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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pain control

Tuesday, November 18, 2014

Interesting events were happening even before  one NFL game was played this weekend. Team physicians were visited by Drug Enforcement Administration investigators to see what narcotics and other restricted medications might be in their possession as they travelled along with their players to away games. The DEA actions might be part of an investigation triggered by a player class action lawsuit that alleged indiscriminate pain medication distribution by doctors, trainers and coaches, in an attempt to return injured players to the game.

It is not illegal for physicians to prescribe and also dispense narcotic medications, but there are stringent rules, regulations and paperwork that needs to be followed. Most often, physicians prescribe drugs and pharmacists dispense them. There is a check and balance in place to help patients understand dosing, side effects and potential medication interactions. For narcotic prescriptions there are more legal layers in place. A physician not only needs a medical license, but also a DEA certificate (and in some states like Texas, a state controlled substance license). There is a whole other set of regulations in place and documentation required if a doctor decides to dispense narcotic pain pills. This is where NFL team doctors may run afoul of the law. DEA certificates are assigned to a specific location, so a team doctor in Seattle cannot use the same DEA number in Miami. Narcotics for commercial use cannot usually be transported across state lines and there needs to be a medical record that notes the diagnosis and rationale for prescribing pain pills. Then comes the dispensing issue, with documentation matching inventory and prescriptions, and medication lot numbers and expiry dates in case a medication recall should occur.

That physicians sometimes inappropriately prescribed pain pills is not the real story. It all has to do with the expectation of patients and family when it comes to pain control. Perhaps one of the most influential changes in the practice of medicine occurred when pain was promoted as the fifth vital sign. But where blood pressure, pulse, respiration rate and temperature can be objectively measured, pain is very subjective. When zero became no pain and ten, the worst one could imagine, patients were expected to decide their own vital sign and expectations of pain control slowly changed. There are hospital quality indicators that ask nurses to assess pain status, regardless of whether the patient visit is associated with an injury or illness. Patient satisfaction scores often ask the patient to rate how well their pain was managed and this has led to perhaps to a societal expectation of a pain free experience.

The NFL experience proves different. Collisions on the field yield bumps and bruises, broken bones and torn ligaments and yet players want to play as soon as possible. Their coaches and general managers also want them back on the field. Pain medications, whether it is an injection of Toradol (an anti-inflammatory) or a couple of Vicodin pills (hydrocodone-acetaminophen combination) will mask the pain but not necessarily help recover from an injury. Yet playing is important. The average NFL player’s career lasts less than 100 games and there is always another player to take an injured player’s spot on the roster. Playing in pain is expected.

The real world is different. Most pain cannot be completely resolved but can be controlled. Patients should not suffer but the expectation of zero on a pain scale is unrealistic. Patients with new onset abdominal pain or broken bones can have their pain controlled so that they don’t suffer, but pain free may not be possible. Too often it is difficult for the patient, nurse and care provider to understand each other’s perception of pain. While a patient may be suffering significantly and coping by talking on their cell phone, the provider may see that patient chatting away and presume that the pain is not intense. Or vice versa. A patient who is trembling and sweating on the gurney may not see their pain as severe enough to need help.

Unfortunately, there are less than scrupulous physicians and less than scrupulous patients. Some doctors can’t say no to a patient who asks for narcotics and some patients either abuse or divert their narcotic prescription. Aside from DEA regulations, states have set up websites that allow physicians and pharmacists to monitor the number of narcotic prescriptions and the number of pills that have been dispensed to a patient. And for those who decide to divert their narcotics, there is a healthy incentive to sell their medications on the street. Oxycontin (a long acting pain medication) can sell for $1 per milligram. A prescription of 40 mg tablets taken twice a day for a month works out to a street value of about $2,500.

Somewhere between “a little pain never hurt anyone” and “there is no trophy for hurting” lies the reality of medical care. Trying to measure pain is difficult since it is different for every patient. In the NFL, pain is better when the player can return to the game but that level of pain may not be tolerable for a frail patient with cancer or a broken hip. In the end, doctors and patients have to talk to each other, manage expectations and goals. Somehow that does not translate well to a zero to ten pain scale and deciding appropriateness of care based on something that is so subjective seems unfair to both patient and physician.

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