Over the past several weeks I have emphasized in-hospital pain control. Regularly I find patients with "legitimate" pain who complain about their pain control. The resident's default order for many years is (pick your opioid) q 3 or 4 hours p.r.n.
My palliative care colleagues have stressed that we should schedule pain control rather than provide "as needed" in those circumstances when patients will clearly have ongoing pain. They taught me to write orders as scheduled with a may refuse provision. More recently I have added a "do not awaken" clause from a couple of bad experiences.
When the patient really has pain, do not make them hit the button and wait for someone to bring them their pain medication. What would you want for your pain control?
{ 4 comments… read them below or add one }
Of course, we should control pain well. There is another phenomenon I’ve observed in the past several years. We are giving too much pain medication. When I was in training 20 yrs ago, we gave narcotics for severe pain – heart attacks, kidney stones, etc. Now, patients on every ward are getting dilaudid every 3 hrs for abd pain. I presume that other physicians are having the same experience. This puts the patients at risk of a 2nd disease, narcotic dependence and addiction. It also has created the expectation of narcotics when they are readmitted with similar symptoms. We don’t want too little pain medicines or too much either. http://www.MDWhistleblower.blogspot.com
Maybe becaue DB doesn’t work in outpatient medicine anymore (and doesn’t get the patient coming in for refills and expectations of ongoing use of opiods) his perspective is we’re undertreating pain.
My take tends to line up more with Dr. Kirsch’s.
That being said, I’m sure we can all agree that using opiods optimally (or other appropriate pain meds) in the acute setting is an important skill. Problems often occur, however, when the acute pain doesn’t have an easy solution, and becomes a subacute or chronic condition. Often, due to time constraints (or an unwillingness to get involved in what is often a complicated situation) the inpatient doc simply turns the dilaudid faucet on. (A short term patch that can complicate things further and increase the chance of addiction for the patient. )
As the saying goes, where you stand depends on where you sit. As an oncologist who dabbles in hospice and palliative care, I’m with Dr. Centor on this. But then again, whatever secondary gain my patients may have, all of them have bona fide malignant causes for their pain – my practice demographic doesn’t include people with chronic low back pain or fibromyalgia.
I agree with david / Dr Bob on this. Initially I attempt to estimate the pain level postoperatively, and I err on the low side, so that PRN can top it up to an adequate level. Every day, though, I look at the previous day’s total opioid use, and attempt to provide it on the next day as 2/3 regular, 1/3 PRN. This way if the patient’s pain gets a lot better, they only get their regular opioid and I can automatically wean them. If the pain is getting worse I can see this and increase the baseline.
I also have a rule of no acetaminophen, no opioids.