Pain Management: Painful or Painless?
Thursday, March 4th, 2010I don’t know how you feel about pain management, both acute and chronic, but articles like the recent one in Annals of Internal Medicine(“Opioid Prescriptions for Chronic Pain and Overdose” 1/19/2010, vol 152, #2, pp88) don’t make it even easer.
Basically the article said that 3% of adults are on long term opioids, and that the older the patient and the higher the dose, the higher the risk of overdose. Add benzos in to the mix, and the risk goes up even higher. Additionally, the highest chance of accidental over dose is upon initiation of the drug. The situations that I think are potentially dangerous are the times you have a Little Old Lady right out of surgery, on her valium for sleep (“I’ve been on it for years, Sweetie!”) who now needs narcotics for her hip replacement. And yup, the orthopods want you, trusty hospitalist, to manage her pain!
I hate PCAs. I really hate PCAs and Little Old Ladies. (I don’t however, hate Little Old Ladies!) So whenever possible, I nix the PCAs and try to convert patients on to oxycodone (no acetaminophen–I like to dose that separately), and occasionally on to ms contin with oxycodone for breakthrough. The only issue I have with this is that nursing staff can get really busy and not get the oral analgesic to the LOL on time, and the pain level sky rockets, and LOL ends up with a shot of morphine or dilaudid.
So what to do? Anyone know of slick tricks around this so that the Little Old Lady has her pain managed with oral medications delivered on time? (By the way, is not a rap on the hands of nursing–I just want to be realistic!) Let me know how you manage pain in this vulnerable population!