To Prescribe or Not to Prescribe?: Pain Management for Post-Thoracotomy Patients

Amy J. Hoffman, MSN, PhD, RN

Amy Hoffman is an assistant professor at Michigan State University College of Nursing in East Lansing.

“Let me show you my incision. It’s nearly 2 feet long! I never imagined I would be in this much pain. I was sent home with 30 Vicodin for pain to get me through the first week, but I’m worried I may need more pain medicine.”

This is the typical greeting I receive when I first meet my post-thoracotomy patients after they return home from the hospital. The incision is shockingly large, the pain is outrageously significant, and consequently, their longer term plan for pain control has them very apprehensive. Unfortunately, more often than not, the post-thoracotomy patients’ apprehension is proven correct, and their severe pain is continuing well past the first week of their home recovery.^1-5

However, many patients choose not to call their providers, stating their fear of being labeled “drug seeking” or a “wimp,” believing that since they were given no refills for their pain medication, the expectation must be that they should not need more when they run out.⁶ Instead, many patients choose to “tough it out” and try in vain to treat their pain by taking over-the-counter medications and limiting their mobility. Further, the continuous pain and lack of movement initiates and/ or exacerbates other symptoms like weakness, fatigue, dyspnea, difficulty remembering things, and distress, thus leaving the patient in a dangerous downward spiral during what should be their recovery process and decreasing functional status and quality of life.^5,7 Unfortunately, it appears that an unintended consequence of addressing opioid abuse has been the reluctance of providers to prescribe and an unwillingness of patients to request needed and appropriate pain medication.^8-9

Healthcare policy and provider behaviors in response to anti-opioid reporting continue to cast a pall over access to effective pain management for those who suffer from acute and chronic pain. The crux of the problem lies in the National Institutes of Health, National Institute of Drug Abuse report that abuse of prescription medications is on the rise with more than 5.1 million people reported using prescription painkillers non-medically in 2010, that is, using them without a prescription.¹⁰

Reports such as these have cast a black cloud over all providers and patients such that providers under prescribe so they cannot be accused of over-prescribing, while patients under report their pain so they cannot be accused of being an “addict.” This combination of under-prescribed pain medication, coupled with underreporting by patients, has created the perfect storm for post-thoracotomy patients. As a result, many post-thoracotomy patients act as good soldiers following orders without complaint, left to their own devices to fight their severe pain with over-the- counter medications.

Unfortunately, the deleterious effects of the pain often take a significant toll, ultimately leading to a call to their provider—not by the patient— by the emergency room, who is trying to piece together what to do to alleviate the multiple, significant issues the patient presents. Consequently, although healthcare policy has changed, some things have not changed since Margo McCaffery stated in 1968: “Pain is whatever the experiencing person says it is, existing whenever he says it does.”¹¹ Pain after a thoracotomy is very severe, and more than likely the most severe pain ever experienced after surgery—just ask someone who has had this surgery.¹²

One look at a post-thoracotomy patient’s incision would leave even the staunchest opponent to opioid prescriptions asking for their prescription pad to help alleviate pain for 1 more week of recovery. I know that if you had asked my grandfather who had a thoracotomy and later passed away from lung cancer in 1975, he would have told you that he can attest to the post-thoracotomy pain that he and many of his heroic buddies who stormed the beaches with him in Normandy experienced.¹³

Moreover, although I was only 10 at the time, I clearly witnessed my grandfather suffer through the pain caused by his huge incision, retraction, resection, fracture of ribs, irritated pleura, injured nerves, and more normal responses of the human thoracotomy experience expressed as pain, including other comorbid diseases. I would have to agree that when he said he had severe pain, I had to believe what he said was true—it truly was pain.

While abuse of prescription drugs is a phenomenon that needs to be addressed, the phenomenon of under medicated pain for post-thoracotomy patients must also be addressed.

Judgment must be used, such that pain management no longer negatively stigmatizes patients and providers alike, especially in obvious areas of need such as for post-thoracotomy patients. To prescribe or not to prescribe is no longer the question for post-thoracotomy patients. To prescribe is the answer, and work is needed to remove the disincentives to prescribing and the stigmas attached to requesting help when obvious pain is out of control.

References

• Bayman EO, Brennan TJ. Incidence and severity of chronic pain at 3 and 6 months after thoracotomy: meta-analysis. J Pain. 2014;15(9):887-897.
• Yang P, Cheville AL, Wampfler JA, et al. Quality of life and symptom burden among long-term lung cancer survivors. J Thorac Oncol. 2012;7(1):64-70.
• Sarna L, Cooley ME, Brown JK, et al. Symptom severity 1 to 4 months after thoracotomy for lung cancer. Am J Crit Care. 2008;17(5):455-67.
• Brown JK, Cooley ME, Chernecky C, et al. A symptom cluster and sentinel symptom experienced by women with lung cancer. Oncol Nurs Forum. 2011;38(6):E425-E435.
• Handy JR, Asaph JW, Skokan L, et al. What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery. Chest. 2002;122(1):21-30.
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• Simoff MJ, Lally B, Slade MG et al. Symptom management in patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(suppl 5):e455S-e497S.
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• National Institute on Drug Abuse, National Institutes of Health. Popping pills: Prescription drug abuse in America 2014. http://www. drugabuse.gov/related-topics/trends-statistics/infographics/popping- pills-prescription-drug-abuse-in-america. Accessed November 12, 2014.
• McCaffery M. Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-environment Interactions. Los Angeles, CA: UCLA Students’ Store; 1968.
• Gerner P. Post-thoracotomy pain management problems. Anesthesiol Clin. 2008;26(2):355-367.
• Blades B, Dugan DJ. War wounds of the chest observed at Thoracic Center, Walter Reed General Hospital. J Thorac. Surg. 1944;13:294- 306.