How much pain medication should you give your patients to take home? The ideal? As much as they need for adequate relief for a reasonable period of time. The reality? Nowhere near enough.
I see this problem from every level of provider, from interns to senior physicians. I recently underwent surgery on my arm as an outpatient procedure. I was sent home with a prescription for oxycodone 5mg / acetominophen 500mg. It was written to be taken 1-2 tabs q4-6 hours as needed for pain. How many did I get? Twenty!
Now, let’s do the math. If I were to take the maximum 8 per day, this would last me exactly 2.5 days. I’m scheduled to see my provider in 8 days. In the US, this is a Schedule II narcotic, which means my pharmacist needs a paper prescription in his hand to fill it. Phone or fax orders are not acceptable. If I need more before my office visit, I have to get a phone order for a less powerful analgesic, or I have to ask someone to drive to the office and pick up a new paper prescription. For more than 20, I hope. And what if it were a weekend?
Bottom line: DO THE MATH! Give your patients enough medication to get them to their next appointment, commensurate with the amount of pain you expect them to have. For the prescription above 50-60 tabs would have been more appropriate, or a little less (40) if you expected them to taper their dose during the week. Patients with legitimate analgesia needs cannot get addicted in these short time frames for minor to moderate injury.
One of the tenets of clinical c-spine clearance is that there be no “distracting injury.” What does this mean exactly? Can the clinician adequately judge which injuries are too distracting?
The Loyola group prospectively looked at 160 patients needing c-spine clearance over a 9 month period. GCS had to be 14 or 15, and the patients were excluded if they were intoxicated or received an analgesic prior to the clearance attempt. A total of 84% had no neck pain, and 82% of those had no peripheral, potentially distracting pain. Patients with perceived distracting pain and those without had very similar Visual Analog Scores (VAS) for pain.
Overall, the majority of patients and physicians did not believe that distracting pain was present, and when pain was present there was little agreement whether it was distracting. The few patients who did have spine fractures had a VAS for pain >5. The use of physician judgment for distracting pain and clearance worked just fine in this study.
Bottom line: The authors recommend using clinician judgment as to the degree of distracting pain when clearing the c-spine. If you want to be more objective, if the patient complains of a Visual Analog Score for pain of more than 5, then you may want to delay clearance. Note: this is a small study that really needs to be replicated before widespread use.
Reference: C-spine clearance: don’t be distracted – just trust your judgment. Presented at the 24th annual scientific assembly of EAST, Session II, Paper 9. Click here to see the abstract.