Pendulum Swinging too Far on Pain Meds?

[Emergent, RN]

A good friend of mine's hubby is waiting for a hip replacement surgery. He's the farthest thing from a drug seeker I can think of. He's in a lot of pain, bone on bone. He's a karate instructor as a sideline, probably that repetitive motion contributed to this problem, he's in his mid 60s.

He didn't like the oxycodones which made him itch, but Tramadol helped. The doctor wouldn't let him have 1-2 every 6 hrs like he had before. They wrote the script for 1 every 6 hrs. They told him he needed to wean down before surgery, that it would make pain control afterwards easier.

If they checked the controlled drug database, they'd see that this fellow hasn't needed pain medication until now. Are the doctors under so much pressure to meet goals to satisfy the overseers that they are under medicating?

Previously I always thought that the policies on opiates were too liberal and contributing to addiction. But now I sense an almost puritanical attitude on the part of some.

Isn't there a middle ground?

[loriangel14, RN]

Ok I have never heard anything so ridiculous. Denying pain meds now to make it easier later? That is the stupidest thing I have ever heard. He must be in excruciating pain. He needs to be given adequate pain control now. See another doctor.

[KatieMI, BSN, MSN, RN]

Well, find another doc. Better yet, ask for ortho pain clinic referral (NOT your next strip mall one). They are few and far between, but people there really know their drugs and other things like prolonged nerve blocks.

But there is much more to this:

The hospital pharmacy may not carry tramadol (because of some local policy - schmolicy made up X+1 year ago after an "internal investigation" due to an accidental overdose). Another schmolicy may preclude splitting pills: either 1 or 2 pills, but not 1 1/2. Yet another one may dictate that "we only use morphine or dilaudid for postops", so patient who was alive and well on tramal will be switched to dilaudid, and 98 out of 100 providers do not do correct dose convertions. Patients may automatically get order for 1 mg of dilaudid q4 for pain over 6/10 the moment they hit PACU and keep it active till discharge, and floor nurses may not be trained in recognizing overdose symptoms, or may not have immediate access to Narcan. Your doc may know much more than you might ever imagine about these details. And it's correct: it all can make postop pain management VERY complicated, for everyone involved. And docs are grilled about Press Ganeys just like we are.

[Jensmom7, BSN, RN]

Some people butt-dial, I apparently butt-type.

[nutella, MSN, RN]

I and my coworkers wonder a lot lately...

Granted, I work in end-of-life care and there is a lot of symptom management related to terminal illness. There has always been the group of providers who are very hesitant to prescribe narcotics for symptom management pain and would not prescribe liquid morphine to deal with SOB unless the patient decided to be CMO.

Pain management is not that easy to begin with if a person has more than the standard pain issues or prior substance use. When we see patients who have a prior narcotic history or are already on high doses they may do better with methadone but many prescribers do not have the experience and do not like to deal with it for example. I had a patient basically screaming out in severe pain because of cancer and the patient had a prior tolerance history with taking up to 200 mg of morphine a day. What can I say? methadone fixed the problem but it was an act to get there....

I do think that providers need to be more educated about prescribing narcotics and also utilize other medications and methods.

[Anna Flaxis, BSN, RN]

No, I don't think this is a case of under-medicating. It is reasonable to start at the low end of the dosing range, and it's true that he should be thinking ahead to his post-operative pain management situation.

[Emergent, RN]

No, I don't think this is a case of under-medicating. It is reasonable to start at the low end of the dosing range, and it's true that he should be thinking ahead to his post-operative pain management situation.

I think you misunderstood. Friend's hubby was on Tramedol with previous doc for severe hip pain that is getting worse. Dosage was 1-2 tabs every 6 hrs. Finally referred to ortho doc after determined surgery is needed for bone on bone. Surgeon's PA lowered dosage to 1 every 6 hrs, saying that they needed to wean him back otherwise pain control will be too hard after surgery.

Then they called, said pain is out of control, they refused to change it. Hubby is suffering badly, can barely walk from garage to house.

[HeySis, BSN, RN]

I understand your friend is not a drug seeker... but that's not the important part here for me.

And I also believe in teaching patients that to expect 0/10 is unrealistic, they need to understand post-op pain that rates 2-3 is well managed, but allowing pain to be 6/10 or greater without trying more interventions (medications as well as non-Pharm) is harmful.

Pre-op and post-op is not the time to "fix" someone's narcotic use..... We will not cure/prevent addiction by allowing these patients to have extreme pain.

What we will do is prevent them from getting up and around, from doing their deep breathing, from eating properly... all because the pain is not managed.

[Anonymous865]

I understand your friend is not a drug seeker... but that's not the important part here for me.

And I also believe in teaching patients that to expect 0/10 is unrealistic, they need to understand post-op pain that rates 2-3 is well managed, but allowing pain to be 6/10 or greater without trying more interventions (medications as well as non-Pharm) is harmful.

Pre-op and post-op is not the time to "fix" someone's narcotic use..... We will not cure/prevent addiction by allowing these patients to have extreme pain.

What we will do is prevent them from getting up and around, from doing their deep breathing, from eating properly... all because the pain is not managed.

You are so right.

To add to your thoughts -

You don't taper someone down before the surgery which will fix the condition causing the pain. You wait until after the surgery and after the period of acute pain caused by the surgery. Then you gradually wean them off the pain med.

You don't "taper" someone down by suddenly cutting their pain medication in half. You decrease the medication gradually.

This is not a patient who wants to be on narcotics indefinitely. He has surgery scheduled. He wants pain medication to allow him to function until the surgery can be done. That is a very appropriate use of pain meds.

OP, yes. In some states providers are under extreme pressure to not prescribe pain meds.

My state has passed a lot of laws the past few years to "fix" the narcotic abuse problem.

The state flags the top 100 prescribers of schedule drugs. No provider wants to be on that list and to be subjected to the added scrutiny it entails.

The state has classified tramadol as a schedule II drug even though the fed classifies it as schedule IV.

Prescribers are limited to the total amount, to the number of doses a day, and to the length of time they can prescribe w/o being a pain specialist (i.e. fellowship trained in pain managment).

It goes on and on.

The good news is that the amount of scheduled drugs prescribed has decreased since these laws were passed. The bad news is that the use of illegal drugs (especially heroin) has increased at the same rate during that time period.

[mmc51264, BSN, MSN, RN]

Lots of options between oxy and Tramadol. Our doc use a multi modal protocol: celebrex, lyrica, tylenol, and a narcotic. Tramadol is usually not used unless it is pt request or out very elderly pts. I would say that this pain management plan is not optimal. He almost should be on something long-acting like MSContin if he can't tolerate the oxy group. I would have him speak to the surgeon, not the PA. PAs tend to be a lot more conservative.

[Emergent, RN]

The point of my post was not to argue my friend's individual case actually. That was merely an example of what sounds like fear or hesitancy to prescribe controlled substances. I suspect this might be due to increased scrutiny of prescribers.

The reason given sounded rather bogus. And, Tramadol is hardly the drug seekers preference in the first place. My friend, who is a nurse, said she felt they were being treated like drug seekers.

There has been a drastic shift from what I was taught in school, to cater to people in pain. That philosophy led to the problem we see today, mass prescription opiate dependence and abuse. Are we now swinging too far the other way?

[KatieMI, BSN, MSN, RN]

Anonimous865,

I really would like to know which state took it upon itself to change federally approved drug schedule to its own "needs"? (So that I would never, ever entertain an idea to move there before I retire for good. This level of Big Brother overseeing is not something I would put up with)