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Tramadol and its use in nursing homes

There is a new group gathering political support for a say in the way the Drug Enforcement Administration runs the “war on drugs”. Although there is no doubt of the need for firm action to reduce the availability of addictive drugs on the streets, the latest DEA crackdown does little more than penalize large numbers of ordinary people in pain. This April sees a Senate panel taking evidence from the owners and operators of nursing homes, doctors, nurse practitioners, and pharmacists. There is great concern at the new rules requiring pharmacies to wait for a prescription signed by a licensed doctor before dispensing the more powerful of painkillers. In hospitals and nursing homes, the standard practice used to allow nursing staff to place orders for drugs orally, with the prescriptions being written up later. This smoothed the treatment regime, ensuring a continuous supply of medication without any delays caused by missing paperwork. That practice is now prohibited in nursing homes. Why should this matter? The answer lies in the numbers. Nationally, there are about 16,000 nursing homes and they are literally “home” for some two million patients. An average of about 60% of these people have problems with chronic pain. They are vulnerable. Many are old or confined to bed. They cannot fend for themselves by going to see a doctor and getting a prescription filled by a pharmacy. They depend on the medical staff to supply the drugs they need to manage the pain. In fact, many are left for days in acute pain without relief because the paperwork in the hands of the pharmacy does not match DEA requirements.

In fact, the DEA has stepped up enforcement with recent prosecutions in Ohio, Michigan, Virginia and Wisconsin. This action is justified in two ways. First, there is a need to prevent the diversion of drugs from hospitals, clinics and nursing homes. If drugs are dispensed without paperwork, hospital staff could sell them on for street distribution. Secondly, some powerful meds are used by lazy nursing staff to dope any patient thought disruptive. This abuse of the vulnerable is made less likely if all dispensing is supervised by the attending physicians. But strict enforcement ignores the reality of life in nursing homes. Unlike hospitals, there are fewer doctors around and more day-to-day responsibility falls on the nursing practitioners. If nurses cannot be considered the agent of the supervising doctors, there can be serious delays in getting any prescription signed.

All systems are set up with checks and balances. In this case, there are real problems to be addressed on both sides and it will be interesting to see where the Senate panel draws the line. If we were talking only about the less addictive painkillers like tramadol, there would be less cause to worry. Drugs which are not habit-forming should be made available with the minimum of formality within the nursing home environment. This gives relief for the majority of people. Where the level of pain goes beyond tramadol‘s limits, doctors should be more closely monitoring their patients’ health. The balance of benefits and costs in the use of the more powerful drugs changes as people age and their health deteriorates. It might be reasonable to use the opiates for a person dying of cancer. Here, you want the maximum pain relief to make the person’s last days more comfortable. In other cases, the use of stronger drugs should be careful monitored.