narcotics role is changing

Monday, August 29, 2016

Football is a violent sport and with it comes injury and that begets pain. Some injuries are self-evident, like the tibia and fibula fracture sustained by Chicago Bears quarterback, Connor Shaw. His leg was splinted and he was carted off the field in obvious pain. Other injuries take some time to sort out, like the Cowboys’ Tony Romo, who failed to talk his way into playing in the same game and was later found to have a compression fracture of his lumbar spine. Both injuries hurt and both players will likely be prescribed narcotic pain medication in the first few days of recovery. NFL players have been known to take a variety of legal and illicit medications to allow them to play through the pain each weekend, but that mindset does not translate well into the real world off the playing field.

The Fifth Vital Sign

Not too long ago, pain was added to the medical mind frame as the fifth vital sign. It followed blood pressure, pulse respiratory rate and temperature. Regardless of the reason for the doctor’s visit, patients were often asked whether they were having pain and their assessment, often on a scale of zero to ten. Kids had the smiley/ frowny face pain scale option. Pain is not normal and medicine is all about keeping vital signs in their normal range. Patients didn’t want to hurt and it was easy for a doctor to write a prescription for narcotics.

Doctors like to make their patients feel better but there was another benefit to writing the prescription. Patient satisfaction scores for doctor performance might have been tied to giving patients what they want. Who knew that excessive narcotic prescribing habits might lead to an increase in drug dependence, addiction and become a gateway to the increase abuse of heroin and other illegal street drugs.

The pendulum is beginning to swing back and patients might take a while to understand that a pain-free life may not be available through the use of narcotics. They may not like the doctor who says no to their request and those negative feelings are being expressed by examples of falling patient satisfaction scores.

Wisconsin Prescribing Guidelines

The Wisconsin Medical Examining Board, the governing agency that licenses doctors in the state) has published guidelines about prescribing narcotics, including when to use them what drug to prescribe, how many pills and the expectation to look for patients who exhibit drug seeking behavior. Doctors in the state need to listen and act according. Without a medical license, their career has effectively ended. Just a few of the highlights:

  • It is difficult to know how much a patient hurts. Find out why there is pain and treat the underlying cause. Use non-opioid (non-narcotic) medicines like acetaminophen, ibuprofen or naproxen.
  • If prescribing narcotics, use the lowest dose and fewest number of pills. Most patients will need less than three days of treatment and rarely more than five.
  • There is little evidence that narcotics should be used to treat chronic pain.
  • “Physicians should avoid using intravenous or intramuscular opioid injections for patients with exacerbations of chronic non-cancer pain in the emergency department or urgent care setting.
  • Physicians are encouraged to check Wisconsin Prescription Drug Monitoring Program website to see whether the patient is already receiving narcotics from other doctors. This becomes law in April, 2017 before prescribing any controlled substance for greater than a three-day supply.
  • “The use of oxycodone is discouraged.”

Patient Satisfaction

Patients may not be satisfied with the result of their doctor visit if expectations for pain control are not met. This might be especially true for chronic pain patients who have come to rely on narcotics for their symptom control. It may take time to consider treatment alternatives and still meet the needs and demands of the patient.

The New York Times reported on the experience at Marion (Indiana) General Hospital. Over the course of 18 months, emergency physicians decreased their narcotic prescribing by 50%. Patients weren’t happy and ER satisfaction scores fell from the 58th percentile (of 1100 similar hospitals) to the 14th. Does that mean that the doctors practiced bad medicine or did it mean that there was a disconnect between what the patient wanted and what they received. The words of Mick Jagger and Keith Richards might have been ahead of their time describing this phenomenon.

You can’t always get what you want…you get what you need.

 

 

 

 

 

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