Pain Medications

[Steve123]

I am happy to notice that doctors prescribe much less pain medications now then they did even five years ago. Some nurses say that new approach makes some patients to suffer unnecessary. Well, lets compare pain medications with antibiotics. Antibiotics save tens of thousands lives but at the same time some patients die due to adverse reaction to antibiotics such as anaphylactic shock. Should we stop using antibiotics just because one out of million patients may die due to anaphylactic shock? Of course not. A lot of Americans became addicted to pain medications, hundreds of thousands already died of overdose of pain medications. Should 60 thousands Americans die every year d/t overdose just because few patients have "ligimite" pain and suffer unnecessary d/t new strict prescription guideline? My answer is "No".

[NRSKarenRN, BSN, RN]

Please visit allnurses Pain Management forum for educational articles I've posted about pain management along with others expert advice.

This is a topic dear to my heart. I've been in healthcare since 1973, nurse since 1977: patients in acute and chronic pain were not being adequately controlled prior to 1980's, especially sickle cell and cancer patients. So pain scales developed, focus on pain management with improved pain control. Some drug companies were overly aggressive in educating physicians about every new narcotic drug developed, with some docs poorly understanding pain management, especially pain ladders (start with low dose OTC meds, add adjuvents then narcotics, titrate as needed etc.).

Worked in Hospice 2 years and home care now for 25yrs. Pendulum has swung way to far to the right denying legitimate chronic pain patients effective pain mgmt. I've 2 family members with chronic pain: one had CVA with severe spastcity; another with over 70 kidney stones, new ones forming every 6-8wks + seen at pain center for management. My health systems insurance Blue Cross plan now requires preauthorization for Percocet and restricting amounts given.

I'll never forget my hospice patient with acute severe pain only being prescribed Morphine 15 mg every 6 hrs, crying out in pain on just moving her arms + being turned for skin assessment; PCP refused to order higher dose "cause his colleagues told him DEA would be after him for ordering higher doses" ---gave him a tongue lashing, brief pain management lecure, left articles and had hospice director speak with him --- the patient returned to hospital immediately as needed IV Morphine to get pain under control. A year later, doctor saw me in the hallways and thanked me for educating him and beamed telling me he had a patient on morphine drip at 100mg/hr and finally comfortable. Opposite scenario: A different doctor prescribed Duragesic 25mg (new narcotic being touted) for an opiate naive patient with arthritis for flare unrelieved by Tylenol; observed him staggering while opening door to let me in for visit -- inquired what new med given, immediately took off Duragesic patch, promptly calling PCP + "educated" PCP in potency of Duragesic --got order changed to Aleeve 2 tabs every 12hrs with improved pain. Now, Pennsylvania along with several other states requires that all narcotics dispensed be sent to state database and that physicians must query database prior to new prescriptions written, even for Tramadol/Ultram to determine doctor shopping/indiscriminent prescribing patterns.

Excellent article in June 2015 Critical Care Nurse: Effective Pain Management and Improvements in Patients' Outcomes and Satisfaction that provider education is sorely needed.

Crit Care Nurse June 2015 vol. 35 no. 3 33-41

....In a column in USA Today, Pho 29 wrote that according to the American Society of Interventional Pain Physicians, 80% to 90% of physicians have had no formal training in prescribing controlled substances, and only 5 of the 133 medical schools in the United States have required courses on pain management. According to Relieving Pain in America,3 medical schools' training in knowledge of pain management is not well assimilated into medical practice, and the care of pain in patients is delayed and inadequate. The average teaching time in training students about pain management in US medical schools has ranged from 1 to 31 hours.3 The Institute of Medicine has recommended courses to enhance better understanding of pain assessment and management strategies in hopes of increasing the number of health care professionals with expertise in pain care.30

The American Nurse Credentialing Center31 reported that as of 2013, only 1672 registered nurses in the United States were certified in pain management. The Nurse Practitioner Healthcare Foundation has suggested development of a standardized curriculum in pain management and better training in the knowledge of prescribing opioids for patients with acute pain.3 Nurse practitioners most likely will have an increasingly important role in the future of pain management because most pain care is the responsibility of primary care physicians and too few of these physicians exist to carry the burden. ...

Articles on opioid crises from May Philadelphia Inquirer newspaper:

May 24, 2018:

Lost in the battle to create fewer new patients addicted to opioids: Longtime pain patients

...Experts say that most people with an opioid addiction today got started on prescription pain pills - either their own or someone else's. New rules seek to contain the number of leftover pills available for diversion and reduce the number of pain patients who become dependent or suffer serious side effects. But longtime users with chronic pain contend that these rules are hurting law-abiding people. They and some doctors worry that the opioids pendulum, which initially swung too far toward prescribing the pills, has now swung too far toward taking them away.

Situations like Houser's will likely become more common next January when Medicare starts enforcing its new rules on opioids, which will make it harder, though not impossible, for doctors to prescribe high doses. Medicare, which often leads on insurance coverage policy, is coming later to this issue. But, with its 58.5 million senior and disabled beneficiaries - --- it wields huge influence.

In addition to rules from many private insurers and state governments that make it more of a hassle to prescribe high doses of opioids, doctors are also feeling pressured by law enforcement agencies, which monitor prescribing patterns, patients and their advocates said. Pain specialists say they're seeing an influx of chronic pain patients who have been dumped by other doctors.

In part due to such restrictions, opioid prescribing has continued to decline from its peak in 2011. Yet U.S. doctors still prescribe more opioids per capita than doctors anywhere else in the world.....

....Some chronic pain patients and experts argue that those who are accustomed to high doses and are doing well on them should be treated differently. Cutting their doses could lead to greater disability, depression, suicide and illicit drug use. Besides, they note, patients often don't have access to pain specialists or the multimodal pain programs - employing not only medicine but also physical and emotional therapy - that research suggests is most effective....

May 29, 2018: How the opioid crisis is changing how Philadelphia emergency room doctors care for patients

...A case study by Perrone and colleagues at Thomas Jefferson University Hospital and Penn Presbyterian Medical Center, published recently on the New England Journal of Medicine's Catalyst website, found that opioid prescribing had dropped by an average of 37 percent between 2011 and 2016 at eight area hospitals in the working group. Fifteen hospitals in the group have gone on to develop new opioid-prescribing guidelines; before they started meeting, only four hospitals in the group had done so.

"Efforts to galvanize the network of EDs across an urban center can have significant impact on a potentially higher-risk, city-wide population and can rapidly change patient and provider expectations about opioid use," the authors wrote. The report goes on to say that even though emergency doctors specialize in acute problems, they also can be "ideal partners and agents in developing innovative approaches to public health issues" by giving people in addiction medication to encourage their recovery. ...

... Since last fall, Penn Presbyterian's ER has run a version of "warm handoffs," connecting its patients with treatment directly with the help of peer specialists who have been through addiction and recovery themselves. But before then, hospital policy dictated that doctors could prescribe suboxone only for a patient who was already on it and just needed a prescription renewed.

Perrone and her colleagues lobbied administrators to allow new suboxone prescriptions so they could take advantage of the crucial hours when a patient may be shaken by a crisis, and open to help. Other area hospitals, like Temple University, also employ this practice.

The change is more than a matter of hospital policy, though. Any doctor can dose a patient with suboxone in the hospital. But U.S. Drug Enforcement Administration regulations allow only physicians who have had extra training to send a patient home with a suboxone prescription. ER doctors don't want to stand in for long-term treatment, which also includes talk therapy and other interventions. But they do want patients to have enough to tide them over until they can get into a treatment clinic....

Sign I've seen posted in every cubicle at Thomas Jefferson University Hospital ED. Karen

In my experience, we've gone too far.... need middle of road approach. I've read an early textbook book, multiple articles and attended a lecture on pain management by Chris Pasero MS RN-BC FAAN and Margo McCaffery MS RN-BC FAAN, Nursing Pain Management experts. Sadly, just learned that Margo McCaffery passed away January 2018; She will be missed by me.

Highly recommend their last 2010 text: Pain Assessment and Pharmacologic Management