Handling Abuse of Pain Meds in the Wound Care Clinic

  My 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.

Treating Pain Today

  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 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-treatment-related 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 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.   Patients whose non-treatment-related 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.   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. Tere Sigler is the clinical director of the Archbold Center for Wound Management at Archbold Memorial Hospital, Thomasville, GA.