My Pain Philosophy
1) The smallest dose of narcotics that is effective in relieving pain is the optimum dose.
2) Higher doses of narcotics than are required to relieve pain cause problematic and sometimes dangerous side effects.
3) The optimum endpoint for a patient who presents to the ER with a painful condition is to be discharged in a pain-free state while also being awake, alert, and able to ambulate without assistance. Just like a normal person, in other words.
4) Some patients are not able to obtain relief of pain and still meet the criteria in #3, so compromises are often required in one or more of the endpoints. The preferences of the physician and the patient regarding the ideal balancing of these compromises (and the risks involved) do not always agree.
5) Some patients do not want to achieve the optimum endpoint in #3, instead desiring the euphoric side effects of the narcotics whether or not their pain is relieved. In fact, their desired endpoint is not exclusively pain relief but rather the state of narcosis. These patients refuse non-narcotic medications that are often superior pain relievers because pain relief is not their only goal (and occasionally not even their primary goal).
6) A patient's expectations regarding pain relief and the setting in which it is provided greatly affect the outcome and success of the visit.
7) A patient who comes in to the ER asking for a specific dose of a narcotic and gets it without an argument is likely to ask for another dose before discharge. A patient who asks for a specific dose of narcotic and gets only half of that dose (and is informed of that fact) is certain to ask for the other half 30 minutes later, but they usually won't ask for a third dose before discharge. Thus their total narcotic dose is minimized, and is therefore more optimal.
8) A patient who agrees to take whatever medications that my years of experience have taught me will relieve their pain will sometimes require no narcotics at all. But if they do require narcotics, the total amount will nearly always be less than the dose that they thought would be necessary, as long as they trust me and accept my promise that when they leave they will be comfortable. These patients will also be much closer to the optimum endpoint stated in #3 than any other group.
9) If a patient refuses that reasonable approach and still insists on getting "their usual shot," then they are probably a drug-seeker and will be treated with suspicion.
Labels: drug-seekers, ER, pain, tips
posted by scalpel at 5:58 PM
35 Comments:
Oh, this'll bring out the trolls...
I tell a lot of folks presenting with exacerbations of chronic pain syndromes that our therapeutic endpoint in the ED is not going to be pain relief. As you say, pain relief may not be possible without inducing general anesthesia. So we set the goal lower, for pain management, which may be more attainable. I find that setting this expectation in advance really expedites a successful disposition, meaning one in which both provider and patient are content with the outcome, in a reasonable time frame.
I also tend to avoid parenteral pain meds whenever possible. If the alimentary tract is working, it is almost always the best route for controlling pain, so long as dosing is appropriate.
IV pain meds are a bad idea because the drug crosses the blood-brain barrier so rapidly that it induces an intense euphoria which is very habituating. When people refuse oral meds and insist that only a shot will work, it generally tells me that they are looking for the rush, not pain relief. Nice post.
Great post.
Well Scalpel, I must say you surprise me. Just when I agree with almost nothing you say, you come out with a post that I don't know how anyone could argue with.
I am a chronic pain patient and I have not ever been to the ER for pain control and I take NO narcotics. Well maybe I do, because I guess there is debate about ultram being a narcotic or not (my PCP tells me it is not) but this is what I take and I even worry about it. I have had two joints replaced and soon will have a 2 level fusion, so yes, I know what pain is.
If I ever come to the ER for my pains, what you just said would suit me just fine. Thank you!
The best thing a hospital can do is take Demerol off formulary. I used to work somewhere where they did that and there was an immediate drop in the number of seekers. (I guess a small stash of it could be kept for those with a TRUE Morphine allergy)
I had surgery a year ago to repair a broken bone (hip). I was very sleepy and content after surgery for the two days in the hospital but when I got home with TWO prescriptions for pain meds (one was hydrocodone) the stuff made me miserable. I truly hated it and stopped using any of it.
An Ibuprofin half an hour before the physical therapist arrived, and half an hour before bedtime did the trick for a week. After that, alternating cold packs and the heating pad was sufficient. I still had pain, but it was manageable, did not interfere with moving around or sleeping. The pain meds were the first I've ever used and I cannot imagine anyone using them "recreationally"!
The odd thing to me was that on my final follow-up visit with the surgeon, he asked me three times if I wanted a refill on the pain meds. I explained why I didn't want refills, then the third time he asked me I just said 'no'. But why was he almost insistent? Everything healed perfectly, he was a great doctor, but that bit about refilling the pain med prescriptions baffled me.
Very nice Scalpel.
In my blog I recount my current experience with pain in the form of intense pulsating neuralgia of the right greater occipital nerve. An event on a Monday triggered gradually increasing pain and decreased range of motion in my neck. By Friday that week I was in tears from the pain. An ER nurse friend of mine was trying to convince me to go to the ER for relief. There were at least two occasions where I almost caved and thought about driving myself in. She even offered to come out and pick me up. I decided not to go. I knew there would be a long wait and I didn't want anything narcotic for pain because I still need to work. If they were going to give me something non-narcotic, I figured I could do that at home, 1g of acetaminophen or 800mgs ibuprofen I already had in my cabinet. Throw in the diagnostic tests and ER was the last place I wanted to go. While relief would have been devine, (still would be)why go there and then say, I have extreme pain but I don't want you to relieve it with any pain meds?
teehee! i tell my patients that they are not going to be painfree - they will be comfortable but painfree is unlikely without major side effects.
only a select few places in the hospital have pethidine - obstetrics for example - but you still get people begging for it. i'm all for limiting availability of the crazy narcotics.
and nothing tells you whether someone's in pain or not by offering them im ketorolac or an indomethacin up the butt.
Bravo.
I really enjoy your blog. I am on of those people that just cannot tolerate narcotics. I have had several minor surgeries (bunion, neuroma, wisdom teeth) and I have been given Vicodin and Darvacette (sp?) for those surgeries. I took two doses, felt awful and just went to extra strength tylenol and aleve. How do people who "abuse" narcotic pain killers get hooked on it in the first place? I couldn't take enough to actually get there.
Thanks for your insightful posts.
Elissa
Good post Scalpel. I can't imagine going to the ED and telling the medical staff what drug and how much they should give me. Well maybe that isn't 100% true.
I have gone and said don't EVER give me Dilauded or Morphine because it makes me sick. I do know from experience that Demerol is ok and have said that but I still wouldn't presume to say how much and I don't even know.
I was on Percocet intermittently when the ureteral stents were in and for a couple of injuries I also had. Except for a few extremely painful times s/p stent placement and other work done or removal...I never took the maximum doses. I was afraid of becoming addicted. A co-worker told me early on that I won't become addicted as long as it is only taken for pain and I have found that was true.
Still...I wonder if I did build somewhat of a tolerance to narcotics because not only did I have the percocet but I was in the OR 7 times in a year for procedures -not major surgery and I was also given IV pain meds whenever in the hospital and sometimes the Percocet was given too.
Pecocet normal doses still affected me even this past fall for an office procedure but Last fall 06 I had a routine colonoscopy done and post procedure the nurse commented that the Doc was surprised how much medication he had to give me.
Does THAT mean that I have built up a tolerance? If the answer is yes...then will that reverse since I no longer have the drugs in my system? Just wondering.
Funny thing...well not to the doctor. At 6am on the day of my discharge the nurse came in to remove the foley cath. I asked him for some I-buprofen because I was getting a bad headache and was concerned about it turning into a migraine. He said it wasn't in my orders and that he would have to call the doctor. He came back with the I-buprofen and my headache went away.
Later when that PCP came in to discharge me...he went over my instructions and when he got to the door to leave, he purposefully turned around, walked back over to me and said..."BY-the-way...you DON'T have the staff wake up a physician at SIX IN THE MORNING for I-buprofen when you have DEMEROL A-N-D PERCOCET at-your-disposal!" He wasn't my regular PCP and didn't know me well back then and I don't know if that would make a difference in attitude. I did say I was sorry and when I was in his office he acted like it wasn't a big deal when I apologized again.
I have read enough blogs to know doctors have some tough call nights and I can appreciate how inane that request must've seemed to him...but wasn't it better that I only wanted I-buprofen? I always kind of wondered about that. I-buprofen ALWAYS knocks out a headache if I catch it in time but I now know it isn't good for the kidneys.
Narcotic high sucks. I know--I've been overmedicated for days, according to my surgeon. Well, acually the high is fun, but it doesn't last very long and is destructive (and I really enjoy being able to pooh). I don't get why people throw away their lives chasing that 3 minute high!
Great post Scalpel although I fear you will hear long and loudly from the trolls.
I don't think your post is trollable if it is read as you have logically presented it. :)
I have to admit I did expect a bit more of a backlash, and I appreciate the kind comments so far.
And yes, Seaspray, repeated doses of narcotics do cause tolerance ( a higher dose requirement to obtain the same effect) but that problem does seem to be improved by drug vacations and is more of a problem in chronic daily users than those with intermittent narcotic use.
That's why some chronic pain patients take their entire month's worth of narcotics in the first week or two and then go the rest of the month without any.
Wow! So do they do that because it no longer works on the pain or for the euphoric affect?
If the former...then shouldn't they be working on that with their physician?
When I was in between stents in October 06...I had gotten over zealous swimming at the Y and caused myself to get a cervical fasciitis. It was one of the most painful things I had except for the kidney stones. The Ortho doc prescribed a packet of something that didn't seem to touch it. I had left over Percocet which also didn't seem to help much. The he called in some muscle relaxants and that did the trick. ANYTHING...that caused me to move my neck in any position caused excruciating pain.
If you are talking about people that really have to live with that kind of pain indefinitely...then OMG...I don't know how they do it. It would seem they are between a rock and a hard place with the hideous pain and the increasing tolerance to the pain meds.
The good that came out of that awful week of pain is that I discovered the blogosphere. The only time I was comfortable was with the medication and sitting up straight and not letting my head touch anything. So I sat at the computer to look up urology info and discovered Urostream and read her entire blog and other med blogs for the entire weekend. if it wasn't for that...I probably wouldn't be blogging today and would be missing out on a wonderful hobby. :)
Who better to know how a med works for them than the person in pain? I know if I have a headache Tylenol does nada for me, but Advil works every time.
Magnify that to cancer or post-op pain proportions and damn straight a patient in that much pain might really want what has relieved their pain in the past. Add to that the fear of the docs choice drug not working, having to languish in pain til it wears off and old faithful can be pushed.
But yeah, 99% of the ones (who have no medical background) coming in requesting narcotics by name and dose (or the pretenders.. "hmm doc this one pill really worked for me, I just can't recall the name.. I think it began with V and rhymes with.. Icodin" are full of it.
Okay, I am missing something. Why did everyone expect some kind of angry backlash from this post? It seems like common sense and basic guidelines, totally non-controversial.
I enjoy your blog very much. I've had two operations (c-section and hysterectomy) and both times, I ditched the pain meds as fast as I could. With the narcotics, I still hurt, I just didn't care.
I think the hard part for physicians is trying to formulate a long term treatment plan that will allow the patient to function at the highest level with the least medication possible. Many who suffer with chronic pain have already tried physical therapy or chiropractic, but for some, alternative therapies such as acupuncture, Reiki, or yoga may be able to provide them with additional relief.
www.blog.wellnessprofessionals.com
Well that caused a bit of consternation!!
Did you know that opioids are rarely required for chronic pain? and that they are often prescribed in ED, then leading the individual to (1) expect immediate pain relief on admission (2) learn through conditioning that pain is to be feared and that opioids make them feel good (3) therefore reinforcing repeat excursions to ED.
Opioids actually provoke pain 'wind-up' in some chronic pain patients, and for this reason alone are probably an inappropriate medication, especially for reducing distress.
A lot of people attend ED with chronic pain because they are scared that they 'can't cope' or 'won't cope'; their family are scared and prompt them attending; they worry they have something serious going on that hasn't been diagnosed 'yet'; they've confused a normal fluctuation of their pain intensity with a new and more serious event; they haven't yet develop pain coping strategies that are more helpful.
Opioids won't help any of these except by proxy - pain reduction often reduces distress (but not always).
ED isn't the right place for people with persistent pain - it's for acute pain, acute medical conditions. ED staff aren't trained to treat people with chronic pain and they respond as if all pain is acute therefore represents harm (or that the person is intentionally seeking a high or attention).
I really hope that if you do see people with chronic pain you don't view them as nuts, psychotic, malingerers, pathetic, non-copers or any other pejorative title. Please see them as people in huge distress needing really good distress reduction (reassurance), and speedy referral to a chronic pain management facility.
Great post!
Bronnie
http://www.healthskills.wordpress.com
I'm not a big fan of pain meds; the NSAIDS are usually all I ever need (maybe Imetrex if the migraine really bites). However, after a laparoscopic surgery 2 years ago, I was very happy to be on a morphine PCA overnight and have liquid pain med (forget the name, but a liquid morphine type) at home. Not for the incisions....those didn't bother me. However, the referred shoulder pain from the CO2 was such agony that I used the PCA every time I could, and took the liquid as ordered every 4 hours for almost a full week until my body absorbed the CO2. It hurt so much to move my arm, and nothing else touched the pain.
But, as a RN, I knew 2 important things:
1. If you are taking meds for PAIN RELIEF only, you usually don't become addicted (tolerance may build up, but that is not necessarily addiction)
2. A non-addicted person will be able to stop the medications as soon as the pain need is gone.
The pain ended, I stopped the meds, and life goes on. But it has rather put me off ever accepting the laparoscopic route for surgery...
For both a LEEP and two natural births I have gotten continual medication offers from my drs. I guess pain is all in the perception as I really felt fine. The one time I needed pain relief for a kidney infection I had to hobble down the ER hallway crying to beg for ibuprofin. All I wanted was 800 mg of magical ibuprofin...
Also someone asked about why anyone would abuse opiods when they make you feel sick-chronic opiate users will actually learn to look forward to the nausea as it always comes before the high.
Now valium on the other hand... I can see why that might be nice to take now and then...
Scalpel,
What I took away from your post is that you manage patient expectations before pushing medicine. This is an excellent plan that takes some discipline on the provider's part but is hard to argue with, provided that patient is reasonable.
I enjoy your blog.
This is an absolutely wonderful post. You hit the proverbial nail on the head.
I am always amazed when patients say "that doesn't work for me" when they haven't tried a particular medication for a specific illness/injury.
Wow, a post I - as a chronic pain patient - actually agree with! Good work. Can you come work in my local ER? The docs there seem to delight in kicking me out of the door hardly able to walk or talk.
Sea spray said:Does THAT mean that I have built up a tolerance? I doubt it. Not unless you are on it all the time , every day. If my long acting wears off by the time for the morning dose, I start to get NASTY rebound pain. I am constantly trying to keep my daily short actings as low as I can, because of the tolerance issue. Sometimes surprisingly, a lower dose is sometimes more effective and I think it's because I'm not constantly sneaking another half a pill here and there. Not unless I'm in enough pain to warrant. I read on the web that heroin junkies kill themselve because their supply runs low, in a short time their tolerance goes DOWN then they find a bonanza, they shoot it and and up in the ER, or dead.
ER nursey said:Great post Scalpel although I fear you will hear long and loudly from the trolls. This is a troll statement. Shadowfax said:oh this'll bring out the trolls. You are goading people to make emotional responses to this post. I feel your pain, you guys put up with a lot of s--t but this isn't helping anyone. Let's be honest. You WANT the trolls.
You just don't realize that by definition every time one of you puts up a post bashing people who are in pain, you are behaving like trolls.
I am probably going to be dismissed as a troll for posting this, but so be it.
And before you label me as just another piece of drug seeking scum, I'll just state that the last time I had any opiate pain relievers, was 20 some years ago when I had 1 percocet (or something similar) after having my wisdom teeth removed. (Well, I suppose whatever they gave me a few years ago to knock me out for my colonoscopy may have included an opiate. I really don't know.)
Prior to that (though my childhood), I had about 16 (mostly orthopedic) surgeries, after only one of which I got post operative pain medicine.
So while I have (thank any gods out there) have never had to deal with chronic pain, between the surgeries, shingles, assorted injuries, a botched cystoscopy, and mumble mumble years of dealing with doctors of many levels of competencies, I have some idea of what pain is.
In fairness, I should add that I have had a bad experience with a doctor who did not understand the concept of "pain bad". I kept going to a urologist whose treatment plan was making my overall condition worse and worse for much longer than I should have out of fear having to repeat an extremely painful test. As it turned out, 99.99% of that pain was caused by the first doctor's incompetence and /or indifference to the pain he was causing. The delay in changing doctors cost me several months of misery and a few infections that I did not need to have. So my cynicism may be showing.
That being said, your "other people's pain philosophy" seems to boil down to:
1. Patients must blindly accept what ever treatment you offer.
2. Patients must adapt expectations regarding pain relief that you want them to have.
3. Any patient who challenges your treatment offer is probably a drug seeker.
4. Any patient who knows what has worked for him in the past is probably a drug seeker.
5. Lowering a patients expectations is an adequate substation for relieving their pain.
Obviously, I have some problems with your philosophy. The biggest problem I have you seem to demand total trust from the patient while assuming that any patients with pain that don't give you blind trust are drug seekers.
I find this particularly ironic, since you made it clear in your "Nursing Philosophy" post that you are willing to lie to patients, at least via proxies.
I'm not saying that you should hand out opiates like candy or that you should send someone out on the street punch drunk from pain meds (if the are in that much pain, maybe you should be giving them the option of an admission ), but maybe it's time to turn the patients with significant pain over to someone else.
At the very least, you should be letting them know up front that you feel that limiting their access to opiates is more important to you than giving them adequate pain relief and that your definition of reasonable expectations of pain relief is the only one that counts.
We're obviously talking about chronic pain patients here, because acute pain patients don't ask questions and aren't so demanding about specific treatments.
I'm delighted to turn the care of chronic pain patients over to someone else....their own pain specialist. If that doctor wants to admit them to the hospital, I'm quite happy to help arrange it. Of course, that never happens.
There isn't anyone else to turn over their care to. I'm certainly not admitting a chronic mystery pain patient to a hospitalist, and since I'm the only doc in the ER it's my way or the highway.
The ER isn't like a bar where you can ask for a "double" or request that I mix your own specific cocktail. I don't take orders from "customers." If you don't like the service, then you are welcome to go elsewhere.
It won't hurt my feelings one bit.
Because of chronic back pain--I know! The worst kind!...no, maybe abdominal is worse snce I'm female and ANYTHING could be going wrong in there--as well as a genetic predisposition to meds tolerance (not just pain meds), I am very hard to medicate. I ended up in more pain than I would've liked post-op from a laproscopic gall bladder removal because, on paper, the doses I'd need to actually adequately manage pain would kill me.
I went to the emergency room, after having been on anti-depressants for two months, with ideation of suicide from a spike in my pain level. I live at about a four. I was between an eight and nine for two days. While they sent the psych to talk to me, they refused to offer me any sort of pain relief. Not even OTC meds (which wouldn't have done anything, as Percocet is like candy to my system at this point, for all the good it does). But because I am a chronic pain patient, NO pain relief was offered. I ended up going to another ER that same night. They didn't offer me narcs, either, which was fine with me--because he wanted to try another option (muscle relaxant + IM anti-inflammatory). It helped a bit. I went home in less pain and no longer wanting to literally die.
I happen to know from recent experience that IV fentanyl and morphine do exactly squat for me. When they were offered, I agreed, because I'd not had them before. However, I'm on the fentanyl patch, so the IV stuff had zero effect. I'm guessing morphine is chemically similar to something else I've taken, as I felt nothing--no pain relief, no swimmy head, no itching, which I've heard is a common side effect. Thus far, the obly thing that helps other pain is dilaudid, no idea what dose. I know that saying so makes me sound like a junkie. I say so to the doctor and nurses (I know requesting a specific drug makes me sound like a seeker, but I just have tried, on other occasions, other solutions...and this one is the only one that helps). I used to be someone who wouldn't take Tylenol for a headache, so this is such a huge, awful, and humiliating change for me.
I do have a question, though. With two exceptions (one being the suicidal thoughts), I go to the same ER every time I'm having problems. It's where they (on the third visit) finally figured out that I needed my gall bladder out. Incidentally, I'm pretty sure that took so long because of my chronic issue; I wasn't taken seriously complaining of pain, and it took that third trip to finally actually run a scan and see the blocking stone. Anyway. If I were truly drug-seeking for the sake of getting high, and not pain relief, wouldn't I be going to every ER in town? Wouldn't I deny that I had a primary care doctor so that her office didn't get the report of my visit?
I realize that any time I'm in the ER or actually admitted, I will not experience total pain relief. That will not happen unless and until my regular doctor and the pain clinic find a solution. I just wish that medical folks would see that SOME pain relief is better than none, and that having chronic pain doesn't leave out different pain, or increased pain, as possibilities.
Well Scalpel,
I do hope that you warn your subjects ahead of time that it is "your way or the highway" so that they can consider whether there is a greater risk in:
- going else where and delaying their treatment
or
- being treated by a doctor with that attitude, which might mean a longer delay in getting to a second doctor if you don't feel their condition is worthy of treatment.
(I am not just talking about people with pain issues. I assume that your philosophy extends to other conditions.)
I know that I would except quite a large amount of risk to avoid being treated by a doctor with that attitude.
You just don't get it. To borrow some terms from the IT field, just because someone has a chronic problem that needs to be managed long term, doesn't mean that they won't have incidents that need to be dealt with. A chronic condition that is suddenly uncontrolled does become an acute issue.
As for your feelings being hurt, why should they be? You still get to bill the same whether you fix the acute issue or just tell your subject to shut up, suffer, and leave.
Shadowfax said:
(I tell a lot of folks presenting with exacerbations of chronic pain syndromes that our therapeutic endpoint in the ED is not going to be pain relief.) Do you tell a diabetic that normalizing his blood sugar isn't possible, so lets lower the bar, and shoot for, oh, say 75% better blood sugar? You need to google"dorsal horn damage". That you are actually out there practicing medicine is SCARY.
"Do you tell a diabetic that normalizing his blood sugar isn't possible, so lets lower the bar, and shoot for, oh, say 75% better blood sugar?"
Indeed we do.
But in the ER, 75% better blood sugar is a bit overaggressive. I'm happy with 50% most of the time.
Bad analogy, friend.
I must say.. having just stumbled upon this during a search that I'm a bit taken aback by many of the attitudes expressed here. I am probably one of those patients that you would immediately red flag, and be tempted to show to the door. Thankfully the docs in our local ER have always listened to either myself or my husband. I live with chronic pain from MS, occasionally it spikes and gets away from me.. when it gets away from me.. and I cannot get it back to manageble level I end up in ER. I know what it takes to bring it back down to level that I can use my regular pain management meds and techniques. However for me once I've "lost it" or let it get the best of me.. there is no other option. I know from experience what "cocktail" works. It's pretty simple and there is no need for a battery of testing, to look for some neurological injury, to go through a boatload of things that simply are not neded, nor to automatically assume because I can tell you as a provider what does not work and what does that I am drug seeking or expecting miracles.
I just want my pain back down to a level that will allow me to rest perhaps even sleep.
I'm sorry but I don't feel like you have a very good grasp of understanding the needs of chronic pain patients.
I'm not ordering a cocktail as you said, but rather asking for the combination that after many years of trying whatever the ER doc would hand me - an having it not work - knowing now what combinations do work.
Listen to the patient!! People who live with high levels of chronic pain generally save the ER as an absolute last resort simply because it's usually such an awful experience due to the factors and attitude expressed by many here.
For many of us who live with chronic pain and chronic disase, we are often more knowledgeable about it's management than an ER doc.. nothing against the ER docs.. but chronic disease management is not your area!
As for me.. I'm not looking for a complete relief.. but I do have to get it back to manageable level or it continues to spiral into a mess that will require hospitalization just to get me back on track.
Again blanket statements never work well in medicine. Each patient is different and again - especially with those patients living with chronic pain and a chronic disease - I suggest you listen a bit more closely to the patient.. and then form your opinion.
Oh and I do ask for meds by name and dose.. really makes me look like drug seeker eh?
When I ask for parental that means all of the oral options have failed.. not that I am looking for a rush...
and just for the record.. before I became disabled..I was a trauma nurse.
Tut tut, never mind those expensive tests....just give me my Dilaudid and Phenergan and I'll be happily on my way.
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