphine now for most providers, 180-200 MME/day.

[psu_213, BSN, RN]

I totally get that. I think the opioid epidemic is truly terrifying. A lot of people have psych problems too. I feel they are more vulnerable to addiction, wanting to kill the pain in more ways than one. But, are opiates the only solution?

Definitely not. I know it's still pharmacological, but I have seen even those who use higher level of opioids at home get relief with IV acetaminophen. It may not help everybody, but it is worth a try.