Pendulum Swinging too Far on Pain Meds?

Nurses General Nursing

Published

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?

I have a feeling this case is due to a misguided PA than a sign of the times. I've never heard of tapering pain meds (by one tab??) for surgery. Time to seek another provider in the practice.

Edit: Not an ortho nurse. Just googled this. Apparently tapering is a thing?

Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
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?

I hope your friend has his THR scheduled very very soon. What a great operation for degenerative arthritis sufferers.

After a great deal of literature being published in the1990s about patients being under medicated for pain, specifically in the ED and during procedures in the critical care areas, the pendulum has swung the other way. This is partially due to SOME physicians over prescribing for chronic pain. Pain is a complicated concept. Because of the increased scrutiny, physicians are scared. In my humble opinion, there is a middle road, and the OP's story reflects a goof. Kudos to the patient's wife who is a nurse who will continue to advocate for him. He's going to need that.

Let us know when he has his surgery. I've heard patients say, " I wish I had done it sooner."

Specializes in ER.

Did a scan of the web and, yes, the new CDC mandates are making doctors hesitant to prescribe pain medicine. Apparently, the rules were hastily thrown together, and aren't well thought out, which doesn't surprise me coming from a government entity.

I also found this excellent and informative article.

The Wrenching Dilemmas of a Caring Doctor Helping Those in Pain | Alternet

Specializes in Medical-Surgical/Float Pool/Stepdown.
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?

As a surgical nurse at heart I find this very frustrating. For one, Tramadol I believe is an agonist-antagonist and essentially has a ceiling on it which is why it is often preferred as to be less likely abused or addictive. If you are giving a Pt Tramadol and say morphine for breakthrough - depending on their individual pain tolerances - the morphine, etc may not be as effective because the antagonist properties of the Tramadol will block the receptors. This is just my basic understanding of the meds pharmacokinetics. Very similar to Nubain givin to birthing moms as to not depress the baby's respiratory drive.

IMHO, this is absolutely ridiculous! I don't have studies on hand but with the proper Pt education on pain meds with appropriate weaning AFTER surgery, adequate (not having zero pain, as another poster mentioned, which is not realistic) pain control not only has shown to speed recovery, decrease poor outcomes (post-OP pneumonia, DVT, etc), and also can decrease the risk of acute pain turning into lifelong chronic pain because the Pt can actively participate in their recovery!

Five minutes to educate (more than once mind you) that when you are at a general point in recovery - whatever the timeline suggests for specific surgery - that it is often a good idea to start to space pain meds farther out, or even only take half the pill or both. It is normal for you to feel an increase in generalized body aches, for your heart rate to increase, for your nose to run, you may even experience diarrhea as well because your pain medicine has been essentially tricking your body into thinking you're having less pain and now your bodies natural pain control mechanisms are waking up and getting back in the groove of working. This is normal. PS, please keep these meds under lock and key and away from children/teenagers/etc.

I personally do not think that anyone on Capitol Hill that does not have an MD should have any say in what we do as a medical profession. They should be focused on the topics that they are educated on and be looking to educated MD's to guide these decisions and not just using propaganda to scare the US from one extreme to another.

For the poster that commented on the floor nurses and IVP pain meds...education...I don't give any med unless I have a basic understanding of it, why the Pt is getting it, and parameters for a reasonable dose. :facepalm:

I will try to get off my soapbox now as a nurse with five years Med-Surg experience that deals with both extremes (from the post-OP or dying CA Pt to the generalized ABD pain or chest pain, scans/tests are all normal and I've been admitted three times this week) that just worked a very long and exhausting 12 hour night shift and may have not been very coherent in my ramblings above. I'll prepare to be flamed...after I wake up that is! :sleep:

Specializes in Medical-Surgical/Float Pool/Stepdown.

PS Emergent, I hope your friend gets appropriate pain control sooner than later like he deserves!

Specializes in ICU, LTACH, Internal Medicine.

There is a middle ground. But in order to reach it, we need to find a thinking provider for each patient. And destroy a lot of schmolicies meantime.

I reviewed "admission packages" of orders every new patient gets on admission in this one particular hospital. There are like 20+ of them, and at least 3/4 has opioids included automatically, whether patients took them before or not. There are flashing banners reminding admitting provider to order DVT prophylaxis, IV access.... and "pain management", which has "preferred options" of Norco, Morphine or dilaudid, or any combination of them without any jystifying indications except clicking the butyon "pain". Every room has beautiful flyer pinned to the door or board screaming "we take your pain seriously!" Nurses are gnawed and grinded alive every day about getting pain meds within 15 min max from the call light going on. Now, ortho floor has a new goal, posted on every corner, for everybody to see: 100% pain free floor. Floor dedicated to spine surgeries, mind you. Floor where Narcan order is not automatic and tele is not 100%, mind you, too.

The LTACH gets mass clientelle from this facility, and 80+ % of these people come from this hospital stay as fully addicted and tolerant to the point that two or three of them consume 24h Pixis supply of dilaudid. We spend a whole lot of time to at least stop these poor souls from escalating.

Specializes in Adult Internal Medicine.

This is a huge issue in primary care, something I deal with every day.

We are talking with all of our non-cancer chronic narcotic users and starting a dialogue based partially on CDC info, partially on our state changes, partially on insurance changes, and partially on having re-evaluated the extant data on the topic. We are encouraging (well in some cases mandating) that patients re-trial PT/OT, get evaluated by a pain specialist, try CAM modalities.

If a patient has surgery scheduled that's one thing and I doubt I would spend much time dealing with it prior to surgery but i would have the conversation that after surgery there is a 6-week plan to be off the meds. More commonly I am seeing the people that are two or three years s/p THR that are still on the same amount of narctoics, or even more frequently, people that have very minimal disease and have not tried any other modalities or interventions. We are making dependent patients in those cases.

I have some major concerns about chronic pain syndrome in which after the initial 6-12 weeks the pain is no longer associated with the initial insult: you can fix the underlying problem and the patient still is not able to tolerate life off of narcotics. I especially have issues with 18-30 year-olds that are on chronic non-cancer pain opiates and those patients taking more than 180mg/day of morphine equivalent.

Now, ortho floor has a new goal, posted on every corner, for everybody to see: 100% pain free floor. Floor dedicated to spine surgeries, mind you. Floor where Narcan order is not automatic and tele is not 100%, mind you, too.

:eek: What on EARTH??!!?!? Where, within the bounds of reality, is this even achievable??? Are you KIDDING me? I would be tendering my resignation and RUNNING out the door of that facility.

This is a huge issue in primary care, something I deal with every day.

We are talking with all of our non-cancer chronic narcotic users and starting a dialogue based partially on CDC info, partially on our state changes, partially on insurance changes, and partially on having re-evaluated the extant data on the topic. We are encouraging (well in some cases mandating) that patients re-trial PT/OT, get evaluated by a pain specialist, try CAM modalities.

If a patient has surgery scheduled that's one thing and I doubt I would spend much time dealing with it prior to surgery but i would have the conversation that after surgery there is a 6-week plan to be off the meds. More commonly I am seeing the people that are two or three years s/p THR that are still on the same amount of narctoics, or even more frequently, people that have very minimal disease and have not tried any other modalities or interventions. We are making dependent patients in those cases.

I have some major concerns about chronic pain syndrome in which after the initial 6-12 weeks the pain is no longer associated with the initial insult: you can fix the underlying problem and the patient still is not able to tolerate life off of narcotics. I especially have issues with 18-30 year-olds that are on chronic non-cancer pain opiates and those patients taking more than 180mg/day of morphine equivalent.

Pain management is complex in many cases and I agree that there are problems with chronic pain patients who do not have cancer. Not that long ago I talked to a pat who had an accident some years ago with spine injury, hip and leg. The patient was on more than 200 mg morphine equivalent a day for many years until his PCP retired and the new one was not willing to go that route. He did a controlled tapering over 3 months and got off narcotics. After half a year without narcotics the patient get re-admitted and low and behold now has 10/10 pain due to cancer. No narcotic helped and the patient got non responsive with still huge pain. Methadone was the way to go but the primary physician was not aware that methadone would be the best choice for pain and kept on telling the patient to make himself CMO instead so he could receive mega doses narcotics. He got switched to methadone with significant improvement after 3 days and continued to improve with pain.

The other group that has problems with narcotic addiction are sickle cell patients with frequent crisis as they require high doses to control the pain. There is a good protocol now and those patients go home on methadone for a couple of days and are on no narcotics between crisis.

There are patients who go to the pain clinic only to reject all non narcotic solutions and circle back to the ER...

Specializes in ICU, LTACH, Internal Medicine.
:eek: What on EARTH??!!?!? Where, within the bounds of reality, is this even achievable??? Are you KIDDING me? I would be tendering my resignation and RUNNING out the door of that facility.

It is named "patient satisfaction", you'now;) Ant it is quite achievable in a parallel universe of policies, schmolicies and Press Ganeys, all followed up to the latest point.

Specializes in ICU, LTACH, Internal Medicine.
...try CAM modalities..

Hallelujah! Except that core yoga with a sertified instructor who knows something not only about mantras and energy flow, but also about basic anatomy, cost $120/hout where I leave. Aquatics (which work great for FBM) $15/session, which has to be done every other day at least. And do not start me about high quality massage, "hot/cold" stones, needles... And zI am afraid to think about price on all that in Boston!

Specializes in Case Management.

Just wanted to pipe in on this regarding your original question regard MDs and pain meds and the environment becoming puritanical with an example of the insanity. I have a pt who was pegged as drug seeking several years ago...but now we are s/p L AKA, and they wont give pt anything for pain. Keeps going back to the ER complaining of pain they wont give anything...dehiscence of the stump everything getting necrotic, pt in pain, wont give anything. Finally has a blow out moment where home health wound care goes to see pt and finds maggots in the wound. So back to the ER pt goes. They finally go in with an angiogram and end up having to do a mechanical thrombectomy and revascularize the illiac with a stent....so stump has been ischemic this whole time. I imagine that's probably pretty painful.

The problem here is that because someone is labeled as drug seeking they get NO PAIN needs met! Its really frustrating and impossibly hard to advocate in this environment.

+ Add a Comment