The Importance of Good Pain Management

Ever since my days as a Palliative care nurse I have been interested in Pain Management. I was always amazed at the high doses of narcotics the palliative patients were on, and yet they were still functioning. During my time as a palliative nurse I learnt about various ways of managing pain in conjunction with narcotics.

When I went into Critical Care nursing many of my colleagues worried about administering to much narcotic for fear of putting their patient into respiratory arrest. Through my years of nursing I have seen pain management approached in many ways. Statistically they say that most patients are under medicated, and that patients don't report pain as often as they should. This under reporting and under medicating can have long term effects.

Over my nursing career I had attended many pain management seminars and it was only the last one I attended back in February that they actually talked about alternative treatments. At this particular seminar the guest speaker was talking about treatments and measurement tools that I was using over 15 years ago in Palliative care! I have been told that palliative care was and still is years ahead of other fields when it comes to pain management.

The other day I received a patient from the O.R. who just underwent a hip replacement. This woman was only 47 years old. Very young for a hip replacement. The anaesthetist was giving me report on the patient and told me that this young woman was on extremely high doses of narcotics and other medications. When she told me the amount of narcotics this young woman used my eyes widened and my chin dropped.

Many questions entered my head. Firstly, how is it that this young woman could be on such high doses of narcotics? What was her doctor thinking? Had she tried alternative ways of dealing with her pain? What strategies were in place for this woman once she got through her surgery to help her get off these high doses?

At this point you are most probably wondering what I consider high dosage....This patient starts her day with 200mg of Oxycontin and 1200mg of Gabapentin (this was originally used to treat seizure disorders but it has been found to help on neurolgic pain as well)....then around noon she has another 100mg of Oxycontin and another 1200mg of Gabapentin.....at bedtimes she has 200mg of Oxycontin and 1200mg of Gabapentin. So in a 24 hour period she is having 500mg of Oxycontin and 3600mg of Gabapentin. In additions to this she has Oxycodone for breakthrough pain!

Now I don't know about you, but I have nursed many many patients who have had hip replacement and have not required this amount of narcotic preoperative.

Having a sister who has dealt with chronic pain issues and who has also had a hip replacement I can most certainly sympathize with this individuals pain issues. The question for me is what was the doctor thinking prescribing such high doses? More times than not nowadays doctor's are recommending to their patients that they seek out physiotherapy, water therapy, message, yoga and meditation to name a few. Why wasn't the doctor suggesting that this patient be connected with a Pain Management clinic? To just continue to increase this patients dosages seems irresponsible to me.

At this point this patient is now addicted to these pain medications. This in itself presents a very difficult position for myself as a nurse as these patient tend to be very challenging when it comes to dealing with postoperative pain. Case in point. When this surgery was performed, it was performed under a spinal with a nerve block. When the patient arrived in the recovery room she was alert and in no apparent pain. After a neurovascular check it was evident that this patient had a good spinal in place. The anaesthetist had written orders for this patient to have what we call a "Patient Controlled Analgesia". PCA is a way for patient's to control their own pain medication. The theory behind PCA's is that it is believed that it provides the patients with a feeling control over their pain management and that they actively participate in their healing process. These patient often tend to do better and are discharged home sooner. The PCA is a machine which is programed with a narcotic set to deliver a certain amount of medication at certain intervals. There is a safe guard in the machine that will only deliver the drug within the given time...so the patient can push the button as much as they want...but the machine will only give the medication when programmed to do so. Most patients find this very satisfying and in fact statistically speaking patients tend to under medicate themselves when using this device.

Back to this patient. Upon her arrival it was determined that I would give the patient her afternoon dose of Oxycontin and the Gabapentin, so it would be on board when the spinal started to wear off. I also got the PCA going early and showed her how to use it. I worked with this patient for over an hour before I was finished my shift. She was using the pump relatively frequently but did not express signs of pain. Her vital signs were all stable. The next day I asked my colleague how the patient made out. Well as it turned out the patient went into a pain crisis. The anaesthetist had to come back in and provide more spinal medications and other narcotics. Unfortunately, the narcotics all caught up with her and she stopped breathing at one point. As a result she ended up in a step down surgical unit where she could be closely monitored.

This brings me back to my original question, why wasn't this woman on some form of pain management regime prior to her surgery? Why was she allowed to be on such high doses of narcotic?

It is so important to identify patients early on who might be at risk for narcotic abuse or that might require treatment for pain management. There are many things that can be done before increasing a persons pain medications, and there are many tools available to health care practitioner to asses their patient for possible narcotic abuse.

Pain management is so important and "good" pain management benefits everyone in the long run.