My contact with pain patients was extensive during my
residency in Aurora, North Carolina, a coastal town of about 400, with a
patient population compromising of retirees, commercial fisherman and
above-ground miners from a phosphate mine. I knew from that experience that
even if I never found a job as an NP, I would not choose to do pain management.
Of course, pain management is an invaluable specialty, but in its practice a
few bad apples spoil the whole cart. So much unproductive time is necessary with
these patients, who are tangential by necessity (talking around what they
really want) and, well, manipulative (getting me to give them what they want).
Since I started my job as a new NP at the health department,
I've had many "establishing care" patients whose chief complaint is "pain." The
usual outcome of such visits is that what I can offer for pain syndromes -
NSAIDs, muscle relaxants, tramadol, and/or gabepentin if there is a nerve
component - are inefficacious. When questioned what had helped in the past, the
answer would be one of the opiates. In many instances, all the non-narcotic
pain medications are listed among "allergies/intolerances."
The saving grace at moments like this is to inform these
patients of the "No Narcotics" policy instituted by an MD who was three
providers before me in the last 2 years. It's probably obvious in the small
community that I serve -- word gets out that there's a new provider in town who
may not have heard their stories before. They have no way of knowing, of course,
that the state's substance reporting system contains information on every
controlled substance prescribed for and filled by a patient with a mere entry
of a name and date of birth. We also request prior medical records from one of
the 5 primary care providers in the district and oftentimes these same patients
have been fired from their practices for abusing pain medications.
For those with insurance, a local surgeon whose practice is
a bit slow offered to take on my pain patients, although even he has stopped his open door policy and
will now review a patient's chart, and even conduct a personal interview,
before he will take one on. He has turned down three of my referrals in the
last 2 weeks. He has obviously discovered that even with a pay source it's not
Despite it all, during these "establishing care" visits, I
do manage to divert their attention long enough to discuss preventative care,
and the free programs and discounted labs offered by the health department. Surprisingly,
many of these patients, both male and female (males predominate), have remained
with me for their primary care. In fact, my nurses tell me that I see many more
male patients than any of the previous providers had seen.
If I'm sounding a bit cynical I don't mean to be. It'll be 1
year into my job and I still wake up every morning feeling that I'm the
luckiest girl in the world. I do feel "old before my time" in terms of my
NP-hood, but in a very good way!