Why do you prefer PRN over scheduled dosing?

What is the question/concern?: As CCP of 20 years I find if I get behind the pain I have a tougher time bringing the pain to a manageable level. Why do you prefer PRN dosing over ATC or scheduled dosing?

A friend of mine sent a message to DrMikeSays.com and I felt like I had not sent out an actual blog in a while, so this seemed like a good way to kill 2 birds with one stone.

In order to best answer your question Tony, I need to break it in a few parts.

The first part is: If I get behind the pain...?

First of all, thanks for this REALLY good question. So let me start with this - two things can be true. It can be absolutely true that if you "get behind on your pain" then you can create a hole in which you digging out of it is extremely hard and even traumatic. I see you. Where we might have some disagreement in the land that I call "Baskin Robbins" (that is we all just have our different flavors), is that the second part of your question really doesn't have anything to do with the first part of your question.

Neither you, nor I believe you should fall behind your pain, or as I put it another way, there is not a real moral victory in RAW DOGGING your pain for an extended period of time. You should not, unless you are doing a medication reset, intentionally put yourself in the hurt locker and think it will be easy to climb out. It will not. We see 100% eye to eye here. The difference comes in when we ask ourselves the question:

How do we stay out of the hole?

And herein likes the second part of your question. Is it better to use medication PRN or ATC (around the clock for anyone who needs clarification)? My actual answer is neither, but we will begin with your premise first, the ATC.

ATC or pain blankets are not very effective:

In my book, I wrote an entire chapter on this called "Pain blankets do not work" and here is where you and I may truly have different flavors. If ATC works for you, please continue the plan that works. But the reason I BELIEVE that pain blankets do not work is that life does not fit into a schedule. Pain blankets or ATC dosing assumes that if we keep enough medicine in your system, then pain will not intrude into your day, or at least it will not be overly disruptive. I find that life creates endless ways to penetrate the pain blanket midway between doses and causes you to be in as much disability that if you had never taken the last pain pill. The premise that you can "guard against onset of pain", to me, is a fallacy.

BUT I also don't think PRN dosing works much better. PRN dosing requires that you wait until you hurt to a certain level before you dose and by the time the medicine "kicks in" your pain has already increased to the point that you are in the hole you tried to avoid. So, here I want you to see me seeing the flaw you are presenting in your question. You are right about this too.

So then what?

I actually believe that you take your medication with no regard to your pain on a 1-10 or whatever scale but that you actually dose your medication based on what your life has you doing at a given point. In the same chapter I have already mentioned, I describe dosing your pain medication based on what you have to accomplish. Here is a greatly simplified version using 4x/day dosing. ATC would be q 6 right? PRN would be - if you run out of your 4 pills early in the day life sucks, right?

So instead, I advocate dividing your day into clusters of activity. Pill one on awakening because who can get started in uncontrolled pain. Pill 2 is at beginning of big cluster 1 - getting folks out the door (including you), on their way and doing first part of days chores. Then there is a designated point in which you have planned lower activity because you know there is no pain med to cover that moment. But Pill 3 happens mid afternoon as folks arrive home, crap has to be taken care of so the house can function and we need to nourish ourselves and have family time. Pill 4 is end of day because we need to rest.

The key difference between this and PRN or ATC is that the clock is the least relevant piece of information. The number of doses is the most relevant. Arranging your day and premedicating to activity clusters is the best way to manage pain and yes, that means that no matter what, even this plan does not work every day. Remember, some days, the pain just wins. We need to be okay that. I love you all, no buts.