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New Grad NP

Pain Patients

Published September 6, 2012 1:29 PM by Elizabeth Huston

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 easy money.

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!

3 comments

As a new grad nurse practitioner, prescribing pain medications can be a daunting task.  I think Elizabeth's first paragraph captures these feelings well.  I don't believe Elizabeth is narrow minded.  Rather, I see her as expressing the complexity of being a new NP and making prescribing decisions for patients.

As RNs, we are taught to always believe our patients' pain levels (Joint Commission).  Yet let's be honest.  Haven't we all, as bedside nurses, cared for patients who requested high levels of pain medications for situations that typically resulted in low levels of pain?  Sometimes, I have felt that this view of "always believing" is too simplistic of a view given the reality of drug addiction in this country.

In my undergraduate program, I was taught that at least 10% of the populations has addiction issues.  With prescription medications being the most used addiction drug in US.

With prescribing comes the responsibility to make decisions about your patient's "subjective" comments regarding pain. Especially when the "objective" physical examination yields nothing to support the "subjective" comments.   I do think that NPs have a responsibility to work with patients to reduce the harm that addictive medications can cause.  Working with patients to set realistic non-judgmental action plans are important.  

I too am very glad that the clinic where I am employed has set strict prescribing policies to pain medications.  We don't prescribe any opiates to first time patients.  We also refer these individuals to behavioral health/counseling.  This policy has helped me so much as a new grad NP.  

I appreciated this post.  

Brenda September 8, 2012 3:48 PM

Adrianne,

We just completed a patient satisfaction survey and to a one, none of my patients would agree with your instant assessment of me, nor my mentors, preceptors, classmates, colleagues. I took the risk of incurring ire from those who suffer from chronic pain, and I have many patients who do. My frustration comes from the small segment of my practice, as evidenced by them being fired from other local practices for abusing pain meds, and those not being taken on by the surgeon who volunteered to dose narcotics because it is the dictum of my consulting physician (required in NC) that I do not.

By no means did I paint a diverse group with a broad brush; on the other hand, no one group comprise only of angels.

You don't know me. Suffice it to say, there are much more civil ways to disagree.

Elizabeth

Elizabeth Huston September 6, 2012 7:37 PM

Wow.  Your opening paragraph sets the tone for how narrow-minded you are.  How can you group all patients with chronic pain into 1 negative stereotype?

As a registered nurse in the home care and insurance fields for 20 years I certainly ran across people who were not the easiest to treat, but would never think of referring to all my Medicaid, or Medicare, or diabetics, or COPD patients as manipulative or anything else.  And, I highly take offense of you referring to all people with chronic pain that way.

I experience chronic, intractable pain and have for the past 5 years.  Thankfully, I have caring healthcare providers who are more than willing to work with me in finding treatments/therapies that work best for me.  Yes, my pain management physician does at times spend more time with me than he would with a "regular" patient.  But, he's willing to do that because he cares!

Do you not think the majority of us have tried many, many different therapies before we reluctantly agree to opiate analgesics?  True people with chronic pain wish and pray for other modalities to work and when they find the few that work, they use them as well as medications.

I can say with confidence that I pity the poor people who end up having you as a healthcare provider.  If you can be so insensitive to the needs of 1 group of people, you certainly will be insensitive to the needs of others.

Adrianne

Adrianne September 6, 2012 6:56 PM
Concord CA

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