The Call to Action, Pain Management Edition

Sep 05 2016 Published by under Life of a Physician

We have now completed two months of the new academic year, and times have been a-changing. We had to rearrange the way our patients get covered by residents in the hospital. We attendings have been taking more direct night call on our inpatients as a result. After taking insistent calls from nurses, I have become even more concerned about how we assess and treat pain.

For example, a kid with a kidney disease or transplant comes in with an infection in the urine or a virus. They are not taking fluids well, and they need some intravenous support and/or antibiotics. The kid looks like they feel sick from whatever the underlying problem may be. We start acetaminophen for fever and pain. Later on, when routine vitals get collected, they get asked if they have pain. They then rate the pain on the infamous 1-10 scale. Then, we start getting called about "unrelieved pain."

Patients with kidney problems, including transplants, must avoid non-steroidal anti-inflammatory drugs (NSAIDs; Advil etc). Filtration in the kidney is often dependent on prostaglandins, and these drugs work by inhibiting prostaglandins. In sick infected patients, generous dosing of NSAIDs can lead to  kidney failure that might even be permanent. That means pain unrelieved by acetaminophen quickly escalates to pain requiring opioids.

If the kid is sick enough to be admitted, I have no objection to the occasional dose of hydrocodone in the evening (even if I would have told my own kid to put on their big kid underwear and deal with it in a similar situation). It often becomes difficult to scale back the medication during an inpatient stay because we have become so focused on "unrelieved pain" assessment. The number of calls for this while covering a handful of relatively well patients was startling. I cannot imagine the pressure to just hand out "the candy" with more problematic patients and a busier service.

Treating pain is important, but we need to have strategies that do not involve medications. Children often respond well to distraction, relaxation, and other behavioral techniques. Unfortunately, these may be difficult to administer, especially in the middle of the night. And why are we waking them up and asking about pain when they should be sleeping anyway?

I am not a pain doctor. I just wish for a more rational strategy that does not create obvious rewards for overtreatment that may lead to addiction.

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