Refusing to prescribe narcotics

[MyNameIsOtto]

---

Members do not see this ad.

As a thought experiment, what would be the consequences if, as a resident, one were to take a stance against prescribing narcotics for any pain, be it acute or chronic? However, to keep things interesting, one would continue to order morphine for chest pain, unstable angina and other pain that could possibly lead to a catecholamine surge on the heart?

As a PGY-3 I've reached a conclusion, such as many others, that the narcotics we prescribe do more harm than good for the majority of patients.

Is there no end to this madness?

 

[jdh71]

As a thought experiment, what would be the consequences if, as a resident, one were to take a stance against prescribing narcotics for any pain, be it acute or chronic? However, to keep things interesting, one would continue to order morphine for chest pain, unstable angina and other pain that could possibly lead to a catecholamine surge on the heart?

As a PGY-3 I've reached a conclusion, such as many others, that the narcotics we prescribe do more harm than good for the majority of patients.

Is there no end to this madness?

Yeah. Narcs (more correctly opiates or opioids) are a problem.

Luckily I don't have to deal with them much anymore as I can usually punt pain control to a PCP. Is that kind of a d-bag move? I don't think so. The PCP is going to see the patient more than I will and I don't have time to deal with pain on top of pulmonary problems.

While in residency I avoided narcs like the plague and would tell patient's as much, and those willing to stick with my pain treatment algorithm could eventually get narcs on a contract (and I'd test urine once a month) - those who were shopping never came back.

 

[Socrates25]

As a thought experiment, what would be the consequences if, as a resident, one were to take a stance against prescribing narcotics for any pain, be it acute or chronic? However, to keep things interesting, one would continue to order morphine for chest pain, unstable angina and other pain that could possibly lead to a catecholamine surge on the heart?

As a PGY-3 I've reached a conclusion, such as many others, that the narcotics we prescribe do more harm than good for the majority of patients.

Is there no end to this madness?

This is a good question. Unfortunately, many hospitals will FORCE you to carry an active DEA number, which costs $800 for 3 years and its a total waste of money if you dont plan on scripting for narcs outside the hospital setting.

 

[LoudBark]

As a thought experiment, what would be the consequences if, as a resident, one were to take a stance against prescribing narcotics for any pain, be it acute or chronic? However, to keep things interesting, one would continue to order morphine for chest pain, unstable angina and other pain that could possibly lead to a catecholamine surge on the heart?

As a PGY-3 I've reached a conclusion, such as many others, that the narcotics we prescribe do more harm than good for the majority of patients.

Is there no end to this madness?

Unfortunately nurses are now taught that pain is the "5th vital sign". Every time they evaluate a patient they must ask if the patient is having pain. If the answer is yes, then they must ask on a scale of 1-10 what is your pain. Inevitably, 99% of the time the answer is a 10. (Sometimes the patient will say 11 out of 10.)

The nurse then calls some unsuspecting intern at 2am and says the patient is having 10 out of 10 pain.

 

[NotAProgDirector]

A total ban on narcs is unreasonable. Patients with acute pain needs -- a factured limb, severe pancreatitis, etc -- clearly need narcotics. In addition, chronic cancer pain needs narcotics.

So, what you probably are asking is this: Would it be OK to refuse to use narcotics for chronic non-malignant pain?

In fact, I usually don't in these patients. There are two types of patients -- those who are using narcs for obvious secondary gain, and those with functional disorders who think that narcs will help their symptoms. The first group is unfixable in the acute setting, the only solution is to refuse to prescribe. The second group is the challenging one.

I try to explain to them that narcs do not work, or work in the very short term and then make matters worse in the long term. I try to explore other symptom control options. It's difficult.

The real problem (and the reason, at least as a resident, you can't simply refuse altogether) is that some outpt docs will simply ramp up the narcs, and then send them to be admitted for a "flare" when the dose gets too high. It would borderline on malpractice to stop narcs like this cold turkey. In this case, I usually put them back on their baseline dose (which should prevent withdrawal) and then again try to work with other options for pain control.

All that said, I have had some patients who have short bursts of unexplained pain that respond to narcotics, who then don't need them between episodes. I have successfully managed patients like this on a fixed amount per month.

I've also had a few elderly patients with OA pain that responds nicely to a chronic low dose of narcs.

So, rather than making a blanket statement of "no narcs", I'd encourage you to not use narcs when they're not indicated, but still treat patients who demand them with encouragement and respect.

 

[FutureInternist]

We had one resident in my class how almost never (or per the floor nurses NEVER) gave any lortab while on overnight call. Made the nurses hate him but he stuck to his guns.
I did once get a page for lortab @ 2-ish & happened to be near the floor. Said OK on the phone & then just walked over to find the patient sound asleep !!! 🙄.
What does a lortab pill go for on the street ?

 

[brc12]

A blanket ban on narcotics for any pain acute or chronic is ridiculous and borderline malpractice in my opinion. There are many valid uses of narcotics for pain control. Of course there are situations where narcotics are inappopriate. I would expect you as a physician to exercise clinical judgement. I'm sure a resident who was refusing to prescribe for say a hip fracture, or a terminal cancer patient would be quickly and severely reprimanded.

 

[LoudBark]

A blanket ban on narcotics for any pain acute or chronic is ridiculous and borderline malpractice in my opinion. There are many valid uses of narcotics for pain control. Of course there are situations where narcotics are inappopriate. I would expect you as a physician to exercise clinical judgement. I'm sure a resident who was refusing to prescribe for say a hip fracture, or a terminal cancer patient would be quickly and severely reprimanded.

I will give the original poster the benefit of the doubt and say that his post is in pure jest and is just having some fun. I know you are taking this post seriously, but I don't think OP or anyone else TRULY thinks narcotics should be outlawed for all patients.

The OP was probably frustrated by some drug seeking a-hole while on call like everyone has been at some point.