Pain management scenario

[HeyHeyitsMaay]

Your patient is a male in his mid 60's with a hospice so of ES COPD and is dependent on 6L O2 continuous per NC to maintain sats at or above 90%. Comorbidities: morbid obesity, htn, poly substance abuse use disorder. Most recent hospitalization required intubation w/mechanical ventilation secondary to acute ETOH intoxication with COPD exacerbation upon being discovered unresponsive in the home where he resides independently. Pt. Is bed to chair with WC for mobility requiring assist x 3-4 for xfers from bed to WC due to generalized weakness and dyspnea to minimal exertion. He is alert and oriented x 4 and able to express needs verbally. Client is dependent x 2-4 for all adls.

Client was recently sent to LTC for respite stay while waiting for approval for nursing home Medicaid. The pt. Has a daughter who is moderately involved in decision making and pt. Care. On arrival to LTC for respite stay, patients medications were reconciled with patient reporting lumbosacral pain of 10/10 to numeric scale. Pt. Was ordered comfort pack starting dose of roxanol 5 mg q 4 hrs sob/severe pain and Norco 10-325 x 1 PO Q 4 hrs prn pain. Pt requested Norco on initiation of hospice nurse assessment due to increased pain with O2 sat 89% to 6L O2, respirations labored, bp, pulse and temp stable to patient's historical baseline and wnl. Last bm 2 days prior to xfer to LTC facility.

Medication reconciliation performed following assessment and patient interview with bottle containing 30 day supply of Norco brought from pt. home and filled 1 week prior to this visit per bottle label found empty. Pt. Advised that bottle was empty and asked if medication had been stored in a different bottle or left at home. Pt. Reports that lumbosacral pain was so severe that he took too many Norco in an attempt to reduce pain levels. Pain management methods-both pharmacological and non pharmacological reviewed with patient with encouragement that we believe he truly does have pain and encouragement to advise nurses of any changes to quality or increase in pain as quickly as he can so that we can work together to find the right combination of pain control methods to manage his pain.

MD was contacted with assessment findings with new order for 50 mcg fentanyl patch. Pt. Educated on purpose and use of fentanyl with both pt, facility staff and pt. Daughter verbalizing marked improvement and patient's mood affect, increased participation in facility activities and over improvement in mood 1 week following initiation of fentanyl patch.

Three days later, facility nurse contacts you and advises that since the fentanyl has started, the pt. now sets his alarm clock in his room to go off every 4 hours, over 24 hours daily to remind him to request both Norco and morphine which has been increased to 10 mg from 5 in the last week. If nurses are with other patients or can't administer his prn medications immediately pt. Throws himself into floor and screams until medication is administered. Facility nurses are becoming fearful of administering morphine and Norco simultaneously to patient and are additionally frustrated as pt. Has begun to report that staff have not administered medications in spite of documentation to the contrary.

Your interventions:

1. You contact MD and advise of assessment findings along with patient report that pain level has increased to 10/10 during all waking hours and that without Norco and roxanol together every 4 hours fentanyl is no longer effective to manage pain. Receive order to continue PRN opioid analgesics but to stagger administration times so that pt. Does not end up in a pain chasing cycle and increase fentanyl to 75 mcg.

2. You educate facility nurses regarding pain control methods, pharmacological action of all medications ordered for pain and possible adverse reactions specific to each drug.

3. Suggest to LTC to implement signature sheet for pt. To sign with each medication administration.

4. Perform new pain assessment with pain intervention assessment, spend time listening to patient's frustration with facility staff and belief that staff feels that he's "trying to get high". Provide empathetic listening and educate on alternative options for pain management inclusive of assessment to be added to the LTC restorative program due to decreased mobility and chronic pain. Client becomes very angry at suggestion of restorative program, discussion of possibility of use of other drugs such as calcitonin or NSAIDS for lumbosacral pain and states that if he cannot have Norco and morphine together around the clock he doesn't want anything else. You continue to provide empathetic listening, affirmation of frustration and gentle but assertive discourse regarding effective methods of communication that don't involve verbal abuse of staff and encourage use of 24 hour on call hospice number.

What else should you be doing? What interventions have you not tried that might work with achieving pain control to this client's personal pain could goals?

[CoffeeRTC, BSN, RN]

Psych eval? Depression related to nursing home stay?

I'm the LTC nurse that would be calling you. I like the idea of having the resident sign off on getting the medication too. Does the fent patch need to be increased again? If he is truely in pain, that might help. I'd also make sure he is on a good bowel regime. Of course, I would be making sure everything is documented out of the wazoo and care planed.

[Katillac, RN]

I'm not sure that unless you put him on a PCA with no lockout wherein when he gets sedated enough he will just go to sleep until he wakes and presses the button again you will be able to come up with a plan that meets this patient's "personal pain relief goals". His refusal to consider any adjuvant therapy as well as the tantrums if his dose is delayed are pretty good indicators he is seeking the euphoria that comes with the opioids in addition to pain relief. No judgement there, but his history with ETOH and poly substance abuse can't be disregarded in managing him any more than his other comorbidities.

What's the rationale for giving both Norco and morphine as PRNs? Norco really doesn't have a place in a chronic pain management regimen due to the APAP, and a Norco 10/325's equivalent is morphine 10 mg anyway.

Also not sure about the rationale for staggering the PRNs. Ordering them effectively Q2 gives him twice as many opportunities to become anxious about getting his next dose with minimal increase in effective analgesia. If the concern truly is that the med is peaking too fast and is out of his system by four hours, either up the long acting again or give him 15 mg PRN Q 3.

The recommendation is that when you have someone using more than 4 PRNs/24 hours you need to increase the long acting. A regimen of staggered Norco and morphine will mean 12 PRNs he's setting his clock for. If it were a typical pt, you would take that 120 mg total and divide it in half to give the Fentanyl increase he should have so he should be getting 60 mcg plus 75 mcg of Fent/hr for a total of either 125 or 150mcg depending on whether you want to be conservative or liberal - but then the PRN dose should go up to 25 or 30 mg. But this isn't a typical pt and its highly unlikely he's seeking just pain relief so I suspect within 48 hours he would acclimate to the new dose and start looking for more. Again, no judgement. My feeling is if he wants to spend his last months stoned and with pain relieved to his satisfaction I can support that.

BUT and it's an important one, I could never get that accomplished in an LTC. It's tough enough to do it in a hospice residence. I had a case like that not long ago, a youngish person who loved their Dilaudid and wanted their 8 mg PO Q 2 - or whenever they woke up. Always 10 or more pain, would sometimes call out a number immediately upon seeing anyone in a uniform, but with no nonverbal signs of pain and no clear etiology for it. In any conversations about it, the desire to protect the supply far outweighed any interest in developing or pursuing any other end of life goals or considering any other options for pain relief - well, except massage and that of course was in addition to the meds already ordered. It was sad to witness what priorities the addiction drove but not only were we not in a position to offer therapy for the addiction but we didn't have a right to as far as I was concerned.