UDM Solutions

My friend, who is in her eighties, was recently hospitalized for back surgery and then stayed at a nursing home/rehabilitation center after her hospital discharge. Both in the hospital and in the nursing/rehabilitation facility, she was under-treated for her pain. In the hospital, she was prescribed hydrocodone as needed (PRN) and morphine around the clock (ATC). She was not being administered her morphine ATC and was mostly being administered hydrocodone which did not alleviate her pain. Only after I spoke with her clinicians did she receive her morphine as ordered. Even then, her morphine dose would be administered late, leaving her in pain during the intermediate time interval.

When I visited her at the nursing home, a mutual friend informed me that although she was in extreme pain, she did not want to "upset" anybody and was reluctant to inform her physician of her pain. Her prescription regimen was for oxycodone every eight hours PRN, and she would have to ask her nurse for the pain medication every time. With this regimen, she experienced pain during the entire 3-4 hours prior to her next dose. I told her that I would speak to her physician to review her pain medication. At first, she was extremely anxious because she feared she would be perceived as a difficult patient. Later, however, she thanked me. After communicating with her clinicians, she was ordered a slightly lower dose of oxycodone every four hours ATC. This helped better control her pain and contribute to a better quality of life during the post surgical period.

In both my personal and professional experience, it is extremely common that patients are prescribed generic medication regimens that are not individualized for their specific needs compounded by an ineffective follow-through by practitioners for optimizing patient pharmacotherapy. My personal friends and family have been affected by this type of healthcare standard that currently exists. As clinicians, we need to transform the subjective and generic dynamic in which we select, prescribe and monitor medication regimens, especially for our elderly patients, and create a scientific standard founded on objectifying their pharmacotherapy.

If my friend had undergone clinically relevant genetic testing, especially cytochrome P450 (CYP450) 2D6 testing, her team could have obtained objective data to assist in optimizing her pain medication regimen at the initiation of treatment. As a clinician, I wanted to know her CYP2D6 metabolism prior to making my recommendations to her team. In addition, we need to create the environment, communication tools and time needed to help enhance communication with our patients. We need to take into account the various psycho-social and biological factors that can impede our ability to individualize treatment. My friend could have been assigned a regimen that was individualized for her. Instead, she endured weeks of pain until her final regimen adjustment. This situation was worsened by a breakdown in communication and follow through between my friend and those responsible for her care. We need to improve our patients' pharmacotherapy and safety by implementing these tools as the standard of care, especially in our elderly population.

Fortunately, my friend has since recovered from her post surgical pain and is doing well.