Managing pain in primary care

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Clinicians should have patience and an open avenue of discussion with patients about the expectations of pain management in primary care.
Clinicians should have patience and an open avenue of discussion with patients about the expectations of pain management in primary care.

I work in primary care as a Family Nurse Practitioner, but there are days I feel more like I am primarily a pain management provider who also practices primary care.  Prescribing chronic opioids on a regular basis is not something I particularly enjoy, and there are times I feel like a little piece of my soul dies with every prescription. To be clear, I do not doubt that my patients are in pain (or at least believe they are in pain). In many cases I feel as though these patients were placed on chronic opioids inappropriately, and it has become too difficult for them to stop. Providers may think, “We've done nothing for your pain, and we're all out of ideas, so here are some opioids.”

When I see my patients on chronic opioid therapy, I talk to them about why they are on the medication, how long they've been taking it, and how they feel about being prescribed opioids. Many patients would like to take less — decrease their pill burden — but I am finding that some patients are afraid of being in pain if they stop medication completely. Thus, a vicious cycle begins.

Now, that's not to say that pain management in primary care isn't entertaining. I realized at one encounter that I've been missing out on a lot of interesting parties. One patient I saw stated that the reason methamphetamine was present in his urine drug screen was because he snorted a line of meth at a party during a game of truth or dare.

Another patient said that the reason she was discharged from a pain management program was because on her way to the appointment, she had stopped for coffee, and some teenagers might have poured methamphetamine in her cup when she wasn't looking. Of course, the pain management provider just wouldn't listen to reason.

Once, I almost had to call the Vet for consultation. A patient explained that the reason for his discharge from pain management was because the pet cat found the bottle of oxycodone in a pillowcase and swallowed all of the pills. No fear, the kitty is ok.

When I share these stories with other peers, the question that arises is, how do we keep our objectivity?  What prevents us from becoming even more jaded and thinking everyone who asks for opioids is just a ‘pill-popper'?

Well, my last patient is a long time chronic pain patient who has been on incredibly high doses of opioids.  After almost 2 years of dose adjustments and discussions about other options to treat his pain, he tells me today that he wants to stop all opioids and explore other options. He admits he was afraid of pain, but the side effects of opioids have become too much to handle.

So what is the answer?  All I can suggest is for clinicians to have patience and an open avenue of discussion with patients about the expectations of pain management in primary care. At no time is it acceptable to abandon patients, or treat them as a ‘junkie.' The goal is for pain management patients to have the best life possible while dealing with their pain.

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