Recently, it has come to my attention that MDs have been targeted for over prescribing narcotics for pain control. My mother has become one of the victims of these new laws that have made it difficult for primary care physicians to assist patients with managing their pain. First of all, I would like to say that this is a quality of life issue and for those that do abuse drugs under a physician's care, their plight is not what I am writing about. This is not the case with my mother. Her pain medications have been well controlled.
My mother has back pain and tremors that have caused her much distress since her mid-50s and before 2 years ago, she had never been on narcotics. Getting her to go to the doctor was a strain and now it has become a necessity. Her pain is constant with intermittent acute episodes. It is also difficult to deal with because she has progressively become more forgetful and confused with personality changes over the last 5 years. She fell and broke her hip 1.5 years ago and her shaking makes her a much higher fall risk and her pain makes her a suicide risk. My sister and I are trying to keep her at home, but the anxiety and pain keep her awake.
For fear of loosing her pain management regime, she had elected not to change physicians. This was a mistake. This primary care doctor has a wonderful nurse practitioner that understood her condition. Her doctor was asked for a neurology consult and pain management consult and instead was condescending and rude. She has been on Norco 7.5 and Ativan 1 mg BID for 1 year and intermittent use before this for approximately 1 year. Her medications where well controlled and changing them had been discussed repeatedly with no results.
Upon her final visit to her doctor's office, my mother had been complaining about a strange intermittent sharp pain in her peri area. My sister had requested the nurse practitioner for the pelvic exam and the doctor insisted on doing it himself. He abruptly cut my mother off about her pain complaints and stopped all pain medications and prescribed her Prozac. At other visits, I requested attention be given to her signs and symptoms of dementia that have made her anxiety and pain control worse. At her last visit he accused my mother of being a drug addict and refused to listen to her or my sister. I can go on and on, but I know that had she changed her MD sooner, this may not have happened.
She did change physicians and her new physician was as rude as her previous one. This time I was present. It was obvious this doctor had in some way communicated with her previous physician. Her new doctor was up front about not prescribing narcotics. I told her that I understood her position, but could she at least prescribe enough to get her through till her pain management appointment. My mother interrupted me by having a fit in her office, but not directed at the doctor. It was due to lack of sleep and her mentality. It is obvious that my mom has progressive dementia and that her actions were directly from her frustrations. The dementia symptoms started years before the narcotics were in place and her demeanor was always calm and kind before.
We, as medical providers, can debate the side affects of anxiolytics, especially on the elderly and why, but the big picture is informed consent and quality of life.
I have been a nurse for 20 years and I was trained repeated that we are NOT rehabilitation nurses and that pain is subjective. Any nurse with experience, knows what I am talking about.
Pain management in this country has taken a giant leap backwards, taking on a medieval, draconian mindset.
15-20 years ago there was a movement in the medical community to treat pain as the 5th vital sign. "Pain is what the pt says it is" was in all the nursing education annual competencies, and it was used as a subjective pt assessment tool. MS Contin had been around for years before this, and this long acting pain medication seemed to be used without any untoward societal consequences, as there were no daily news stories of abuse and death that I can recall back then when I was a new nurse. Then oxycontin was created as another adjunctive tool to ease the suffering, and increase the quality of life for of millions of chronic pain pt's. Before long a glut of news stories began to surface - reporting waves of crime, substance abuse, and death - hitting the daily news like a hail storm.
What lead to this? Did oxycontin itself act as the catalyst that created this epidemic? That is certainly what I've surmised from the countless articles I've read on the subject over the years. But is this true? Did oxycontin create a hoard of mindless, slavering drug addicts - who'd sell their mother for a fix - from once previously pious, everyday people?
Suddenly chronic pain pt's - all chronic pain pt's - were under scrutiny, and became objects of suspicion. It became a shameful thing to suffer from chronic pain and take routine Rx pain medication to offset the agony.
Seemingly over night the view point regarding chronic pain did a 180° turnabout, leaving countless genuine pain sufferers in the lurch.
Rx narcotic regulations changed, stating acute pain in some states could only be treated up to a 72 hr limit, and postoperative surgical pain for up to 7 days. Chronic pain is more difficult to receive proper treatment for now than ever. And if you actually have chronic pain you better be able to prove it beyond a shadow of a doubt.
What if you, or one of your loved one's suffered chronic severe pain? What then?
Those whom have abused narcotics, and those whom have abused and died from overdoses, have become the new poster children for the face of chronic pain. Due to the internet, news stories are able to be all around the world in a matter of hours, sensationalizing it even further.
Long before the oxycontin news stories became a dime a dozen, there were still people who abused and misused - oxycontin didn't create these behaviors. And I'd like to point out those whom will abuse Rx narcotics will likely abuse any substance: ETOH, street drugs, illegally obtained Rx narcotics, cigarettes, aerosol chemicals, bath salts … the list goes on and on.
What does this mean for those folks whom genuinely have a moderate-severe to severe chronic pain problem? They are SOL now, because those who've never experienced intractable, unremitting chronic pain have bundled them all together into one giant group and now treat them all the same.
Many provider's attitudes toward pain is: "Pain hurts, and it is to be endured". There are people who literally cannot imagine what it is like to experience pain that never gets better or goes away. Pain that takes your breath away … pain that makes you cry. Most people's experiences with pain are acute situations that usually get better over time, move toward resolution, and eventually is gone for good. If you're lucky that is.
Of course there are people who abuse narcotics - we've all meet them in the course of our career - or even in our private lives, however there are also those people who do not. Those that use their Rx meds exactly as Rx'd, who've stayed at the same dose well managed for years, who don't ask for early refills, don't come up with ridiculous stories that their Rx was stolen/lost/accidentally thrown out, don't ask for higher doses, don't have other illicit substances in their urine, don't doctor shop, don't visit the ER's, whom use the same pharmacy every time, and tough out their acute pain flairs at home quietly.
My mother was that person before she died.
Those people don't deserve to suffer as a group unfairly because of other people's actions. Each pt needs to be treated on a case by case basis. This does take time and energy - but what's the alternative? Condemning people to endure a lifetime of suffering that could otherwise be alleviated? I agree with the OP - this set's some pain sufferers up for suicide risk. I can think if at least 3 pt's in the past 22 years of my nursing career that were medically mismanaged and couldn't stand the constant severe pain a minute longer, taking matters into their own hands to do just that.
I feel so very lucky my mother's pain was well managed, and she didn't live to experience the current totalitarian cultural climate of chronic pain pt's always being under suspicion. To see her suffer would have broken my heart.
The Rx pain meds she took enhanced the quality of her life, and she told me many times that she would rather die than suffer though the pain she had underneath, that which the Rx pain meds blurred and softened around the edges, but never took entirely away.
I agree that addiction to legal narcotics is a huge problem in this country. That said, having been a nurse for many years I have seen many trends come and go. For awhile the trend was "Pain is the fifth vital sign and MUST be treated immediately." Currently, the "flavor of the month" is that everyone prescribed narcotics is or will become an addict. This too will pass, but I wonder how many folks will suffer in pain until the pendulum swings back the other direction. We've seen the same phenomena in other areas as well. When my children were born, (30 years ago), new parents were told babies MUST unequivocally be laid to sleep on their stomachs, lest they suffer SIDS. My grandchildren's parents are being told the EXACT OPPOSITE. A baby must never sleep on their stomach because it CAUSES crib death. Again, the flavor of the month. Please don't site any research studies in reply. You can find a research study to support any opinion you personally hold, and I don't care. My point is, nothing is black and white. Yes, addiction happens with prescription drugs. Untreated pain also happens. I guess I'd prefer to err on the side of compassion rather than accusation. Just my personal opinion. Nothing more.
While I do not have all of the answers I strongly disagree with pain is whatever the patient says it is. It might work if the patients were not aware of the rule. When you are sucking down a big mac meal and playing candy crush chuckling with your visitors, you do not need a phenergan shot for severe nausea and your pain is NOT a 10/10.
The idea that pain is always "subjective" was meant well, as already written about above, but also led to a lot of over prescribing and easy access to narcotics.
So far I have not met any doctor who will have problems prescribing narcotics for a patient who has cancer especially when there is no cure and only palliation. But there are a lot of other pain problems that also respond to non narcotic medication and other interventions. Narcotics are not the answer to every pain problem and have side effects as well. In my area, providers have been very conservative with narcotics and often refer complex cases to the pain management clinic. Patients have caught up on the 1-10 game and know that if they do not say 10/10 they will most likely have to wait and not get their pain medication any time soon...
Is you mother addicted? Everybody who takes daily narcotics develops a tolerance and most likely will go through withdrawal symptoms when stopping them. There is physical dependence, pseudo- addiction, addiction, and tolerance.
Since your mom seems to have other problems like dementia, it is probably best to get her evaluated for that by a specialist to figure out how that impact her overall functional status as well as the ability to communicate clearly.
Someone here on AN posted not too long ago that she is seeing Tylenol prescribed for cancer pain and how inadequate it is for this population.
As professionals, we nurses need to contact our lawmakers to teach them about the suffering we see because doctors are so scared to prescribe pain meds now. If we each gave up one or two visits here, we could probably contact all of our elected Senators and Congressmen and Congresswomen. Also AMA president and other listened-to and respected doctors.
It's terrible that a doctor would cut off a patient and her daughters, not even hear them out, and cause them to suffer. I think doctors who do this should be reported to their licensing Boards. It is inhumane.
Or sic a lawyer on them.
And fill out those Health Grades surveys (and similar sites).
I once cared for a pt with terminal Ca. Skin and bones, almost non-responsive, starting to Kussmaul.
The nurse who relieved me said she was reluctant to give pain med because the pt was drug-seeking.
If not, just have her see the doctors you want her to see, including a Pain Management person. That might be the only way these days to get adequate pain control, tapering of Norco and benzo's, etc.
Peri pain could be from her spine? See a Gynecologist - could be gyn Ca, not to alarm you.
This really makes me mad! You mother's doctor(supposedly an educated health care professional), appears to be one of those doctors who truly does not care about the welfare of his patients. He is in it for money and perhaps prestige only and will jump when he fears he may be questioned and conform with total disregard to his patients well being.
When did he decide your mother was an addict? Probably when a harder look was taken at the pain medication prescribed in the US and reports of overdoses were high. He KNOWS your mother for how long ? All of a sudden she is an addict. MMmm. Even if this were true who prescribed this medication to her in the first place?
Each case needs to be looked at individually. Your mother appears legit. I wonder if this doctor is? Maybe she is paying the cost for the others he did treat without pain. Either way you shouldn' t take any body off long term therapy like this. It is dangerous. I would try perhaps to look for a pain clinic and tell them what is going on. Of course another doctor is going to be suspicious, but maybe with persistance you can find a good one , who after testing and examination will treat her. Goodluck to mom and your family.
I have had sickle cell patients that would color with magic markers, watch tv and talk on the phone when in crisis. Everyone deals with pain differently. Look at women in labor. Who are we to judge? Being aware of bloodwork, and other testing, and good nursing assessment will in most cases will be the final judge. Looking at what they do or if they cry or laugh suggests little when you have a person with chronic or long term pain.
I have had sickle cell patients that would color with magic markers, watch tv and talk on the phone when in crisis. Everyone deals with pain differently. Look at women in labor. Who are we to judge? Being aware of bloodwork, and other testing, and good nursing assessment will in most cases will be the final judge. Individuals behavoir , laughing, crying, grimacing, walking, talking, are used as coping mechanisms to deal with discomfort and pain and not indicators of a persons level of pain.
I can understand how difficult this must be for you, as a nurse, and for your poor mother. I'm sorry that you are experiencing this.
Medical professionals have extensive education. The public (and lawmakers) need to trust our judgement. Pain can cause significant changes in the body, not just with vital signs but also with nutrition, sleep, and quality of life. We need to be able to adequately control a patient's pain. We also need to revisit "pain is what the patient says it is" because it's not a very great tool.
I had a hysterectomy after nursing school was over (literally, the day after) because I had stage four endometriosis. I couldn't have the surgery until school was over, I only had one semester left, and I couldn't take narcotics during clinicals. I had a prescription for percocet, but went back to the OBGYN because I couldn't handle the pain with just Tylenol the day before and during clinical. My doctor wasn't in that day, and I saw his partner at the practice. I explained the pain I was having, and right before I request a non-narcotic she told me that there was no way she could prescribe me anything stronger. When I told her I didn't want a narcotic, she rolled her eyes at me.
You read that right.
I've given birth, and I went 36 hours without the epidural. The pain I had with the endometriosis was worse than labor. Unlike labor, there wasn't a break. And this doctor, who helped to deliver babies, rolled her eyes at me. After my hysterectomy, my doctor told me that he didn't understand how I had handled life for the last six months based on what he saw.
How is it that one doctor can be so understanding and the other doctor isn't? One doctor was the mentor, the other was fairly new and that colored their experience.
Try to find a doctor who is older. I think they may be more understanding of your mother's pain. I am so sorry that you are experiencing this.
Ugh, what a privileged jerk. I don't usually wish pain on others, but I think that people like that could use a bout of kidney stones, a back labor, a broken bone, a throbbing back muscle sprain, etc. to give perspective and hopefully empathy.
I once reported a doctor who said of one of my patients, "He's from the streets. I'm not giving him pain meds." She was also known for discontinuing the scheduled home pain meds and relaxants of patients who were hospitalized. Yeah, it was so bad that I'd actually recommend that her patients request different hospitalists.
I've seen both sides of the story. I've seen people fake conditions like sickle cell anemia (yes, that's possible until they test you), and leave AMA when they don't get their preferred pain meds. I have also received surgery and have chronic back pain due to an occupational injury. My relatively light pain and ability to afford and attend workman's comp, massages, chiropractors, heating pads, and lidoderm patches are comparatively luxurious compared to people who are trapped by their pain and can't afford such care. I see the potential for abuse, but I absolutely will not keep someone in pain due to my judgment. I can also see why people would turn to heroin after being cut off from their legal pain meds or not being able to afford them.
Once in a while I'll hear about new technologies being developed like cone snail venom. Come on people (lawmakers, grant endowners, technologists, pharmacy companies). You want people to stop being dependent on opioids? Develop non-narc analgesia that works! Then again, we live in a country that doesn't want unwanted pregnancies yet cuts birth control at every opportunity.
Specializes in EMT since 92, Paramedic since 97, RN and PHRN 2021.
I am a firm believer that a lot of the current prescription opioid addiction is a result of Big Pharma (Purdue Pharm) and their marketing techniques towards Doctors. When Oxycontin first came out they were touting it as a very low risk of addiction, we all obviously know that isn't correct. The public is now suffering the fall out of the prescribing practices of Doctors who were given very misleading and down right false information.
Axgrinder
256 Posts
Pain management in this country has taken a giant leap backwards, taking on a medieval, draconian mindset.
15-20 years ago there was a movement in the medical community to treat pain as the 5th vital sign. "Pain is what the pt says it is" was in all the nursing education annual competencies, and it was used as a subjective pt assessment tool. MS Contin had been around for years before this, and this long acting pain medication seemed to be used without any untoward societal consequences, as there were no daily news stories of abuse and death that I can recall back then when I was a new nurse. Then oxycontin was created as another adjunctive tool to ease the suffering, and increase the quality of life for of millions of chronic pain pt's. Before long a glut of news stories began to surface - reporting waves of crime, substance abuse, and death - hitting the daily news like a hail storm.
What lead to this? Did oxycontin itself act as the catalyst that created this epidemic? That is certainly what I've surmised from the countless articles I've read on the subject over the years. But is this true? Did oxycontin create a hoard of mindless, slavering drug addicts - who'd sell their mother for a fix - from once previously pious, everyday people?
Suddenly chronic pain pt's - all chronic pain pt's - were under scrutiny, and became objects of suspicion. It became a shameful thing to suffer from chronic pain and take routine Rx pain medication to offset the agony.
Seemingly over night the view point regarding chronic pain did a 180° turnabout, leaving countless genuine pain sufferers in the lurch.
Rx narcotic regulations changed, stating acute pain in some states could only be treated up to a 72 hr limit, and postoperative surgical pain for up to 7 days. Chronic pain is more difficult to receive proper treatment for now than ever. And if you actually have chronic pain you better be able to prove it beyond a shadow of a doubt.
What if you, or one of your loved one's suffered chronic severe pain? What then?
Those whom have abused narcotics, and those whom have abused and died from overdoses, have become the new poster children for the face of chronic pain. Due to the internet, news stories are able to be all around the world in a matter of hours, sensationalizing it even further.
Long before the oxycontin news stories became a dime a dozen, there were still people who abused and misused - oxycontin didn't create these behaviors. And I'd like to point out those whom will abuse Rx narcotics will likely abuse any substance: ETOH, street drugs, illegally obtained Rx narcotics, cigarettes, aerosol chemicals, bath salts … the list goes on and on.
What does this mean for those folks whom genuinely have a moderate-severe to severe chronic pain problem? They are SOL now, because those who've never experienced intractable, unremitting chronic pain have bundled them all together into one giant group and now treat them all the same.
Many provider's attitudes toward pain is: "Pain hurts, and it is to be endured". There are people who literally cannot imagine what it is like to experience pain that never gets better or goes away. Pain that takes your breath away … pain that makes you cry. Most people's experiences with pain are acute situations that usually get better over time, move toward resolution, and eventually is gone for good. If you're lucky that is.
Of course there are people who abuse narcotics - we've all meet them in the course of our career - or even in our private lives, however there are also those people who do not. Those that use their Rx meds exactly as Rx'd, who've stayed at the same dose well managed for years, who don't ask for early refills, don't come up with ridiculous stories that their Rx was stolen/lost/accidentally thrown out, don't ask for higher doses, don't have other illicit substances in their urine, don't doctor shop, don't visit the ER's, whom use the same pharmacy every time, and tough out their acute pain flairs at home quietly.
My mother was that person before she died.
Those people don't deserve to suffer as a group unfairly because of other people's actions. Each pt needs to be treated on a case by case basis. This does take time and energy - but what's the alternative? Condemning people to endure a lifetime of suffering that could otherwise be alleviated? I agree with the OP - this set's some pain sufferers up for suicide risk. I can think if at least 3 pt's in the past 22 years of my nursing career that were medically mismanaged and couldn't stand the constant severe pain a minute longer, taking matters into their own hands to do just that.
I feel so very lucky my mother's pain was well managed, and she didn't live to experience the current totalitarian cultural climate of chronic pain pt's always being under suspicion. To see her suffer would have broken my heart.
The Rx pain meds she took enhanced the quality of her life, and she told me many times that she would rather die than suffer though the pain she had underneath, that which the Rx pain meds blurred and softened around the edges, but never took entirely away.
And I believed her too.