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Wednesday, August 31, 2016

Co-management of pain medication: He was a good partner

Dr. Maren Batalden’s story:
Several months ago, I treated a man in his 40s, a veteran of the war in Afghanistan who had developed both a chronic pain syndrome related to recurrent pancreatitis and a problematic relationship to opioids.  Sometimes the healthcare system had been suspicious of his requests for pain medication. People were nervous, thinking that if they listened to him, and gave him an inch, he’d take a mile, and we would get into a dynamic were we’d never be able to satisfy his needs for narcotics.

I have been thinking a lot about this “co-production” framework for patient care, which invites a more full partnership and more transparency in communication, so I decided to risk putting it all on the table.  “Look, we don’t want you to be in pain.  But it can be hard for us to know whether we are managing your pain or your addiction. You’ll have to help me out with this. You have a high tolerance to narcotics and you have real pain. Let’s figure this out together. What matters most to you?”  Having had a lot of experience in various hospitals, he knew he didn’t want to be on a pump that he could use to dose himself as he knew he might fall asleep and wake up with undermedicated pain; he didn’t want to have to keep ringing the bell to ask the nurse for pain medication that was prescribed as needed or “PRN.”  We put together a plan that involved a combination of long acting and short acting medicines on a regular schedule at doses that he knew would work for him.  

He turned out to be capable of being a very good partner.  The regimen we put together kept him comfortable without over-sedating him.  He did not page the overnight teams with requests for more narcotics. In keeping with parameters I set in our initial conversation, he made no demands for additional narcotics at the time of discharge. I suspect most people want to be good partners with their health professional teams, if we help them understand what we need and want from them and what constraints we are working with.

Often, hospital-based doctors wring their hands behind the scenes in caring for patients like this.  Assuming people with addictions to pain medication will ask for more than they need, doctors feel they have to make decisions by themselves and – not surprisingly – they often don’t get it quite right.  This leads to a lot of back and forth tension about a hospital pain regimen which is frustrating for everyone.

Once you get start looking for ways to improve the quality of the partnership between health professionals and patients, you see it everywhere.

Thanks to Dr. Maren Batalden for her story. Read another of her stories about the co-production of medical care and her article in the British Medical Journal.

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