© 2009 The Medical-Legal News
By Margaret Wacker, RN, PhD
It is estimated that 60 million people in the U.S. live with significant chronic pain. Despite the wide array of treatment modalities and number of pharmacologic agents available, their pain is often under-treated. As a nurse consultant I often am consulted to review pain management issues. Under-treatment continues to be a common problem. However, poor treatment is just as common.
Inadequate treatment of pain contributes to a wide range of negative outcomes. It depresses the immune system, alters glucose levels, stresses the cardiovascular system, contributes to poor oxygenation, reduces cognitive function and creates anxiety, depression and insomnia. In addition, pain threshold is lowered, which affects all future experience of pain. This is particularly problematic when patients have long periods of recovery and additional procedures that need to be done.
Effective control of pain requires individualizing the regimen according to the type of pain being treated and the patient’s medical condition.
It is essential to titrate the dose of the appropriate drug or drugs to achieve the desired effect. This dampens the pain sensitizing neurochemicals that are produced when tissue damage occurs. In addition, it prevents “wind-up.” Wind-up is the progressive increase in the discharge of dorsal horn neurons as a result of repeated, prolonged noxious stimuli. The resulting hyperexcitability and hypersensitivity lead to pain states in which stimuli that are normally innocuous produce pain.
Effective initial treatment of pain accelerates recovery time. When pain is not well controlled the patient experiences pain way beyond what is expected for the particular trauma or procedure and is placed at risk for more complex pain syndromes.
Look for pain documentation
In reviewing charts I am especially alert to physician and nursing notations about pain. The patient may report having experienced a great deal of pain but the notes make little reference to it. Oftentimes the prescribed pharmacologic agent may not have been appropriate. The selection of agent requires careful review of the patient’s history, laboratory results, kind of pain, allergy history and medical condition. Without this review it is likely that treatment will not be optimal. When I discover problems with the pain management intervention, I let my attorney-client know what areas to target during the discovery process. Answers to interrogatories help to locate serious deficits that can be more fully explored at deposition.
Attorneys frequently have clients experiencing significant pain long after a medical event or accident. Many of these people are labeled by their healthcare providers or case managers as maintaining pain symptoms purely for secondary gain. In my experience the incidence of secondary-gain seeking involves a very small percentage of cases.
If pain is managed appropriately at the outset, deceptive symptom maintenance is rarely an issue. Patients return to their usual pre-event level of functioning more quickly and are more realistic about their legal outcomes. When pain persists beyond what is usually expected, a comprehensive review of the record and reassessment of the patient is essential.
Providers may make pain worse
One of the areas I find problematic is the failure of physicians to refer patients to pain specialists when the patients are unable to manage their pain.
Unusual pain syndromes such as Complex Regional Pain Syndrome are often missed. This delay in diagnosis can have a very negative effect on outcome. These patients experience unrelenting pain accompanied by a lack of tolerance for physical activity. They often present in emergency departments and are labeled as “drug seeking” since the origin of their pain is not well understood. By the time the diagnosis is made, significant impairment of function has already occurred.
Failure to prescribe an appropriate pharmacologic agent is another area of concern. Prescribing regular doses of second-line agents such as meperidine for any patient and especially those with renal failure is inexcusable. The neurotoxic effect of the metabolite produces irritability and convulsions. In one case I am familiar with the patient convulsed due to his postoperative pain management with meperidine. He lived in a state where patients with histories of convulsions have driving restrictions. He has filed a suit against the surgeon and the hospital since he was unable to drive to work.
The drugs used for pain, and common problems
Most of the more common narcotics prescribed activate the mu receptors which produce the analgesia. I was consulted to assess a situation where the physician was convinced that the patient was a drug-seeking addict. The patient had a compound fracture of his leg and was complaining of severe pain. The physician had given him an inadequate dose of percocet. The patient continued to complain. The physician wrote in the chart that he was now very convinced the patient was an addict since he had added tramadol to his percocet. He reported that the patient complained that the tramadol did not help and now he felt like he was getting no pain relief. In this case the patient was correct. Tramadol is an unusual medication. It is never supposed to be given to anyone receiving a narcotic since it removes all narcotic from the mu receptors.
Some of the more serious life-threatening incidents have occurred when fentanyl was improperly prescribed in a patch formulation. Fentanyl is about 75 times more powerful than morphine. The patch is available in 25, 50 and 100 microgram doses. It is unique. It is not like a nicotine or estrogen patch. On the first application the special delivery system requires about 8-10 hours to etch a storage depot into the subcutaneous skin. It then releases the fentanyl at the dose prescribed every hour for 72 hours. Subsequent applications do not have the analgesic lag time since there is sufficient fentanyl available in the system to manage pain until the next patch releases. Failure to know how this system works and the length of time over which the narcotic is released into the circulatory system have been responsible for many respiratory arrests. Reversal requires transfer to the ICU and the institution of a naloxone drip since the half-life of naloxone is 45-60 minutes — which is much shorter than the duration of the fentanyl slow release system.
Case on point
The following recently closed case involved a fatal outcome involving misuse of a fentanyl patch in an elderly patient in a long-term care facility. It illustrates the importance of understanding the distinctive features of this long-acting delivery system.
An 80-year-old high-functioning woman was discharged from a hospital to long-term care (LTC) for rehabilitation following a hip repair. Pain was moderately managed during her hospitalization with morphine sulfate. On the day of discharge a 25 mcg fentanyl patch was applied.
On arrival at the LTC facility the nurse noted an order for the fentanyl patch, ordered it from the pharmacy and applied it. The patient continued to complain of pain. On the second day the LTC facility physician prescribed another 25 mcg patch.
This patient was opioid naïve prior to her hospitalization. Although the morphine doses were inadequate to manage her pain, the choice of a long-acting fentanyl patch was not optimal. The Physicians Desk Reference has black-boxed this patch for acute pain and for those who are not opioid tolerant. By the third LTC day she was receiving 100 mcgs of fentanyl. Changes in her condition from lethargy and incontinence of urine to significant sedation did not trigger concerns from the LPN staff. During the evening of the third day she was taken to the hospital by ambulance, continued to deteriorate and expired several days later. The cause of death on autopsy was narcotic overdose.
This case illustrates a major systems failure. The hospital physician prescribed the patch for acute pain when it is indicated for chronic pain. The discharge order from the hospital should have indicated that the patch was applied. The LTC nurse should have noted the time it was applied at the hospital and the site of application. The LTC nurses and LTC physician, by continuing to apply additional patches, did not understand the method of administration and accumulation of an extremely powerful narcotic. The pharmacist did not question the orders. The patient died. Settlement in the plaintiff’s favor was in the six-figure range.
Effective control of pain requires individualizing the regimen according to the type of pain being treated and the patient’s condition. It is essential to titrate the dose of the appropriate drug or drugs to achieve the desired effect. This dampens the pain-sensitizing neurochemicals that are produced when tissue damage occurs. In addition, it prevents wind-up, the progressive increase in the discharge of dorsal horn neurons as a result of repeated, prolonged noxious stimuli. The resulting hyperexcitability and hypersensitivity lead to pain states in which stimuli that are normally innocuous produce pain.
Effective initial treatment of pain accelerates recovery time. When pain is not well controlled, recovery time is lengthened. The patient experiences pain way beyond what is to be expected for that particular trauma or procedure. •
Margaret S. Wacker, RN, PhD, is a pain consultant with more than 30 years of nursing experience. She is a frequent speaker on pain management and palliative care, is a published author in professional journals and is the director of nursing at Lake-Sumter Community College;email@example.com.
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