Pain Management

[chbare]

Ok chbare, it is late July -- how many times have you administered pain medication this year (not including chest pain) ?????? Be honest. And I am sorry, it is not possible to be in "10-10" SCALE PAIN and not have elevated vital signs. You can have some pain, without elevation, but you cant convince me that you are having the WORST pain of your life with vital signs of 110/60. 64, 16.

If I can wait 30 minutes on my pizza, I can wait 20 on pain meds, especially for a chronic condition.

[Citation needed].

[Just Plain Ruff]

You know for everyone who can claim to know who is a drug seeker and who is not, and you know who I am referring to, (my co-workers who may be on this site) and others on this site, Karma is a bitch and I just hope that you get a sympathetic doctor or nurse who believes that you are in pain and not just a drug seeker.

Otherwise, good luck getting any pain medication because, well to them and to you, you are just a drug seeker. Sorry but you brought it on yourself.

But I can tell you this, the one time when you are truly in pain from kidney stones or back pain or god forbid cancer pain of some sort and you need pain relief and that doctor or nurse thinks you are faking it or your vitals are just not fitting the person who is in "pain" and you don't get the medication that you rightfully need, I guarantee that your practice will change. If it doesn't shame on you.

It's not your place to judge people nor decide whether they get pain relief or not. It's not our place to with-hold treatment based on our judgement of someone.

My god man, consider the children. (ok had to throw that one in)

[ERDoc]

We need to admit that there is a problem though. Hospital systems are starting to limit the use of narcotics to people who have frequent visits with no pathology. The US has something like 10% of the world's population but consume something like 90% of the world's supply of norco/vicodin. It is just as dangerous to give people unneeded opiates as it is to withhold them. There is more to this than just saying, "don't be a mean provider and give everyone opiates." Experienced providers can identify those who are seeking or dependent on opiates. Will we get it right every time? No, but do we get anything right every time in medicine?

[Just Plain Ruff]

I'm not saying that doc. But what I am saying is if a patient is on chronic pain management and they need additional pain medicine but let's say that they ran out by mistake or some other circumstances that we don't make them wait for 30 minutes to get them to an ER to give them meds.

That's what I'm saying.

[paramedicmike]

Locally, someone who is on pain management for a chronic condition has a contract with their pain management provider (who is generally not their PCP). Should a chronic pain patient present to the ER I can treat the acute pain. I cannot give them a prescription for narcotics. So when a pain management patient with a chronic pain condition presents to the ER with a story, no matter how true, that they don't have any more of their pain meds I can treat them acutely and that's all I can do. They don't get a script from me. If they want more they need to see their pain management provider. What's more, a copy of their discharge paperwork is automatically forwarded to their pain management provider.

(All of this being said I have more resources in the ER for tracking down prescription history, medical history, past visits and more than what is available on the ambulance. Figuring out if someone is seeking can be somewhat easier in this setting.)

When I'm working on an ambulance I am a lot more liberal with pain medication than some of my coworkers. Some pain complaints are easy. Others are more nebulous. I'll investigate the more nebulous complaints a little more thoroughly in those cases. But I won't refuse someone pain medication simply because their vitals are normal (there's enough literature out there to be pretty clear on this point). This is where assessment skills come into play.

A complicating factor on the ambulance is that in many places it's either narcotic pain medication or nothing. Not that a non-narcotic pain medication, with the exception of nitrous, is going to kick in fast enough for most transports. It's a tough position in which to find yourself. From a pre-hospital perspective I'm more concerned with a needlessly painful transport than with supplying an addict/seeker.

[Timmy]

I think pain management and assessment is generally undertaken in a very insecure manner. I see a lot of clinicians worrying about giving the patient too much analgesia, to little or jumping to the conclusion that the patient is seeking. There seems to be little understanding on how to assess pain thoroughly and then working on a sound management plan and selecting the appropriate analgesia.

No matter what your first thought is of the patient I think it’s still important to do the appropriate assessment, diagnostics and go from there – I’d hate to think someone would base there diagnosis or treatment on a half-hearted history on a patient with no physiological change in vital signs and merely dismiss the patient as a seeker . Process of elimination. Nociceptive pain may have no clear diagnosis, commonly nociceptive lower back pain patient’s present frequently for acute pain management even though the MRI/pathology suggests no cause for concern. Who am I to judge there level of pain? If I think there seeking I may refer them to a pain clinic or similar.

As previously mentioned EMS has limited analgesia options, I guess that’s an upside of being an ED RN. The service in my state carries Morphine, Fentanyl , Methoxyflurane and I think there just about ready to start trialing Ketamine.

I work in a large rural ED and we struggle to get senior doctors, unfortunately it’s common that the junior docs will prescribe unsuitable medications to patients who need more, in fact just the other day I had a young lass with acute abdo pain and the doc didn’t think it warranted opioids because she didn’t want to interfere with the surgical registrars assessment (even though she was some hours away from examining the patient)…

[Just Plain Ruff]

Funny story - my parents had a physician who was quite liberal with the pain meds. My mother has back pain and she was given quite a liberal pain medication regimen. Her specialty was pain management with an internal medicine background

The doctor actually was investigated by the DEA for over prescribing and nearly sanctioned I believe. She was pretty outspoken so I can only imagine what she told the DEA.

Fast forward about a year and same doctor was diagnosed with prostate and bowel cancer. You can imagine that she was in some sort of pain. She kept practicing but with the patients that I guess were her favorites, she kept very limited office hours.

When her time here was coming short, she had one last office visit with each of her patients and made arrangements for follow up care if they had not done that already. In the case of my parents, she also made sure that their medicine regimen would not be altered or interrupted for a very long time. My father asked her if she was worried about the DEA coming after her and she said what are they going to do I'm dying. The amount of narcotics she wrote them was pretty incredible.

She did not fear the DEA, she feared more that her patients were in pain.

She passed away soon after my parents last appointment.

[paramedicmike]

Fast forward about a year and same doctor was diagnosed with prostate and bowel cancer. You can imagine she was in some sort of pain.

With that kind of diagnosis I can imagine she would be in pretty significant pain.

[Just Plain Ruff]

With that kind of diagnosis I can imagine she would be in pretty significant pain.

Yeah, she told my parents that with her pain that she was experiencing she had a entirely new understanding of patients in pain. I went to her with my mother because my dad was unable to make one of the appointments and she told me that she wishes that she knew then what she knows now about the bodies response to pain. She was a talker.

The doctors my parents go to now, are no where near the providers or adequate pain relief that this doctor was to my parents. They provide adequate pain relief but my mothers pain was very very well controlled by her previous doctor.

[paramedicmike]

I think you missed it: she had prostate cancer?

Are you sure?