A 🧵 On the Need for Pain Scoring Research

There needs to be a multi center research project analyzing subjectively reported pain scores and subsequent nursing intervention. This would primarily be looking at inpatient hospital stays, but would provide valuable insight into the perceived importance of treating pain by nursing.

Summary of the Opioid Epidemic

Purdue uses a letter to the editor to say opioids have little addiction risk. Publish video about how patients got their lives back—-many actually did.

The Real Root of my Addiction: a 9/11 Story.

On September 11, 2001 I was a junior in nursing school. I had already left the steet as a paramedic in order to learn more in the ER at @PennMedicine. When the first tower was struck, we were sent home from school. I got a phone call telling me to pack a bag for as long as possible; we all did on that day, except I was told to head in, not to safety. We were less than 90 minutes from Manhattan, we could see the smoke when we were told to, “stand down.” The rescue had become a recovery.

Here are a few papers/case reports to support the long thread on bupe induction I tweeted earlier. pubmed.ncbi.nlm.nih.gov/32650192/

The findings of this study might explain recent reports of difficulty in bupe inductions for persons who use fentanyl, and point to a need to better understand the pharmacokinetics of fentanyl in the context of opioid wd in persons who regularly use fent.

This is an example of why I need to be absolutely vigilant about my care.

I was experiencing a burning sensation and palpitations whenever something is infused through my PICC. Naturally the first thing the physician ordered was a chest x-ray to make sure it hasn’t moved. The first CXR was ordered for “palpitations.” Interestingly, the radiologist never noted the PICC which made me wonder if the order for “palpitations” directed the method of interpretation.

ON BUPRENORPHINE INDUCTION AND NURSE/PHYSICIAN ADVOCACY (RE:ACUTE PAIN)

Sitting in a room for 2 months with no windows facing the outdoors lends itself to quite a bit of time to observe the subtleties of my interactions with staff. First, it has been a rare event to get more than 3-5 minutes with any clinician, so you need to hone communication skills akin to speaking with a politician; unfortunately brevity is a necessary skill you must learn to get your needs met.

This is an outstanding talk by @dorazepam on Xylazine.



I’ve had the privilege of working with Dr. D’Orazio as a guest speaker and also as a patient after my relapse in 2020. After my wife he was the first person I called for help after relapse. After listening to his talk I have several thoughts running through my brain. First has to do with my reporting of bradycardia.

FAIRLY COMPREHENSIVE XYLAZINE THREAD (including personal experience)

Where there’s fentanyl, there’s xylazine.” ~@dorazepam

Xylazine caused so much destruction in my life:
-Terrible, difficult to treat wounds.
-Serious cardiovascular effects.
-Intense withdrawal syndrome. Xylazine has been used as a “cutting agent” for years, but over the past 3 years we’ve seen a dramatic uptick in its presence in street sample crescendoing to a staggering presence in almost every street sample collected.

A THREAD REMINISCING AND REFOCUSING.

One thing I’ve had the opportunity to do while sitting in this room for the past 2 months is reflect on my past advocacy efforts and refocus on the direction we are going in the future based on my neck injury and hospitalization. One thing I miss is working in the field as a harm reductionist. Spending time in the encampments, providing #naloxone, sterile syringes, basic wound care etc. was a highlight of my life.

The nurse caring for me said the overnight medicine physician finally called back and said she doesn’t feel comfortable making any changes to my care so I’ll need to wait till the AM to speak with the other medicine doc. She’s only here for emergencies the nsg supervisor said. So, a man in moderate iatrogenic withdrawal for >24 hours, threatening to leave which statistically increases my likelihood of fatal overdose significantly isn’t considered emergent.

THE CURRENT STATUS OF MY HOSPITALIZATION:

The answer I get when it’s after 5pm and I ask for help because I’m suffering in pain and withdrawal because unqualified clinicians who don’t understand the intricacies and pharmacokinetics of buprenorphine or the subtleties of opioid withdrawal make unilateral decisions with little regard for the consequences is, “sorry, they left for the day so it’ll have to wait till tomorrow.” What they are really saying is this:

1. Unfortunately, even though so many aspects of my care have been excellent at @JeffHealthAb what I’m going through right now is unbearable and completely opposite of what has been discussed when planning my care. Pain mgmt (not the usual NP) just saw me. 2. I explained I am in 9/10 pain and active withdrawal (COWS 20). I proposed 2 ideas to get me through the next 2 days. 1mg of dilaudid q6 in addition to the PCA which is 0.4mg with a 6 minute lockout. To this she said, “absolutely not!”

1/5 I know I talk about a lot of negative issues and I’m very critical of the care I’ve received. I also want to talk about the positives as well. The nurses on 3 Widener East (neuro step down) at @JeffHealthAb are stellar. 2/5 They are by the book on point and take note of minute changes. They can easily hang with the best nurses I worked with on the Rhoads 5 SICU at the University of Pennsylvania.

UPDATE ON DISCHARGE WITH A PICC

Just prior to the change in my condition last week resulting in the need for emergent surgery, we had a fairly involved battle with the internal medicine department ranging from residents, attendings all the way to the chief of the division who we provided with all the recent articles and evidence on people with a SUD history going home with a PICC safely. The evidence is overwhelmingly in my favor.

1. I’ve come to strongly believe we need active drug users like @drcarlhart and @MLLanzillotta1 on decision making committees. Most of the recovery community I’ve interacted with have been brainwashed into believing abusive, punitive, morality based treatment is the only way. 2. This is especially true of medical monitoring programs. In order to successfully complete these programs you need to drink the kool aid. They are the ones who become the poster child for why the programs work.

1. THIS IS HOW STIGMA WORKS 👇.
Yesterday around 1700 I started noticing I no longer felt the effects of the PCA and I was starting to have mild withdrawal symptoms several nurses came and attempted to flush my PICC, they had to use an extreme amount of pressure on the 2. plunger and the distinct taste Of the flush was much more diminished than usual. Prior to this my PICC was easily flushed. They toyed with it, clearly searching for a reason to feel comfortable it was patent, even though the evidence proved it wasn’t.

1. I’ve come to realize that nurses completely underestimate the value in consistency. Every time a different nurse cares for me 1. I need to start from scratch explaining everything. 2. They insist on restraining me at night by putting the bed alarm on. 2. Don’t underestimate the mental health repercussions of this. I’ve been on this unit for almost a month. I’ve built relationships with the nurses here, we trust each other mutually; 1 nurse said they argue who gets me on their assignment due to the nature of our friendships.

1. Despite thorough communication with my addiction medicine physician and having a very clear pain management plan post-op, they decided to stop my buprenorphine and put me on a dilaudid PCA. So now I need to go through a micro induction again. 2. Remember, it took 2 years and double digits of failed inductions prior to this. Moreover, @TempleHealth I had the national expert in micro induction overseeing the induction.

LONG THREAD:
As many of you know I’ve been hospitalized for almost a month. Here is my side of what I experienced. Stigma and discrimination is alive and well in medicine unfortunately. Here is just some of what happened to me. I was admitted on 4/23 to @TempleHealth after waking up and not being able to feel or use my lower extremities and experiencing urinary incontinence.

Thread:

Iv’e long said that no matter how many times I hear people, medical professionals etc. say “addiction is a disease not a moral failing,” everyone’s actions prove otherwise. Often much effort is exerted to hide the truth. Sometimes though, they put it right out there. @nprfreshair host Terry Gross interviewing Dr. Anna Lembke of @Stanford re: her latest book, “Dopamine Nation” closed the interview by asking Dr. Lembke for some practical advice people can use to end their struggle with addiction. Her answer is stunningly ignorant and dangerous.

Absolutely true. I haven’t been to a single stigma event or campaign that hasn’t perpetuated stigma. Destigmatizing addiction will require a multifaceted approach with a heavy focus of America’s Prohibitionist (racist) history. Also need Hollywood, SAG, indie filmmakers

https://twitter.com/sciencenotheism/status/1432172584150474757

Print media, television programs etc. to all undergo extensive education on drug policy, stats (the real ones, not the twisted ones used creatively), the difference between addiction vs dependence, the criminal unintended consequences of blanket, paranoid opioid policy,