Kyle’s Pain Pearls & Pet Peeves
Welcome back to Rounds & Rants, where we tackle the myths, misunderstandings, and maddening habits that make living harder than it needs to be.
For today’s topic I thought I'd bring us back from the clouds where I lived for the first few points and talk about pain. My pearls, my pet peeves, and why I might suppress a roll of my eyes during rounds.
“They don’t even look uncomfortable!”
Pain is not a performance art. If you’re waiting for grimacing and writhing before you believe someone, you’re doing it wrong. Pain is whatever the patient says it is. Chronic pain especially doesn’t come with dramatic vital sign changes or sympathetic responses. If they’re eating cheesy poofs and texting, that doesn’t mean they’re not suffering.
Pearl: Chronic pain looks different than acute pain. Stop judging by appearances.
“Narcotics”
Stop saying “narcotics.” It’s archaic, imprecise, and loaded with stigma. You’re not in a cop show.
Pearl: Use “opioid.” It’s accurate. It means anything that binds the opioid receptor. Morphine is both an opioid and an opiate; fentanyl is only an opioid. While words matter, I'll give you a pass on -ioid vs. -iate.
“We know what happens when you give someone opioids…”
Yes, they get pain relief. And yes, there are side effects. But let’s be precise: the most common unwanted effect is constipation. Not respiratory depression. That’s rare when you dose safely.
Pearl: Always prescribe a bowel regimen with opioids. Senna is your friend (but please break up with docusate). Respiratory depression? Monitor labs, know your pharmacology, and don't fear-monger.
“My usual pain orders aren’t working!”
That’s because pain isn’t one-size-fits-all. There’s nociceptive, neuropathic, nociplastic, and mixed pain. There’s constant pain, breakthrough pain, incidental pain. Your Norco PRN order isn’t magic.
Pearl: Match the med to the pain type and timing. Constant pain needs scheduled meds based on half-life or a nice long-acting agent. Acute pain needs dosing based on time-to-peak (TCmax). Learn the kinetics or keep guessing.
“I gave the PRN two hours ago and it hasn’t worked yet!”
If you don’t know TCmax, you’re flying blind. Oral opioids peak at about an hour. IV peaks in 10 minutes. If you’re dosing too far apart, you’re guaranteeing failure. Though I'll forgive you inpatient folks who need to comply with nursing rules about dose frequency.
Pearl: For acute pain, dose as close to TCmax as possible. For constant pain, use half-life to maintain steady state.
“They’re watching the clock and calling the nurse early!”
That’s (probably) not something nefarious; that’s (almost certainly) under-treated pain. Aberrant behavior has a differential: low health literacy, worsening underlying disease, under-treated pain ("pseudoaddiction" terrible term for another discussion), secondary misuse for whole person suffering ("chemical coping," ditto), opioid use disorder. Don’t jump to conclusions.
Pearl: Keep a broad differential for opioid-related behaviors you don’t like. Bias helps no one.
"They're dying so we don't need to worry about OUD anymore."
The disorder and anguish of use disorders don't magically stop at a prognostic threshold. Just as we don't want to under-treat pain when people come to the end of their life, we also must not feed a use disorder.
Pearl: the overlap of pain, current or historical substance use disorders, and end-of-life is tricky balance. Call on your team of experts. Paging PalPsych!
Final Thoughts
Pain management is science, not superstition. Stop relying on “usual orders” and start thinking pharmacology: TCmax for acute symptoms, half-life for steady state, titrate drips based on bolus use. And for the love of all that is holy, stop saying “narcotics.”
Now go forth and prescribe like you understand what you’re doing. Or at least stop making me roll my eyes during rounds.
—Kyle
