I was deficient in treating pain

Should I Prescribe Another Opioid for This Patient?

http://www.medscape.com/viewarticle/855307

A clinician who performs minor surgical procedures is in a quandary about whether to prescribe an opioid for postprocedure pain to patients who are already taking opioids.

 
Carolyn Buppert, MSN, JD
Healthcare attorney

A nurse practitioner asks about management of acute postoperative pain, but this dilemma is common to all clinicians who perform minor surgical procedures.

As part of my practice, I perform a minor surgical procedure. The procedure usually calls for a controlled analgesic for a few days afterwards. Sometimes, the patient having the procedure is already taking large doses of one or more powerful pain medications for chronic, noncancer pain. If that is the case, should I prescribe the usual postprocedure pain medication? In one case, a patient was already taking powerful analgesics—more powerful than I normally prescribe—so I declined to prescribe yet more pain medication. The patient complained to his insurer, who then wrote me a letter saying that I was deficient in treating pain. Must I, should I, or even can I prescribe pain medication for a patient who already is being treated for pain?

Your reluctance to pile more pain medication onto a patient already being treated with controlled drugs is wise. If I received a deficiency letter from an insurer for making the decision you made, I would probably respond, in writing, describing my reasoning for declining to provide pain medication and asking the insurer to respond with their recommendations for how to handle this decision in the future.

Predicting what is safe for each patient is a complex calculation and requires consideration of unique variables. You are an expert at your procedure but not necessarily an expert on treating pain. You can become an expert on treating pain, if you like, but otherwise you will need help in figuring out what to do with patients who are already being treated for pain. The safest course would be to contact the patient’s prescribing clinician. Decide whether your additional prescription is necessary and appropriate and whether it will compromise the primary provider’s treatment plan. Furthermore, you will need to know whether the patient’s primary prescriber and the patient have agreed that the primary prescriber will be the sole prescriber of pain medication. It is common (and standard of care) for a clinician who treats chronic, noncancer pain with opioids to require that each patient agree not to accept pain medication from any other provider. If the patient knows that and still wants a prescription from you, it may indicate that the patient is not willing to comply with his other prescriber’s requirements. That may be grounds for the primary prescriber to terminate his relationship with the patient.

Another consideration is whether this patient should be treated as being naive to opioids or whether to take tolerance into account. And you will need to consider that your procedure calls for treating acute pain, and the regimen the patient is on prior to your procedure likely is for chronic pain. So you will need to decide whether the patient’s current regimen is going to cover the acute pain.

I recommend that you do some research to see what other clinicians in your line of practice do. Perhaps controlled drugs aren’t necessary for this particular procedure. It makes sense to come up with a practice policy or, at minimum, have your own policy about how you will handle this decision in the future. You want to treat pain responsibly; but, on the other hand, you don’t want to be manipulated by patients or cause a problem for their pain management clinicians.

Here is a resource about pain management that clinicians might find useful: “Acute Pain Assessment and Opioid Prescribing Protocol.” (Editor’s Note: You may also find Medscape’s Pain Management Center useful.)

10 Responses

  1. The outrage and trauma caused by making a person “deal” with the pain when it’s impossible to deal with – is a crime! Add surgery on top of Chronic Pain, and I completely understand how Pain Patient feels. There was so many “mistakes” made on me in 2012, and I could have sued and won, hands down. In fact, a doctor is who still trying to get me back on track said this week “I wish you would have sued – not because I think suing is right, but the what the doctor did was criminal.” True, but I had to think about a few things….. If I sued, would I ever get treated by a pain specialist? I have a pump, so who would take me on? I would rather make sure I have pain medications than to take a change and sue. Although, I made a deal, and he had to read all the research, and the agonizing letters sent to him were exposed. I received so many compliments on the three ring binder, it was said it was like reading the medical books through the eyes of a patient. So that was good enough for me. He came to me and thanked me and said he had already changed how he did things, and he wasn’t through. The main doctor in the practice used that book to educate his staff and the doctor who made the mistake. Everyday, the doctor and the book went into the well known doctors office to have a session. I noticed there was some humility that was sincere! He was against Morphine and was clueless of the pain of RSD/CRSP, Fibro, Neuropathy, TBI, chronic pain, you name it! The story is on my static page, as it brought so much trauma, there is no way to really write what is on my heart and mind. TBI keeps that from flowing!

    Thanks, Pharmacy Steve, for keeping us up to date, (we had our own rounds with Walgreens) and for those who write in to you.

  2. It was around the time of the 1st “shortage” that I was set-up for surgery in N.Y C at a prestigious hospital. My former primary Dr. would not work the hospital for special surgeries post surgical pain mgt care, [An amputation of my rt thumb was/is a possible outcome]. Because of this issue I didn’t have the operation as I probably would’ve died of infection or shock.
    My concern was post surgical pain mgt. As the type of pain is different from the chronic pain I’m in everyday, additional pain medication would be absolutely necessary. Pain mgt in N.Y.C. recommended tapering down until after the operation.

  3. Agree, agree, agree, PK2!! I have had to have three surgeries since becoming a chronic pain patient, and I swore that I would NEVER have another one but who can control life! These are the problems I came upon.

    1. Explaining to your doctors, (surgeon and pain), that your meds are your baseline, not insurance to cover everything!

    2. Having nurses in the recovery room refuse to give you the “extra” pain meds, because you take too much already and they will not be responsible for your death, even though you are in excruciating pain. (As a side, I believe that our nervous system is hypersensitive to more pain, or maybe I am a “baby” with low pain tolerance as I have been told many, many times)

    3. Having nurses lie about what was ordered for you, and not getting enough meds. I have suspected one of stealing my meds.

    4. Getting the damn pharmacies to fill the extra one time script for your eight inch incision, freshly cut, because you take too many pain meds already, or you are already taking that script in a different dosage, regardless of the circumstances.

    The next time I need surgery, I would rather die. No, I am NOT suicidal, just been kicked down and left in agonizing pain too many times. BTW, I live in Florida. Last time I had surgery, 10/30/15, when I was rushed to the hospital for major complications due to gallbladder because I walked around for three weeks with blocked bile ducts. Why? Because I always complain of pain, so no one listens to me, especially my PM. I had no idea something was wrong, until I literally collapsed. I really don’t complain all the time, but if someone is going to ask me about pain levels, I’m not going to be shy about how I have to live.

    Not giving a chronic pain patient pain meds after a “minor surgical procedure” is inhumane. I can’t believe that a medically trained person would even ask, because there never would have been the same question asked before we became the criminals!

  4. I think we should do away with the term “breakthrough” pain. Really, there are only three types of pain: acute, chronic, and terminal. Each of these deserves to be treated separately and equally, but none can be proven to be more painful or detrimental than the other (or less deserving of treatment).

    Because of my jaw problems, seeing a dentist is not only very expensive, but extremely painful. In fact, whenever I have dental work, I have to be put under. Now, if doctors and dentists told me I couldn’t have additional medication to manage the acute pain after these kinds of procedures, I wouldn’t even consider them. Of course, that’s not really a problem, seeing as my last dental procedure (many years ago) was about $10,000 — services I’ll never be able to afford again.

    Dogs are treated better than both chronic pain patients and drug addicts when it comes to acute pain, which just compels them to stay away from any kind of medical treatment whatsoever. Since doctors are a large part of the shaming process, and because of the fear in treating us, why would anyone in pain seek out the help of the medical industry?

  5. As a chronic pain patient who takes regular high-dose opioids. Part of the reason I take these meds is because I have Fibromyalgia, and CRPS (on top of a number of other chronic intractable pain conditions). Because I have these two conditions, any additional painful stimulus (acute on top of chronic) is not managed by my baseline meds. For example, a year ago, I had to have a tooth pulled, and the dentist decided that I did not need additional pain meds.

    The result of this was PTSD and chronic oral pain. I needed my pain to be managed with additional meds, and because of my high tolerance, it would not have been terribly unsafe (according to my pain doctor at the time, and the ER, doc, who ultimately prescribed me an additional low-dose opioid to add to my regular meds for two weeks. Unfortunately, because I had to wait so long to have the pain treated, by the time I got the supplemental medication, and the dose he prescribed was not sufficient, and my body had already created a semi-permanent “pain pathway” so that even when I had healed, I still felt pain for months.

    I hope that you will consider this situation, and if you feel uncomfortable, maybe consult with the patient’s pain doctor about giving them something extra for breakthrough pain.

  6. Kenf
    Do you mean that if a chronic pain patient gets s kidney stone, clavicle fx m, or is ejected in an MVC, they should not get pain treatment in the ER.
    As an Er doc for over 30 years, I would never allow the physiologic stress of acute pain derail my opportunity to help someone through a catastrophe.
    And
    All Acute Pain is Potentially Catastrophic

    Thank god your Hip surgery went smoothly.
    The no brainier is: you did not require additional pain meds. Good for you. If you developed CRPS you would have…

    • Thank you dr. Mark. I have CRPS type 2 and I would not have any surgical procedure at this point because I know my pain is severely undertreated right now and the pain associated with a surgical procedure? Forget about it. Whatever it is that I needed surgery for I would tell them not to talk to me and leave me the f*** alone.

  7. In Florida it is illegal to get more than one opioid pain medicine in duplicate,you cannot get two extended relief or immediate relief at the same time in the same month. Also the terms of my agreement with my pain doctor states that I cannot get any other narcotic from anyone but him. She a professional. Why would she not know that if you are already taking a specific “HigH” dose what would be the purpose of raising it higher. I wouldn’t take it even if it was prescribed and I were able to fill. Even when I had my hips replaced,both of them each time I was not given any extra,the amount I was already on the orthopedic doc felt was way more than enough. I feel its kinda a no brainer.

    • Acute/surgically induced pain..can be a different animal than chronic pain.. and require additional opiates.. what one person considered a “high dose” others who are use to dealing with chronic pain pts.. may be considered barely adequate. There is also the presumption that the pt’s pain was being adequately managed with the amount of opiates that they were receiving before the surgical procedure. When we start treating pts as “clones”… that is when we start abusing/mis-treating pts.. the “Bell Curve” is not just some lame theory

    • I remember when you could get 2 extended release meds along with a break through med too. I don’t see how anyone can put a dose limit on a patient. One size doesn’t all but now days they want to give 0 doses.
      Geez.. what is a high dose anyway? anything more than a 7.5 Vicoden. Good grief..I feel really bad for those patients with severe pain conditions now days..

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