Imagine this scenario: you get a patient transferred from the surgery service. You glance at her home meds and with a flash of dismay, see 60 mg oxycontin BID with 10 mg oxycodone q4h PRN pain for chronic back pain. She just had hip surgery. What do you prescribe for breakthrough pain?
Or this: you are caring for a patient admitted for aspiration pneumonia. Although his breathing seems fine, he complains about the uncomfortable bed and requests something for pain. His social history notes that he currently buys Percs on the street and has used cocaine in the past. Initial doses of 5 mg oxycodone don’t seem to work, and he demands more and more. The nurses grumble about his neediness. What do you do?
I am, despite my bitterness and tough talk, an idealist and softie. I mean, I want to spend my professional life figuring out chronic abdominal pain and treating patients with malabsorption, dysmotility, and postsurgical anatomy. But in my daily practice, I have several fears when prescribing narcotics for inpatients:
- I’m feeding into an addiction. Giving them pain meds will make them worse off in the long run.
- They are taking advantage of me. They are lying to me or being nice to my face but laughing behind my back.
- When they realize they can get whatever they want, they’ll invent more excuses to stay.
Acknowledge these fears. Then let go.
What I’ve come to realize is that despite the patients who burn you, pain is real. Pain may stem from many different sources (deconditioning from being morbidly obese, psychiatric disease, dyspnea, social chaos, nerves that are wired differently and a low pain threshold). We may make us think, c’mon, there is NO way you are actually in that much pain…but they do need SOMETHING treated. Often people just don’t have enough insight to tell you exactly what that is. So your first formulation should be: is this actually pain? Is it anxiety? Is it fear at having to return to an abusive partner? Is it poor coping skills/functional status/dementia? Pain meds are not the only answer.
A final point: in those patients who want to be hooked on pain meds, make up stories, and manipulate the system, isn’t it sad that they would waste their lives trying to get addicted? A patient like this probably needs psychiatric help.
But sometimes you do need pain meds for people with complex pain histories. For instance, like patient #1 above, post-surgical patients have a really real reason to have pain: they just had freaking surgery! Many of your patients may have DEPENDENCE but not be ADDICTED. If you have a patient who is already on oxycodone, like #1 above, it’s a no-brainer they’ll require more than 2.5 mg oxycodone q6h.
NB: You should always make sure the whole team, including nurses, psychiatrists, pain specialists, etc are on the same page about an individual’s regimen. Here are some strategies I’ve seen used successfully:
- Build trust with your patient and taper down gently. When you acknowledge the validity of your patient’s story and show that you care about them as a person, they are much more willing to listen to your suggestions–like, “how about we not do the extra IV dilaudid because I think you’re ready to try the pills? I really want to see you make progress.” In my experience this really separates the people in real pain from the people who have secondary gain.
- Make sure you have a good non-narcotic foundation. Put people on standing Tylenol. Use flexeril if they specifically have spasms. Use lidocaine cream over painful joints. You wouldn’t believe how much relief a heat pack can give.
- Use the appropriate meds for pain-like symptoms: benzodiazepines for anxiety, low-dose antipsychotics for agitation or insomnia, etc.
- Start the patient on standing pain medications q3-4h instead of PRNs. Relying solely on PRNs is like putting a diabetic only on sliding scale insulin. If they ask for more, increase by 25% at a time until they are satisfied.
- If one opiate isn’t working, try another. For some reason, different people respond differently to oxycodone or dilaudid or morphine…cross-tolerance is variable, but you can try using an equi-analgesic conversion.
- I’ve seen methadone work well. It has a 4-8 hr half-life for analgesia (and 24-48 for withdrawal suppression). However it can take several days to titrate and you need to guarantee outpatient followup. If someone comes in already on methadone, you can give them extra narcotics if necessary but you must communicate any changes with their methadone clinic, otherwise, no dice.
- I would not be so bold as to give known opioid abusers a PCA, but some people have found it works well.
- Consider a social work consult (especially if you have a patient like #2 above) and offer substance abuse counseling or detox. If you know they’re going to snort or shoot up when they leave, consider writing a suboxone prescription.
References: a concise article from Anaesthesia
The school of hard knocks