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What do you think? My mother is told she is a drug addict by her primary care physician

Nurses Article   (16,410 Views 34 Replies 649 Words)
by lhome lhome, ASN, RN (New Member) New Member

lhome has 15 years experience as a ASN, RN and specializes in med/surg, homehealth.

1 Article; 1,522 Visitors; 11 Posts

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When it is your mother in chronic/acute pain and anxiety and her Doctor has denied her pain meds and anxiolytics.

What do you think? My mother is told she is a drug addict by her primary care physician

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.

I have been a registered nurse for 20 years working in med-surg, PACU, and homehealth. I love what I do, especially if am able to make a real difference. I welcome all opinions even when I may be wrong.

1 Article; 1,522 Visitors; 11 Posts

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HarleyGrandma has <1 years experience as a ADN, RN, EMT-B and specializes in Emergency.

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I am so sorry that your family is being denied help and compassion. In the rush to prevent drug abuse too many in medicine have forgotten that some patients *need* certain meds if they are to achieve any kind of quality of life. I hope your mom finds a physician that can treat her with dignity and compassion.

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3,095 Visitors; 113 Posts

Abruptly stopping her benzos can be extremely harmful. She needs to be monitored for withdrawal closely. What a jerk

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BSNbeDONE specializes in Med/Surg, LTACH, LTC, Home Health.

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Personally, I believe the legal push for pain control opened the doors for every drug addict to come flooding into the doctors' offices and hospitals all across the nation. Although the concept may have been geared at a specific population (those who truly were in pain and for whatever reason were made or allowed to suffer), the consequences were not really thought through. As such, those same providers who were forced into prescribing those medications, against their better judgment for fear of lawsuits, are now being forced to try to undo the damage that was done. Well, we all know how much easier it is to prevent addiction than it is to reverse addiction. If you can't get it, you can't become addicted to it. But, how can we truly tell if someone is in need or in want? So, everyone appears to have been grouped into one category. In the meantime, innocent people are having to suffer through the aftermath.

I still believe that having non-medical individuals (judges, lawyers with their never-ending commercials against healthcare workers, the general public with their make-me-happy-or-else entitlement attitudes, etc.), to dictate what goes on within the medical field will always harm more individuals that it helps. Granted, there are those providers who require additional 'guidance' and monitoring. But, it seems that every time an incident happens, the entire healthcare culture is held accountable for it. And that is going to affect the patients' right to be treated as the 'individuals' they are. Some people are indeed drug addicts and they treatment plan should be catered to them as such.

My suggestion with this move for increased pain meds within the hospital setting would have been to mandate a period of detoxification prior to being discharged from the hospital, but after the acute inpatient stage was over for those patients who were receiving narcotics every 2-3 hours around the clock for the duration of the stay. But instead, patients 'request' that last dose of narcotics as the IV is about to be removed from the vein and IT IS GIVEN, along with discharge papers!! So, of course, some of those people have no choice but to leave, go around the corner, and check into the next facility's ER before the body begins to crave that next scheduled dose...or return to the same facility within that 30-day-presenting-with-the-same-complaint-non-reimburseable window.

Anyway, hopping off the soapbox, I believe that a person with dementia and other debilitating and deteriorating conditions (mental or physical), or ANY elderly person (if an 80-year-old has been taking narcotics for 20 years, what is the point in stopping this now!) should not be denied pain medications, because who knows what is really going on with these individuals? The time to stand up and call someone an addict should have been before the narcotic floodgates were opened in the first place and should have been directed only to those that it applied to...physicians and patients alike.

For the powers-that-be, be careful what you ask for (or the laws you make) because you just might get more than you bargained for. I think it would behoove us all to really try to think about the negative impacts even harder than the positive ones, and EDUCATE our voting, non-medical family and friends on the messages that are being broadcast so loudly about the healthcare community. That way, an informed decision can be made, as opposed to everyone hopping onto the bandwagon that is playing a song with the most appealing tempo.

Just my opinion on the matter....

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margin261 has 15 years experience and specializes in Urology, HH, med/Surg.

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BSNbDONE- I share your opinion on that!!

Ihome- I don't have an answer for you. I would be so angry & frustrated if it were my mother! I hope you are able to find a doctor to treat your mother with the compassion & dignity she deserves.

The new laws aren't going to affect heroin/opiate epidemic they're intended to stop. They're going to mostly affect the patients that legitimately require narcotics to control pain to have a decent quality of life.

I recently had a HH pt, post op joint replacement, that was having terrible pain with therapy- so much that she couldn't participate properly. The physician cut off the pain medication completely, telling her they give more than 2 rx after sx because 'no one needs it.'

I might agree that in most cases that is probably true. But there are mitigating factors that need to be taken into consideration. A 'rule' such as that, doesn't fit every case- and it didn't fit in hers. And she is suffering needlessly.

The same goes for the new laws. Politicians do not need to be making the decisions regarding who gets medication or not. Those decisions need to be left up to doctors, who actually evaluate the patient. They need to be free to prescribe- or not- based on their findings not out of fear of Press Ganey scores, or now, out of fear of the government taking their license!

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Buyer beware has 40 years experience as a BSN and specializes in GENERAL.

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OP: the history of pain management has been just like everything else in this country a study in one extreme or the other. 15 years ago the word was out through many authoritative agencies that pain was objective and indeed a fifth vital sign and needed under penalty of sanction to be addressed. So any patient that even had the remote documented history of backpain would be treated with a heavy duty opioid like dilaudid and a prescription for percocet or hydrocodone. Then there was Oxycontin. That started the problem.

So many people being what they are took advantage of this well intentioned perogative to treat pain that it became a free-for-all let's go to the ER and get dosed and many ER nurses felt at the time that a majority of their time was spent on taking care of the needs of substance abusers. But you must understand this was the accepted ethic back then. It was only later that states like Florida came to the reality that they almost single-handedly were responsible the scourge of nationwide drug addiction. So the fall-out was that many doctors went to jail, an internet surveillance system was implemented to detect doctor shopping and much to the detriment of people experiencing true intractible pain, a reluctance on the part of practitioners to prescribe pain meds even if they were warranted.

So while what I have related doesn't necessarily help a family seeking to have their mother's pain mitigated, it does I believe provide insight into how to overcome practioner reluctance to prescribing pain meds and what approach might be effective on your part to give a doctor or nurse practitioner the necessary information required so as to make a credible case for pain control intervention. It just can't continue to be this see-saw too much or too little perjorative approach to pain control with the patient being made the whipping boy as always.

Edited by Buyer beware
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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.

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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Dear OP,

while I totally understand your frustration, I must say that your former doctor was very much correct in his tactic, although not in his actions.

As I get it, your mother is in her early to mid 50th. She has chronic pain and tremor, both of unknown origins, some dementia-like symptoms, personality changes and now new pelvic symptoms. It is a description of a complex patient who was, as far as I get it, never was worked up and has no working diagnosis. It is up to your mother to refuse testing, but it doesn't mean that she should be given meds with high addiction potential for this and that symptom just because she likes how they work on her. Your doc was absolutely right in attempting to transfer care, get specialists on board, etc., Sudden changing meds was not appropriate, but he was correct in refusing to escalate dose without proper diagnosis.

Regarding pelvic exam, it is up to provider to determine who is more qualified to do which type of assessment in practice setting. Pelvic exam #1 on difficult diagnostic case needs to be done by whoever knows better, not by whom the patient likes more. Unless the NP was specializing in women's health, she might have very limited experience with abnormal pelvic exams.

Regarding passing info, I can assure you that it is what happens in 100% of cases. No provider in his or her right mind would transfer care without communicating every single detail to accepting care office. Transferring a patient with even traits of "risky behavior" which might affect one's licensing status (even non-compliance, refusing to test, missing appointments, etc) and not telling about it is seen as extremely unprofessional behavior and can kill physician's career.

I do not say that your mother is addicted, but there were several things in your post pointing on developing of at least tolerance. She absolutely should not be treated in primary care setting, it is not safe for her on the long run and you need to understand it. She should be referred to specialists and get diagnosed before making any changes in her meds. As the very least safe step, she should take the same meds in the same doses, but there should be no increasing doses before we know what is really going on.

I have to work on regular basis with highly dependent and escalating patients suffering from chronic neurologic diseases from MS to Alzheimer, and it is incredibly painful, in all senses of the word, for everyone involved. I hope you would be able to convince your mother to get diagnosed and find a capable physician for her.

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My mother has a number of drug allergies/intolerance unfortunately including all of the NSAIDs. This didn't use to be a problem for her to get prescription pain meds in small doses to keep around the house for her to use for headaches, etc., but in recent years it hasn't been possible. Now she just doesn't have pain control as an option other than nonpharmacologic methods or topicals at home.

She went in to the ER after a fall and demanded pain killers for the severe pain in her wrist. It turned out it was broken, but they almost turned her away for "drug seeking behavior" because she was asking for specific medicines. She just knows because she has so many allergies what she can and cannot take. In the fight to make sure they didn't give my "druggie" mom anything for her pain, they almost completely missed that she had broken bones.

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I am very sympathetic - I have two home care patients that use a home physician service that recently stopped their pain medications and told them to go to pain management. One is 750+ pounds and the other is 350+ pounds, both minimally ambulatory (hence need of home visits.) How are they to GET to pain management? What are these people to do? No one wants the responsibility any more.

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brandy1017 is a ASN, RN and specializes in Critical Care.

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That is a very sad situation. Why not go back to the NP that was understanding of your mom's need for pain meds and anxiety meds? This is exactly what I feared would happen with the pressure for Dr's not to prescribe narcotics, that people will be left with uncontrolled pain. I see this already with nurse friends who are treated as drug seekers if they need narcotics for an injury or chronic back problem.

Is there any way you can go back to the NP with her? Otherwise seek out pain management for sure. Sometimes non narcotics can help such as lido patches or a steroid shot, but narcotics should not be withheld from her. Plus she is dealing with anxieity and dementia. The dementia may be increasing the anxiety as she realizes she is forgetting things. I imagine that would be very unsettling.

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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That is a very sad situation. Why not go back to the NP that was understanding of your mom's need for pain meds and anxiety meds? This is exactly what I feared would happen with the pressure for Dr's not to prescribe narcotics, that people will be left with uncontrolled pain. I see this already with nurse friends who are treated as drug seekers if they need narcotics for an injury or chronic back problem.

Is there any way you can go back to the NP with her? Otherwise seek out pain management for sure. Sometimes non narcotics can help such as lido patches or a steroid shot, but narcotics should not be withheld from her. Plus she is dealing with anxieity and dementia. The dementia may be increasing the anxiety as she realizes she is forgetting things. I imagine that would be very unsettling.

During my clinicals, I see pretty often this dynamuc of "the good (cop)/provider" who is "understanding" and "caring" vs. "bad one".

In my opinion, it is the perfect example of how not to do things. The same story as with a dude who somehow passed NCLEX is glorified as an excellent, caring nurse because she is always chatting happily about life and such while others are effectively doing her job, aka keep her patients alive.

The NP works under MD license in PA. By "being good" and satisfying patient's wishes, she adds nothing to the quality of treatment and potentially endangers the MD and her own license. BTW, if after TWO years these two put together did not figure out diagnostic workup plan and basically did nothing beyond treating symptoms, I would run for my life outta their practice. 50 y/o female with multiple and increasing neurological symptoms + dementia smells heavily as a systemic problem.

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