Interested in your thoughts on this issue re: pain tx

[ChillyRN]

I appreciate the thoughts of nurses, physicians, PAs and pharmacists, et al on this one.

We all know drug seeking is a huge problem. I am just a NP student. At my last clinical site, the MD and NP Rx'd percocet and vicodin like they were tic tacs. I wouldn't presume to say it wasn't appropriate, I don't have the experience to make that call. Point is, they were very liberal in that regard, and the practice population reflected it. Since they had a community "rep" for Rx'ing, everyone and their brother with a stubbed toe came in with their tale of woe. Most of it seemed like BS to me, but whatever. I'm still a starry eyed student. I think 30 y/os with diffuse stress and/or anxiety need coping skills, perhaps a little exercise, not benzos. But then I was raised that to give in to pain and take a tylenol was a personal failure. That, and only prostitutes chew gum. I'm warped (thanks Mom).

My new clinical site has a firm policy, no schedule IIs, at all, ever. No one in the practice has a DEA license, and patients are informed up front when they first come to the practice that they will not Rx anything schedule II. Acute pain is referred to specialist du jour if necessary, chronic pain to a pain clinic. This doctor just doesn't want to deal with the issue of drug seekers, so this is how he prefers to handle it.

And I must say, it works. They have a much nicer group of patients. It is so liberating to just take people at face value and not have to be suspicious that they are scamming you. I find myself thinking I might forgo a DEA license just to avoid the hassle of dealing with that segment of the population.

And then I wonder, is that really ethical? I have no idea what percentage of these people really have pain, or home much pain they have, but it strikes me a little like a lawyers ethics, even criminals deserve a defense, etc. Even drug addicts have pain! I am waaaaaay too early in my NP career to be cynical!

So what do you think? No health care providers have a duty to Rx the good stuff even if it might be overkill, just in case it isn't?

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[fab4fan]

I appreciate the thoughts of nurses, physicians, PAs and pharmacists, et al on this one.

We all know drug seeking is a huge problem. I am just a NP student. At my last clinical site, the MD and NP Rx'd percocet and vicodin like they were tic tacs. I wouldn't presume to say it wasn't appropriate, I don't have the experience to make that call. Point is, they were very liberal in that regard, and the practice population reflected it. Since they had a community "rep" for Rx'ing, everyone and their brother with a stubbed toe came in with their tale of woe. Most of it seemed like BS to me, but whatever. I'm still a starry eyed student. I think 30 y/os with diffuse stress and/or anxiety need coping skills, perhaps a little exercise, not benzos. But then I was raised that to give in to pain and take a tylenol was a personal failure. That, and only prostitutes chew gum. I'm warped (thanks Mom).

My new clinical site has a firm policy, no schedule IIs, at all, ever. No one in the practice has a DEA license, and patients are informed up front when they first come to the practice that they will not Rx anything schedule II. Acute pain is referred to specialist du jour if necessary, chronic pain to a pain clinic. This doctor just doesn't want to deal with the issue of drug seekers, so this is how he prefers to handle it.

And I must say, it works. They have a much nicer group of patients. It is so liberating to just take people at face value and not have to be suspicious that they are scamming you. I find myself thinking I might forgo a DEA license just to avoid the hassle of dealing with that segment of the population.

And then I wonder, is that really ethical? I have no idea what percentage of these people really have pain, or home much pain they have, but it strikes me a little like a lawyers ethics, even criminals deserve a defense, etc. Even drug addicts have pain! I am waaaaaay too early in my NP career to be cynical!

So what do you think? No health care providers have a duty to Rx the good stuff even if it might be overkill, just in case it isn't?

I can just tell you what my MDs practice does. Any pain meds require a pain mgmt contract that must be signed by the pt and the physician with very rigid guidelines that must be followed in order to maintain prescription privileges. One strike and you're out. She said it cuts down on the doctor shopping/pharmacy hopping.

I can understand not wanting to deal with "seekers"; they were my least favorite patients in the ED. But people do get pain, and sometimes Advil doesn't cut it, and they can't always get to a pain specialist, so they count on their primary to manage their pain issues.

I guess it's something you'll have to sort out for yourself. I always thought if I were in that position, I'd rather err on the side of giving a seeker meds than turning away someone who was truly in pain. Of course, I have the luxury of working in an area where complaints of pain are never disbelieved, and I'm not the one with the magic pen that writes the orders.

 

[bradt9881]

If you work primary care, you will invariably have to deal with pain management. It's a PITA, but as said above not everyone can go to pain management.

A few pointers to make it work:

Sign them all to a pain management contract. Stick to your guns, don't replace "lost" meds, and don't refill early.

Regularly test them with urine drug screens. Drugs of abuse such as cocaine are automatic disqualifiers for more narcotics. I tend to be more lenient with marijuana, but they need to test negative for THC before they can have their meds again. They also need to test positive for the narcotic prescribed. If they are consistently negative for oxycodone and metabolites, it's a red flag for diversion.

In NC, there is a controlled substance registry where the patient has a list of all narcotics prescribed. Use it, it helps find the doctor shoppers, which is a felony in NC. If they are shopping, report them.


Not all pain is best treated wih narcotics. Narcotics are good for nociopathic pain, but neuropathic pain can be better treated with meds like Cymbalta and Lyrica with less chance of developing tolerance and dependence.

Lastly, be prepared to identify those patients who have become dependent and work to get them proper psychological referral, if not rehab itself.

 

[ChillyRN]

Those are good perspectives, thank you for sharing. I will continue to think about it.

It is the night and day difference between patient populations that is most startling. THe 'no meds" people have a population that want to be well, accept their accountability for their choices and seek support and information in making improvements. The other population is thoroughly invested in the sick role, blame everyone else for their obesity, DM, htn, chole, and COPD, and yes, their Fibromyalgia. They are exhausting and depressing. The communities are not that different with regard to resources, finances, culture, etc. All of them are basically at or below poverty level, w/o insurance unless they are lucky enough to have 'care or 'caid. The narc thing is the only obvious difference, and I admit I'd much much rather work with the happy people vs. the depressed, angry, addicted people.

I realize this is not nearly an evidenced based correlation, lol, and I that need far more experience in primary care before I will know what I'm talking about! I'm just struggling with my own feelings and how they conflict with my "nursing ethos." I likely will continue to, of not this issue, countless others!

I like what you said, fab, about erring on the side of righteousness, lol. Brad, thanks for the pragmatic pearls of wisdom.