State Law Restricting Prescription Painkillers: What Do NP's Think?

I have come to dread the fight that ensues upon discharging drug seeking patients.  I prescribe Ibuprofen for a sprained ankle.  The patient becomes furious, threatens to call Channel 5 News or Bart Durham, a local attorney with sketchy TV ads- you know the type.  Depending on the situation I either hold my ground or acquiesce to the pill-popper's demands.  Call me immoral but sometimes you just can't fight anymore.  Then, at the end of the day I slink out to my car ready to attack the attacker who has surely slashed my tires in this drug-seeking dispute.  I mentally note to intensify my Jillian Michael's DVD workouts to better prepare for these types of situations.  They don't teach you this in school.

As a nurse practitioner I am painfully aware of the prescription drug abuse problem in our country.  "What are you going to do about my pain?" and "The only thing that works for me is the thing that starts with a 'D'...yeah, Dilaudid, that's it" patients often say to me with a sly look on their faces.  Too bad our discharge instruction program doesn't come equipt with a "dilaudid dependence information" handout.  Although most patients are not malingering, others are well aware the pain control is a hot topic in medicine and carries potential professional implications for me as a provider. 

State legislators are beginning to recognize this problem.  Not necessarily on the level of the medical provider, but in an effort to curb deaths related to prescription drug abuse and overdose.  Last year Washington State implemented strict policies on painkiller-use.  In treating flare-ups of chronic pain, ER doctors are directed to consult the patient's primary care provider before handing out a script.  Prescriptions for acute pain are not to exceed 30 tablets. 

In Colorado, signs are going up in ER's notifying patients that hospitals will not longer fill long-term prescriptions for opioid painkillers.  Tighter controls such as mandating that providers look up patients in the state prescription drug database before doling out pain medications are under review.   Bloomberg, not surprisingly, is getting in on the legislative bandwagon surrounding narcotics in New York.  Under new city policies, hospital patients will no longer be prescribed more than three days worth of narcotic painkillers and prescriptions for long-acting drugs such as OxyContin and Fentanyl are prohibited.  Lost, stollen or destroyed prescriptions are not to be refilled.

I'm conflicted over this new painkiller legislative fad.  It would certainly be nice to have the law to blame in my battles with patients over their discharge medications.  "Sorry sir, the law does not allow me to write a prescription for the medication you are requesting- maybe you should take up your penchant for Percocet with the governor".  In dealing with malingerers it would make my life easier.

Unfortunately, these laws will potentially work against many patients and medical providers.  Some patients do necessitate more than three days worth of pain medication.  The most obvious example that comes to mind is patients with fractures.  They may not be able to follow-up with an orthopedist for more than three days, especially if they are uninsured.  Many patients do not have the means to revisit a provider for pain medication refills every three days until their condition has resolved.

Laws restricting painkiller prescriptions can also negatively impact physicians, physician assistants and nurse practitioners.  In general, I am against lawmakers further dictating what we are able to prescribe as medical providers.  Legislation makes our practice much more cumbersome.  It seems that with the passing of each new Medicare guideline and state law the amount of paperwork involved in medical practice becomes increasingly suffocating.  Dr. Alex Rosenau, president of the American College of Emergency Physicians states "Here is my problem with legislative medicine, it prevents me from being a professional and using my judgement".

What do you think about state regulations regarding prescription painkillers?  Are you for or against state control of prescription pain medications?

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Comments

I've been on COAT for more than 12 years; along with several other things to try to control mixed pain. I've been lucky to have a GP during that whom takes pain seriously. I have rheumatoid arthritis, fibromyalgia, nerve pain (from compression), and some thoughts that the real culprit may be a form of sarcoidosis that attacks the nerves. Before I became ill I worked in pharmacy (cpht, but still) for a company that largely did hospice care. I know not only what is possible, but what is largely impossible (at the present time) in the treatment of pain.

Imagine my shock upon being sent to urgent care, and treated by a nurse practitioner because I tripped over a shoe and fell awkwardly onto my desk wrists first. Not only did I add a pair of hairline fractures -- I partially tore a mess of connective tissue. No prescription whatsoever for pain even though I am spiking 8's even with the morphine I take. The body gets used to a certain level of medicine. While it still reduces the number of flares of pain -- any new insult to the body is just that, and one has to roughly double the amount of pain medicine to get relief from a new & severe insult.

Why does this urgent care advertise that they can treat fractures and other severe insults to the body when all they have on the weekends is a lone NP with no prescribing ability? I left there in even more pain than when I went in, and of course the buck gets sent to my GP to write something to handle this pain. My GP goes out on a limb for me, and I've had 4 month appointments with him for about 8 years. My condition isn't changing. I'm stable and still get a benefit, although I will always have pain.

For those of us who are going to be on life-long pain management the scenario is painfully familiar. Either they don't know how to adjust medicines for tolerance or they label you a drug seeker for pointing it out to them what it actually takes. I had an oral surgeon actually say to me "there is no need for medication, what you are taking now should cover that" -- not realizing that some new insult to the body any chronic pain patient is going to feel it. When I pointed this out to him (I'm sure a little woozy from just being woken up from a fentanyl drip for sedation) -- he wrote a prescription for Tylenol 2. I take 120-145mg of morphine per day. I pointed this out to him that other than the Tylenol in it -- it was going to have zero effects other than emptying my wallet. He at least asked "What do you think would help?" At which point I told him an opioid is an opioid for the most part, and rattled off a few that were strong enough to have a good chance at providing relief. You are in a catch-22, if you name something they think you are a drug seeker. If you don't name something the odds are you will be prescribed something inadequate. I wish I had the answers, but I don't.

My GP writes me a certain amount of BT medication per month (its adequate most months). If I have to dig heavily into that - I don't have pain control toward the end of the month.

Rob Koch

This means I'm likely to only receive 1/4 relief from spinal DDD &spondylolisthesis (bone against bone) -this means inability to do my daily activities due to pain. I didn't ask for this condition, but must suffer to save drug addicts? Put them in psych care & let me, who takes my meds properly. I dread my next pain management appt! Im going to be given Advil. Believe me, if that worked, I'd bypass the expense of monthly exams & just get it over the counter-much cheaper! Painkillers give me no "high"-they go to the pain. I want patient care, ..not.. drug addict care-they need mental care

Jenny