Granny caught in the cross-fire again

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Once again the war on drugs catches frail elder patients in the crosshairs. Basically a “drive by” that shouldn't happen.

Hopefully, you are aware of the recent action by the Food and Drug Administration to move hydrocodone combination drugs (schedule III's) into the schedule II category of controlled substances. On Jan. 23, an FDA advisory committee voted 19-10 in favor of moving hydrocodone combination drugs such as Vicodin into the more restrictive schedule II category of controlled substances.

After a two-day hearing, the majority of panelists believed that the drugs are similar enough to, and as susceptible to abuse as the schedule II's, and therefore should be as tightly regulated.

There was testimony given from representatives from the American Cancer Society, the American Academy of Pain Management, and other groups who expressed their concern about patient access if the drugs were changed to schedule II's.

Was there a representative from long-term care explaining how we can't use nurses as agents for the docs to communicate their orders to the pharmacy, and that a nursing facility is totally different from how both acute care facilities and community prescribing works (where the doctor is always present)? I'm not sure, but I am sure of one thing: It wouldn't have made a difference.

(Flashback to “LISTENING SESSION: The War on Drugs Meets the War on Pain: Nursing Home Patients Caught in the Crossfire- March 24, 2010. This was when, during a physician's emotional testimony on the true suffering of her LTC patients due to difficulty in accessing schedule II pain meds, a certain DEA agent sitting behind me whispered to his colleagues, “Next thing you know, they'll be dragging in a grandma in a wheelchair.”)

Man, now that's compassion!

It often feels that no one cares that we have chronically ill older adults near or at the end of life, where as many as 80% of patients have a condition associated with pain (Barkin RL, Barkin SJ, Barkin DS. Perception, assessment, treatment, and management of pain in the elderly. Clin Geriatr Med 2005; 21: 465-490) and where the prevalence of substantial daily pain of LTC patients is estimated as high as 55% (Sawyer P, Lillis JP, Bodner EV, Allman RM. Substantial daily pain among nursing home residents. J Am Med Dir Assoc 2007; 8: 158-165.).

Right now, for example, when a patient is transferred from an acute care facility, post hip replacement, they will need a pain medication because they were on a morphine drip when they left the hospital. They just had surgery for goodness' sakes! So they get to us (Yeah, again on Friday night at 8 p.m.) and they need something for pain. The nurse evaluates them and then calls the new attending who is taking over the care.

The physician is hours away and can't get into the facility, and it is now 9 p.m. or 10 p.m., so they order schedule III's (which the nurse is allowed to communicate to the pharmacy). This should at least hold the until the physician can see the patient the next day. But if everything gets classified to a scheduled II, the doctor would in this case have to send the patient back to the hospital for pain control.

Which will waste billions in Medicare dollars that could be better spent for more appropriate patient care.

Several of the FDA panelists questioned whether a schedule change would have any impact on curbing addiction rates since oxycodone products are tightly regulated and are still widely abused. One panel member was quoted as stating she thought reclassifying is an important step in getting physicians to rethink prescribing practices and look at other approaches to pain management. I think the move may make physicians nervous about legitimately prescribing. (Hmmm, like Big Brother watching).

However, Joseph Rannazzisi, deputy assistant administrator of the office of diversion control at the DEA, was quoted as responding that “Hydrocodone often acts as a gateway drug that gets people started on other opioids.” Yup, he's right. Grandpa on his deathbed wants nothing more than to get high!

Grandma will be jacking up the nurses to get at the opioids.  Oh wait, she can't because she just had her hip replaced and she is in excruciating pain because we can't even get her hydrocodone! “Sorry Mrs. Smith, here's some Tylenol. I know you just had a knee replacement, but suck it up.  If we send you back to the hospital, they'll stop sending us patients because they're monitoring our 30-day readmits”

Seriously, how prevalent is drug addiction in the nursing home population? I can see this being an issue in younger populations and, of course, in the community. But, really, have you seen the medication regulations in LTC? Limited supplies, double-locked systems, counting per shift, major accountability, etc. This isn't retail. And if my end-of-life resident with severe osteoarthritis and post-stroke syndrome gets dependent on a schedule III, BIG DEAL! 

Look, I get the whole addiction and abuse thing. I really do. It is tragic, no humor here at all. And something many of us have experienced addiction with loved ones, coworkers, neighbors, or even ourselves.

I honestly appreciate the concern over drug abuse and diversion. There are physicians who abuse their prescribing power (just read about Florida's pill mills). There are manipulative addicted patients who know that pain is a subjective symptom and are able to “doc shop” till they get what they want. And there are people who die of overdoses on a daily basis, and people whose lives are completely controlled by their need to obtain their drug of choice. 

On the other side, there are frail people in nursing homes and we have to think of a way to serve then as they are in legitimate pain and need access to medications that will control that pain.

We can't create an immediate system change. Current reimbursement does not support the physician “living” in the facility, and until handheld electronic prescribing systems that meet the near impossible demands “prescribed” by the DEA exists (and is affordable) or the nurse agent fix is workable, we need someone to care about our patient population and quit seeing them as an unavoidable, acceptable loss.

And we need some compassion in the “war on drugs” that has CLEARLY been lacking and has sometimes been downright mocked as if we are just making stuff up because we want to “drug up” Granny or divert the drugs.

Our job is to protect the well-being and quality of life of our residents. And in my book, managing their pain outweighs the risk for addiction or abuse.

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates. 

 
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The Real Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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