Pain Management in Five Easy Pieces

Awesome piece. But, as usual...As we all probably know, the current trend in healthcare is all about customer service. That makes questions like "what is your comfort level with pain?" impossible to ask, alternatives such ad NSAIDs not available, and many nursing techniques such as teaching meditation, guided relaxation, feedback, guided imaginary, etc. not usable as they all work much slower than hydromorphone IV and thus potentially produce low Press Ganey scores. Adding to that, the techniques above are much less useful for patients with opioid-induced pain, and in my place we have close to 100% of such patients. Teaching pain relieving non-pharm techniques takes a lot of time, which ordinary floor nurse never has. Using these techniques requires significant effort from the patient, as he has to overcome his fears, the knowledge of the fact that easy help is available, and almost inevitable failure of the first attempts. From the population I work with (chronically critically sick patients), about half of those who are able to communicate express fears of dependency from opioids and want to "try something else" if they are directly asked about it. That happens at the point when these people already spent 2 or 3 weeks in acute care where they got their pills and shots after their first whim. After being taught "pain 101" ( gate theory of pain, pain perception, guided relaxation, sometimes "warm/cold" technique for diagnosed neuropatic pain, meditation) over 2 or 3 days, approximately half of them attempts using these techniques. Of the above, half (so, about 25%) comes to some sort of success in terms of not being "on the clock" callers and tolerating PT/OT without getting stoned beforehead. The rest says "I will think about this, and I want something for my pain right now, gimme my good shot".In addition, the only one pain clinic which practices holistic-oriented pain management for the whole state is not taking any insurance at all. One (and working) course of treatment there for FBM (acupuncture, massage, wraps, hot/cold, diet consult, sleep consult, etc.) is around $5000 paid out of pocket.

I work in ortho where pain is usually issue #1. we have many pts. that have chronic pain issues and are used to taking more than what is usually prescribed/ordered. We also have a Pain Team to help us. I really do not think it should be a huge issue about drug seeking. The short time people are in the hospital is not going to make or break them. We sometimes have to go through bags if we suspect some is double dipping (rare) but in the end we have to address the real pain they have and NOT have them going into withdrawl while under our care. I have had pts come in that have been taking 90 mg of oxycontin TID and 20-40 (or more!) of oxycodone. Then add a traumatic fx to the mix. We have started (about a year now) using ketamine, which os supposed to reset pain receptors. We may also start using lidocaine drips for the hard to manage. We have to believe that their pain is what they say it is. If I feel differently, I speak to docs and they make those decisions.

One of my best way to distract people in pain when transferring them is breathing. People forget to breathe when they are in pain thus all the mind focuses on is the pain. My patients would say, I don't feel as much in pain when I breathe more as I am moving. It is a hard habit to learn though so I educate the everyday , every shift so they can learn it.

I think I have it easy.....I work out patient surgery.....patients are only there one to two house and go home. They are on continuous pulse ox and B/P monitoring. Our pain medications are on a check box standard orders form anesthesia fills out. Anesthesia is in the clinic all day so any issues, concerns, are immediately addressed by them.So it is easy for me to say I am comfortable with patients pain and medicating them......I am certain I would not be so nonchalant if I worked a busy med/surg floor!