prospects for a chronic narcotics patient.

[Guest219794]

As an ER nurse, I think I have a skewed view of pain management. (long term). I was hopiing for some advice from some of you who understand long term pain management.

A good friend has chronic pain issues resulting from MVA trauma. He is high functioning, manages a division with a multi-million dollar budget. Other than a 30 year hx of cigarette and marijuana use, he is healthy. He is physically active, appropriate body weight, etc.

His pain is reasonably managed with Percocet- I am not sure how much. It allows him to function both physically and professionally. He is well aware of the hazards of chronic narcotics, but can't function without them.

As far as I know, the source of the pain is not correctable. (At least not with traditional western medicine. He hasn't looked at other options.) He receives excellent medical care, and apparently, there is no fix.

My question: What are his prospects? Can people continue to function on a high level with ever increasing amounts of narcotics? In the ER, what I see are pain control failures. Also, I take a medication list from every patient, and have never seen a high functioning individual who is on chronic, high dose narcotics.

Any thoughts?

[tewdles, RN]

Yes, there are high functioning people with chronic pain and opioid therapy. The practice is clearly not without problems or difficulties, but with agent rotation and good use of adjuvants many people are able to control their pain AND remain creative, effective, influential members of our society. I notice that you comment that this man uses marijuana at least occasionally, does this provide him with some pain management as well? Many people report that it is very helpful for some nociceptic pain, although most cannot use it during their work hours they find it helpful in the evenings or at bedtime.

[morte, LPN, LVN]

and the reason (at least one reason) you dont see these persons in the ED is because they DONT NEED TO BE THERE, because they are being managed appropriately.

[LethaChristina]

General E, this is so true--patients well-managed on chronic narcotics are often not in the ED... but when they are, they are often mis-assessed, called "substance abusers", or if admitted are willy-nilly taken off their meds, sometimes causing withdrawal psychosis (then wrongly treated), and other such issues. The general knowledge of pain management is still very slight--in spite of ongoing attempts to educate. I must say, however, that few once started on opiates ever are able to successfully wean (even to assess what is beneath the medicine control of sx)... simply because withdrawal is so profoundly awful--and "rebound pain" so difficult. When one is in the midst of all these it can be difficult to see one's way through--and take the step of re-introducing the narcotics. There has been much research into alternate treatments for those in chronic pain; spirituality is an important aspect of this. Since medicine as a whole has very little knowledge of this: there is this tendency to call spiritual people "disordered" among many... the deeper understanding of one's purpose and mission on Earth actually leads to a greater ability to both heal... and live with pain. A "whole person" approach is critical to pain management.

[Munch]

Since being in pain management for 3+ years if I ever need to go to the ED I go to the hospital where my PM doctor practices. That way he can let the doctors in the ED know that I am not a scamming them(I am on a boatload of narcotics and benzos. If I have to have surgery at another hospital my PM doctor and the staff at the other hospital can touch base and let them know what medications I am taking so their are no snags when it comes to pain control in the post-op phase and the other medications I am prescribed on a daily basis. It's so much easier when you have a plan in place(plus your pain is under control that must faster) rather than having to wait to get the other hospitals pain service down to evaluate you(which could take hours...sometimes days), while you are waiting in agony....learned that one the hard way.

[jm394, RN, CRNA]

Working in oncology, we have many patients with chronic cancer pain who are on very high doses of opiate meds (I never call them narcotics, I was taught that "narcotic" has too many legal/moral overtones), and function very highly. Remember, there is no ceiling on these drugs, so chronic users may be on VERY high doses, but it's all relative. Except for constipation, the SEs (including sedation, decreased CNS function, etc...) fade with continued use. I worry about pts with decreased renal function, pts on regimes with too much APAP for their livers, people who are unable to manage their own pain well with PO meds (forget or accidentally double doses) and people who are using opiates to meet psychological rather than pain needs. As a rule, I would argue that analgesia is underused due to fear of addiction/stigma more than it is overused for euphoria.