Handling Abuse of Pain Meds
In the Wound care Clinic
No provider wants to see patients living with chronic pain. But there’s a fine line between helping to
manage that pain and enabling abusive behaviors.
We may never eliminate pain among
wound care patients, but more options are
available today beyond prescription drugs
that reduce treatment-related pain and allow more options for providers who cannot write prescriptions for pain relievers
(eg, barrier films, contact layers, silicone
adhesion, and removal techniques).Warming cleansing solutions and the use of
topical anesthetics help to minimize pain
associated with cleansing and debriding
wounds. Advanced dressing materials and
Patients whose non-treatmentrelated pain is due to underlying
wound etiology: We educate everyone
who’s living with neuropathic ulcers who
complains of neuropathic pain and have
them follow up with the PCP for control of those symptoms. We also explain
that developing pain in the region of the
wound is an important symptom that we
don’t want to mask with pain meds.
Treating Pain Today
must have the surgeon prescribe further
pain meds. A patient prescribed something for chronic back or joint pain by
their PCP who now presents with a
painful wound is required to have only
one provider managing pain medication. Since it is not our role to manage
chronic back or joint pain, we refer to
the PCP. Any patient with a history of
chronic pain medicine use or abuse must
go through the PCP.
tapes that stretch allow for decreased pain
during wear time of the dressing when
applied correctly. However, while some
of the physical modalities available today
are effective in reducing non-treatmentrelated pain in certain individuals, the primary resource remains medication. Now
that I’m on staff within a multidisciplinary
wound clinic, I have daily, direct access to
someone who can prescribe medications,
as we are fortunate to have a full-time
physician assistant (PA) who’s dedicated
to our clinic. Initially, we were fairly liberal in our approach to dispensing pain
medications, but things needed to change
when we recognized some manipulative
behavior among some of our patients.
From claims that “someone stole” their
pain medication to those patients who
would only show up to their wound care
appointments when it was time for a refill,
we realized that our caring nature was being taken advantage of. There have been
times in which our clinic has fielded calls
from pharmacists looking to confirm prescriptions that were never called in as well
as to advise us that a patient we had prescribed a pain medication to had recently
received a full prescription of the same
drug from another provider. We had to
look at our screening measures related to
pain medication. This caused us to swing
the pendulum in the opposite direction.
As a staff, we refrained from requesting
pain meds for patients and instead referred
them to outside sources, such as primary
care providers (PCPs). While we are still
quite conservative in prescribing, over
time our approach to assisting with pain
management has softened. The following
examples and solutions should help guide
anyone who may come up against these
circumstances in the wound care center:
Patients referred to the clinic having already been prescribed pain
meds: Typically, these patients are directed back to the source when refills are
requested. Patients with surgical wounds
y initial exposure to wound care as
a physical therapist (PT) was providing whirlpool treatments on
an inpatient basis. (And, yes, this was back
in the days of Betadine.®) There was not
much thought given back then to pain
management — if patients complained of
pain, we asked the floor nurse to call their
doctor and ask for additional medication.
As my career progressed and my interest
and knowledge in wound care advanced,
I found myself treating wounds entirely in
an outpatient rehab setting. While we still
used some whirlpool (our use of Betadine
had ceased), we had also learned to incorporate other modalities such as electrical
stimulation and intermittent pneumatic
compression. I was personally becoming
more cognizant of wound-related pain in
my patients. Firstly, it had become evident
that while some wounds would be characterized as “non-painful,” the reality is
that some wounds are “less painful” than
others. Essentially, a patient who is not
completely insensate may experience pain
in any type of wound, especially while receiving direct treatment. However, as a PT,
treatment-related pain was generally the
only aspect of pain I could address with
my patients, as they had to go to the referring physician for all pain-medication
requests. As a healthcare provider, I was
frustrated that I couldn’t do more to help
my patients manage their ongoing pain.
Tere Sigler, PT, CWS, CLT-LANA
www.todayswoundclinic.com Patients we’re following for
wounds related to vascular disease:
Those who present with symptoms
of acute phlebitis may be given a short
course of pain medication; however,
we don’t start with pain medication for
complaints of chronic “achiness.” We educate on that type of pain being useful
to monitoring effectiveness of treatment
and explain that if we are adequately reducing and controlling edema, the achiness should resolve. Patients who present
with symptoms of arterial insufficiency
generally have significant pain and are on
pain medication from their PCP. If they
are not, our PA will prescribe pain meds
until vascular studies are completed. If
they are not candidates for an intervention to improve arterial flow, they frequently are referred to a pain-management physician. n
Tere Sigler is the clinical director of the Archbold Center for Wound Management at Archbold Memorial Hospital,Thomasville, GA.
Today’s Wound Clinic® May 2013

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