Ouch! That Hurts!

August 13, 2012


A patient is offered Vicodin (an opioid) at an E.R. for a sprained ankle and level 5 pain. Proponents of the war on drugs (which isn’t winnable) contend that this is inappropriate because of lack of efficacy and the risk of addition/tolerance. As one physician stated (without citing any studies): “Narcotics have no anti-inflammatory properties and are no more efficacious for even moderate or severe pain than anti-inflammatories.”

First, note that Rest-Ice-Compression-Elevation (RICE) is the primary treatment for most soft-tissue injuries (although it does not include pain management) absent complications. Ice addresses the anti-inflammatory part of treatment, and does provide some (very temporary) measure of pain relief

As for the appropriateness of opioids for pain management, your truly, actively engaged in the war on pain (which *is* winnable) posit that:

The strongest NSAIDs are evaluated at 3.5 effectiveness; Vicodin is given a 5. That’s a 70% increase in efficacy. Although opioids are not as effective for neuropathic pain, they are quite effective for acute pain, such as a torn ligament.

The complications most often experienced by patients on narcotics are nausea and lack of gut motility. The threat of addiction/tolerance while healing from an acute injury is small. Certainly treating pain risks feeding addiction, but to what extent should that risk affect pain treatment?

Are there moral hazards for denying opioids to those likely to benefit from them? David Morris, in The Culture of Pain, asserts that denying pain medication to a sufferer is the moral equivalent of inflicting pain upon them.


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8 Responses to Ouch! That Hurts!

  1. Steve on August 13, 2012 at 7:03 pm

    The real victims in the war on drugs are the people who need pain management and are refused due to the hysteria created by the few who abuse drugs. Those with chronic pain must suffer and often die in pain. Terminally ill patients are denied pain management medications on the basis that “they might become addicted”. Really? If you are dying, who cares?

    I agree with David Morris denial of medication is the equivalent of inflicting pain upon them.

    The DEA has now made all physicians who prescribe controlled substances their complicit agent by mandating that physicians require patients to sign a “Medication Contract” that cannot be enforced and is draconian in nature.

    Your doctor is a DEA agent!

  2. Dr. Stephen Grinstead on August 16, 2012 at 4:51 am

    We need to continue a dialog about the use of certain medications. It’s my belief that it can’t be about those “bad” medications–no such thing! It’s how the medications are used and who they are used with that can positive or negative outcomes. Opiates were orignially developed for acute pain management and the case in point here the ER visit with a pain level of 5 would be an example of good use. That is unless the person has a history of personal or family alcoholism or addiction–then it could be a bit risky. Unfortunately, at the ER it’s really hard to take the time or resources to make sure.

    I want to make another comment about the “Medication Contract” that I personally see very theraputic and an important part of patient education and informed consent. It does not make those of us who use this tool anybody’s “agent” and I do NOT believe it is draconian; if it is utilized in an appropriate and therapeutic fashion.

  3. Dr. Graciela Jacob on August 16, 2012 at 4:01 pm

    The professional that dont give a strong medicine for a strong pain denied a human right. The right to be aleviated, that every one has
    I strongly recomend the site http://www.lifebeforedeath.com

  4. a doctor who has seen opiods kill people on August 16, 2012 at 4:16 pm

    FDA just issued an alert about codeine to kids causing deaths, and JC issued a Sentinel Alert about pain mgmt in hospitals. It is crazy to expect a patient with a sprained ankle to have zero pain and achieve that with a narcotic. That “necessary” opiate causes trouble. Read this:

    I was twenty-seven years old when it all began. I already had a history of drug abuse, experimenting with various drugs. I had just delivered my second son. When the Doctor discharged me from the hospital, he sent me home with a large bottle of pain pills. At the time, I was not familiar with the effects of opiates but quickly learned I was going to like them alot! It wasn’t long before they became my very best friend. I could depend on them and they never let me down. I didn’t do anything without them.

    I began to doctor shop in order to feed my addiction and found out I was very good at obtaining what I wanted. The doctors seemed very eager to prescribe them. I thought I had found what I had always been looking for. However, over the next few years I would come to the realization what I had thought was my best friend, had in fact, turned out to be my worst enemy.

    • andrew on August 16, 2012 at 5:53 pm

      it is always convenient to blame doctors . It is time patients took responsibility for their actions

    • Diane on January 31, 2013 at 3:40 am

      The magic words were “I already had a history of drug abuse, experimenting with various drugs.”

      The “necessary opiate” may indeed be necessary, but a person with a history of drug abuse needs to tell the MD to see if there is an alternative….if not, and the drug is considered necessary, then monitoring of the use is needed.

      Don’t blame the drug. The person in the bed next to you who doesn’t have your drug history probably will benefit without problem with the same injury and the same drug.

  5. Janice on August 16, 2012 at 8:42 pm

    I am both a pain management nurse as well as a person with persistant pain.
    There are many types of pain both acute and persistant. Not all medication works for everyone and not all medication will work for each type of pain (some types of back pain opioids work for, some it doesn’t, etc.).
    Re the sprained ankle; I would expect to receive an opioid for the first few days. If appropriate an NSAID would be good as well (please note that while they don’t cause dependence NSAIDs have many many more scary side effects). While opioids are not anti-inflammitory (they are centrally acting) there is more going on with an ankle sprain than just the anti-inflammatory response.
    At this point in time the Medication Contract is not mandatory. In pain management we are trying to get people to understand this is an agreement not a contract and it should never be punitive. I have a problem with these agreements because some prescribers don’t understand them and attempt to misuse them (making them punitive).
    Patients need to be responsible for their actions but prescribers are as well. The response is not to not prescribe opioids but rather follow their patient closely; is this working well; is there another medication and/or non-pharmacological interventions we can add to reduce or possibly even eliminate the opioid? What is right for this person and this pain. Function and Quality of Life have to be some of the things we look at as well.
    Keep in mind that those with addiction problems need pain management as well.
    When we talk about chronic pain so many people associate the term with addiction or drug seeking. Yet even the WHO has said the pain relief dor people with chronic pain is a human right. If I have persistant pain after a surgery is it more legitament if the surgery was for cancer? Pain is pain. Margo McCaffery (who said in 1968 “Pain is what the person says it is” also said “I would rather have 10 people fool me than let one person suffer with pain.” Unfortunately now others now frequently say (or feel), “I would rather 10 people suffer in pain than let one person fool me”.
    One more comment on “Liking pain medicine”, I love my medication what person in pain doesn’t? I also love my blood pressure medication and my inhaler (for asthma)-breathing is such a rush.
    People who take opioids (or any controlled drugs need to be responsible for keeping them safe. I always recommend (and do myself) writing down the time and what you took (so you don’t accidently overdos as well as keeping track); never share your medications, keep them in a safe place preferably a locked cabnet or drawer. Currently the addiction problem is being blamed on pain patients as opposed to addicts who take medications from family members or friends, selling it to supplement their income) or buying it on the streets. This is where there needs to be more accountability.

  6. Noella Cahee on June 7, 2013 at 4:13 am

    Acute pain might be mild and last just a moment, or it might be severe and last for weeks or months. In most cases, acute pain does not last longer than six months, and it disappears when the underlying cause of pain has been treated or has healed. Unrelieved acute pain, however, might lead to chronic pain.

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