The title says it all - has the pendulum swung the opposite way? Are we providing adequate pain relief for our patients or holding back for fear of addiction?
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Recently I had a patient who fractured her femur, mid-shaft. She was unable to have it repaired due to multiple co-morbids. So, she was given a brace and told it would have to heal in time. She developed some wounds from the brace and it had to be removed. She goes to the wound clinic once per week, dialysis three times per week and each time she is transferred by a Hoyer lift into her wheelchair, transferred to the nursing home van and then, at least at dialysis is then transferred again via Hoyer to the dialysis chair. XRays done recently showed nonunion of this fracture which can be attributed to several factors: malnutrition, hyperphosphatemia, osteoporosis.
For pain, she has been Rx'd with: fentanyl 62.5mcg patch changed every 72 hours, percocet 10/325 one orally every 8 hours as needed and tylenol 650mg every 8 hours as needed. Prior to her femur fracture, she had been on a fentanyl 50mcg patch changed every 72 hours as well as Percocet 5/325 every 8 hours as needed due to severe osteoarthritis - made worse by end stage renal disease.
She comes to the dialysis unit crying in pain due to the 10 mile ride from the nursing home to the dialysis unit. There is no medication to give her at the dialysis unit except tylenol. Her pain is not controlled well - she continually rates her pain 8-10/10. She is physically addicted to opioids due to several years of chronic pain meds for her multiple disease processes. When I spoke to the nursing home staff, I was told "we can't continue to contribute to her addiction."
Another incident - a friend (fellow APRN) underwent major abdominal surgery recently. She was opioid naive and prior to her surgery, took no medication. She was healthy and had NKDA. Post-operatively she was given Norco 5/325 one every 8 hours as needed as well as ibuprofen 600mg every 8 hours. However, she rated her pain in the first 24 hours consistently 8/10. One nurse made the comment that she (the nurse) was sorry but the doctor "didn't want her to become addicted."
Two recent incidents, different patients, different reasons for pain yet both were denied adequate pain relief.
Have we gone too far in the opposite direction?
Are we letting our patients suffer in the name of patient safety?
"The National Institutes of Health (NIH) estimate that in the United States, 25.3 million adults have chronic pain." What are we supposed to do? As providers we want to provide adequate pain control for both our chronic pain patients as well as for those with acute pain. "A team of researchers at Wake Forest University and the University of Bath in the U.K. is exploring a new kind of opioid that could relieve pain without affecting breathing or raising the chance for abuse. The new drug, only called by its chemical compound name BU08028, relieved pain in rhesus macaque monkeys. When they had the opportunity to take as much of the drug as they wanted, they didn't abuse it. When taken off the drug, they didn't show signs of painful withdrawal." Perhaps this will be a new medication for both chronic and acute pain.
Some other suggestions:
Non-steroidal anti-inflammatory medication such as ibuprofen - can be used either alone or as an adjunct
Ketamine is now being used for acute pain. Recently the journal AACN Advanced Critical Care included a Drug Update about the use of ketamine in the ICU.
So, what to do? Are we helping to prevent opioid addiction or are we letting our patients suffer needlessly? What are your thoughts?
