The patient’s pain started on an otherwise normal day—another day of hard work as a certified nurse assistant who frequently did more physically demanding work than she should. She awoke with excruciating pain in her back. When she called her family physician, she was told that she didn’t need to be seen, that she just needed to rest and use NSAIDs for a day or so.
Fast forward a few years. The patient, still in the same job, injures her back again, overexerting herself at work. This time, the pain doesn’t go away. The patient is seen by multiple physicians, none of whom alleviate the pain to the patient’s satisfaction, despite ever-increasing doses of opioids.
Does this patient seem familiar to you? She represents your patient in the emergency room, who hears the nurse say quietly, “There’s another drug seeker in bed two.” Or, he is the patient in the exam room who digs in his heels and insists that he has to take multiple doses of Vicodin just to get through the day. Or, she is the customer in the pharmacy being lectured about the dangers of addiction to narcotics. Treating the patient with chronic pain can be difficult, frustrating, and even dangerous—not only to the patient, but also to you.
Facts and Figures
Twenty percent of the general population is significantly affected by chronic nonmalignant pain (CNMP).1 According to Doris K. Cope, MD, a member of the American Society of Anesthesiologists’ Committee on Pain Medicine, the most common types of chronic pain include headaches, back pain, and joint pain.2
Patients want relief from pain while physicians are often concerned about longer-term issues concerning opioid abuse. Patients with untreated pain may feel that the physicians they consult are unfeeling, paternalistic, judgmental gatekeepers, while physicians must be alert to patients with a high potential for substance addiction. In addition, physicians deal with feedback from pharmacists about over-prescribing, pressure from reimbursement channels to hold down costs, bad experiences with other opioid patients, and the knowledge that some of their colleagues have been punished by state medical boards and even indicted for prescribing opiates.
Opioid Use Is Skyrocketing
In the past 10 years in the U.S., prescriptions for hydrocodone and Oxycontin have increased by approximately 300 percent, while the number of opioid-related deaths has increased fourfold. There are tragic reports of iatrogenic inpatient opioid-related deaths from opioid analgesics. Opioids are now number one on the list of drugs implicated in medical malpractice litigation.3
Physicians who treat acute and chronic pain need to be comfortable and secure in their competency. Physicians need to be cognizant of correct dosing guidelines, which may have dramatically changed in the past decade. For example, current dosing recommendations for Dilaudid are much lower than previous recommendations. Before prescribing opioids, physicians need to obtain a patient’s history of any substance and alcohol abuse, his or her psychiatric history for anxiety or depression, and any comorbidities, such as obstructive sleep apnea.
In response to the dramatic increase in opioid use and the fallout complications, the U.S. Food and Drug Administration (FDA), state medical boards, and professional associations are developing regulations and guidelines for the safe and effective use of opioids. Here are a few examples:
We need to adequately treat acute and chronic noncancer pain, protect patients from the unintended consequences of opioids, and ensure patient compliance. Because narcotic prescriptions are aggressively monitored by multiple agencies, physicians may worry that prescribing narcotics can cost them their license.
The Medical Board of California, which provides guidelines for prescribing controlled substances for pain, assures California physicians and surgeons that they need not fear disciplinary or other actions for merely prescribing opioids in the course of treatment of a person for intractable pain. The appropriate use of opioids has been recognized in the California Intractable Pain Treatment Act (Section 2241.5[c] of the California Business and Professions Code). The board expects physicians and surgeons to follow the standard of care in managing pain patients.6
By Susan Shepard, MSN, RN, Director, Patient Safety Education. Updated by Howard Marcus, MD, FACP, Chair, Texas Alliance for Patient Access, and Chairman, The Doctors Company Texas Physician Advisory Board.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.