Reducing NSAID Use PLUS NSAID Prescribing Guideline

Through many years of experience in correctional medicine, I occasionally have come up with a speech or dialogue that works especially well with patients; a speech which I then use over and over again. One of these speeches is one I use to get patients to take fewer NSAIDs.

Inappropriate NSAID use is a common problem in my jails–and outside of jails, as well, for that matter. It is common for new jail patients to arrive with inappropriate prescriptions of NSAIDs. (I have written about NSAIDs before here and here). Some of these are for inappropriately large doses. Some are prescribed to be taken every day instead of PRN. And some patients really should not be taking NSAIDs at all.

When such patients come to the jail, changing such prescriptions can be difficult. Simply by having been prescribed these NSAIDs, patients are tacitly taught that such prescriptions are safe and effective, even when they’re not. It is my job to re-educate them. This takes time, but maybe not as much time as you might think.

Take, for example, a patient who I will call “Jeff.” Jeff is 50ish with a history of cardiac stents in the past (but doing well since), and takes two medications for hypertension as well as omeprazole. He also is prescribed Naproxen for chronic joint achiness twice a day. He never misses a dose.

Hi Jeff! I want to talk to you about the Naproxen you are taking for your joint pain. You are not getting all the benefit you could be getting from the Naproxen. Like all pain medications, your brain receptors gets used to a medicine that you take all the time and that medicine becomes less effective.

If you take Naproxen in the morning, you might get this much benefit from it (I show a gap between my forefinger and thumb). But then, if you take Naproxen again that night, you don’t get that much benefit again, you only get this much (I show a smaller gap with my other hand)! And if you take it yet again the next morning, you get even less benefit (I show an even smaller gap with my first hand).

The bottom line is that the more you take Naproxen, the less well it works. If you can get by taking Tylenol some days, the Naproxen will work that much better when you do take it.

Also, Naproxen can have some bad effects too. It can erode your stomach lining and cause ulcers. It can raise your blood pressure. And it can be bad for your heart. The more you take it, the worse those effects can be. Tylenol is much safer. So the less you take Naproxen, the more benefit you get and the less risk of harm.

I will still leave the Naproxen on the cart for you to use as needed, but remember that the less you use it, the more benefit you get and the less likely it is to hurt you. I’ll make sure you have access to Tylenol to take instead.

Believe it or not, I have found this speech to be very effective in reducing the amount of NSAID that patients take. When I checked a couple of weeks later, “Jeff” had gone from using Naproxen twice a day, every day to taking a dose only about five times a week. Success! And “Jeff” is not unusual.

It will be important for me to schedule a Way-To-Go! follow up clinic visit with “Jeff” in about a month to praise him for reducing his NSAID use! At this visit, I often find that patients’ blood pressures are down and they have less stomach issues.

Total time to do this highly effective speech is around three minutes.

You can find a sample NSAID prescribing guideline here in the Guideline section of JailMedicine.

How do you handle NSAID overuse at your facility? Please comment!

As always, what I have written here is my opinion, based on my training, experience and research. I could be wrong! If you think I am wrong, please say why in comments!

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