By Melanie Prince, MSN, BSN, NE-BC, CCM, FAAN, FCM

Do you experience occasional pain? Or pain daily? Sudden pain following an acute injury? Have you had a dental procedure or surgery that resulted in pain for several days or weeks? If you have recently sought medical care for pain, what has been the treatment? I have shared the pain experiences of family members, friends and neighbors over the past year, and wondered if we may have overcorrected in the use of controlled medications to manage acute pain. Here are a few, abbreviated anecdotes of personal pain experiences.

Friend: Double mastectomy discharged home with surgical drains. Discharge instructions: “purchase acetaminophen over the counter (OTC) and if the pain gets too bad, go to the emergency room because we cannot give you a prescription for something stronger.”

Family Member: Elderly man fractured orbital bone, wrist and femur from a fall. He also has chronic arthritis. The pain experience included severe, debilitating acute and chronic pain. The emergency department provider administered ketorolac tromethamine (Toradol) and the discharge notes were similar to the previous example. “Purchase OTC acetaminophen and if the pain gets worse, return to the emergency department.”

Neighbor: Injured ankle during an aerobics dance class. Hours later, lost her balance due to the pain, and fell down a short flight of stairs. What may have been a sprained ankle originally, was now a fracture in the ankle and foot. Orthopedic surgery two days later and discharged home with ibuprofen 400 mg as needed. She was in tears with inadequate pain relief.

In these examples, no one was able to articulate the “pain management plan.” There was no discussion about optimal use of ibuprofen or acetaminophen, ice/cold therapy, elevation of injured area, mind-body relaxation techniques, safe transfers, etc. However, each person was able to recite “why stronger medicines could not be prescribed due to the opioid epidemic.” Are controlled medications off the outpatient formulary in the midst of today’s opioid public health crisis, even when appropriate for acute pain management?

I contacted two colleagues, who are surgeons, to inquire about their current views on prescribing controlled medications for outpatient pain management. Both colleagues spontaneously sighed deeply and described regulations, electronic health record constraints, monitoring and oversight policies, “extra administrative record reviews” to determine previous patient behavioral patterns and difficulty coordinating provider-pharmacy-payer pre-authorizations for “specialty medication.” Kiang, et. al. (2020) studied opioid prescribing patterns among U.S. medical providers and noted “from 1999 to 2010, opioid prescribing in the US quadrupled reaching a per capita level well beyond that of any other nation.” This is concerning. There is no denying we are losing individuals to opioid addictions and families are significantly impacted by the epidemic. There is evidence to support that over-prescription of narcotics is contributing to the current opioid addiction crisis. In the context of this crisis, what pain management strategies are available for patients in the outpatient setting, in the absence of controlled medications? Is the answer to not prescribe narcotics for acute, severe pain? Kiang, et.al. (2020) described strategies for pain management interventions that reduce inappropriate prescribing of narcotics. But the researchers also noted these same strategies result in misapplication and unintended consequences, leading to poor patient care, for an issue that is nuanced and complex. (Kiang, 2020). How can stronger, non-addicting pain medication become a viable alternative for patients experiencing severe, sometimes incapacitating pain.

I recall nursing school clinicals in 1989, where instructors emphasized pain assessment as weighted heavier on the subjective “words of the patient.” Pain assessment was documented as the patient’s stated response to their individual pain experience. A quick scan of nursing research literature during the late 1980s identified current pain theories explaining pain as a physical, psychological and social experience (Gedaly-Duff, 1988). Fast forward to 2020’s…is the social experience of pain management outweighing the physical and psychological manifestation of the total patient experience? Should the healthcare system reset outpatient pain management in the broader context of social determinants of health? Applied research is warranted in this area.

Questions about current pain management culture are relevant for case managers. Recall my three patient stories. There were themes of repeat and potentially unnecessary utilization of emergency departments, excessive use of the primary care system, potentially avoidable re-hospitalizations from secondary complications related to uncontrolled pain, delayed healing or re-injury. These themes reflect patient outcomes case managers target for improvement. As advocates for our patients/clients, we must probe deeply into our institution’s culture, beliefs and policies around pain management to facilitate appropriate and comprehensive strategies. The use of controlled medications may be restricted, controversial, uncertain, or stigmatized, but we must have the courage to break down barriers to care and facilitate patient-centered interventions.

Disclaimer
The personal stories are not intended as a generalization of all outpatient, primary care or emergency department patient experiences. The author’s opinion is not one of judgement around the topic of opioid misuse or addiction; but rather the lived experiences of some patients who are under-treated for acute pain management.

For more on this topic, download the CMSA Opioid Use Disorder Case Management Guide: https://cmsapmg.wpenginepowered.com/opioid-use-disorder-case-management-guide/

This guide will assist case managers and other healthcare professionals in the assessment, care planning process, and intervention development to address opioid use disorder. FREE to members!

Bio: Melanie A. Prince, is the Immediate Past President of Case Management Society of America (CMSA), 2020 - 2022. She is a retired Active-Duty Military Colonel who was assigned to Headquarters Air Force where she was responsible for developing strategies to eliminate interpersonal violence in the military. Melanie is now the Chief Executive Officer, Care Associates Consulting and MAPyourWAY, LLC. A distinguished leader and mentor in her profession, she has won numerous awards including the distinguished CMSA Chapter, 2003 and National Case Manager of the Year, 2004. Melanie is a CMSA Case Management Fellow (FCM) and Fellow, American Academy of Nursing (FAAN).

References

Gedaly-Duff V. (1988). Pain theories and their relevance to nursing practices. The Nurse Practitioner,13(10), pp. 66–68.

Kiang, M., Humphreys, K., Cullen, M. & Basu, S. (2020). Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study. BMJ, Issue 368:16968. doi: https://doi.org/10.1136/bmj.l6968