pain management - page 2

What do you think about trying to control a patients pain when the etiology of the pain is unclear?... Read More

  1. by   kids
    Originally posted by fab4fan
    ...People who live with chronic pain do not always appear to be in as much pain as they may rate. After a while, it's as if your body gets "used to" that pain, and develops coping to some extent...
    Thank you fab4fan, very nicely put.

    Pain management is a subject near and dear to me but I have a very hard time being articulate. I have lived with chronic pain and have been a patient at my local hospitals pain management clinic for several years. I am very lucky, due to good medication management and a change in direction in my career I am able to continue to work full time as an RN. I have days where I am barely able to get out of bed. Those are the days when my husband or teenage boys dress me for work and put me in my wheel chair. I will turn 39 (this week).

    My nursing program taught pain management based on the ideas of Margo McCaffery, I feel fortunate to have attended several seminars given by her. Pain is exactly what, when, where and the intensity the patient says it is. I think many medical personel sometimes forget that the 0 to 10 scale is totally subjective and based on the persons past experiences with pain. A person who has never experienced significant pain may rate a simple arm fx as a 10, for a person whos only serious pain experience is a migraine every migraine will be a 10. A good example of how subjective and individulized the scale is my experience: I was given Narcan 6 hours post TAH for a MS overdose (wrong concentration in the PCA pump) that was my 10 and nothing I have ever experienced even comes close to it (including drug free child birth and a fx pelvis with no drugs due to being pregnant). On the other hand, I have no recent memory of what a 0, or pain free is. A good day is a 3, around 5 it starts impacting my ability to function. Another consideration to remember is that since it is know that people in pain can and will sleep to escape it, it stands to reason that they may also chat and laugh, watch TV or play a hand held game as a distraction. Why does no-one question how sick a cancer patient is from chemo when they behave in these ways?

    On the VERY rare occasion I end up in the ER for pain it is because I have to be there be there. My arrival is preceeded by a call from my pain management doctor and I still get a ration of crap over "all of the drugs " I am on (a sustained release narcotic, an antidepressant and an NSAID). 9 times out of 10 what I need is a single dose of a muscle relaxer or anti-anxiety med to break the pain cycle and I am OK. I have been well taught and actively practice guided imagery, it works for me and I am one of those people who can very calmly discribing my pain as a 7 or an 8 ... if I am in pain and I get agitated or anxous I will lose that control over the pain and I can become very hysterical. It is not pretty and it is very embarrassing but I have very little control over it, it usually happens when I get treated like a drug addict. I just LOVE getting told "with all the 'drugs' you are on I don't see how you can be in pain" (oh, have you never heard the words tolerence or pain crisis?) or "I'm not going to give you more narcotics" (my usual response: well thank you very much, I really appreciate that...given that I have signed a contract with your hospital saying I will not take any narcotics not prescribed by my PCP and I have at any given time close to 10 THOUSAND mg of MS at home...). It even sucks to wind up in the ER for a migraine...I have had them as far back as I can remember, now I only get one every 1-2 years and I have to be on day 2 or 3 before I'll go to the ER because of the crappy attitude I've gotten...even tho I make it very clear I don't want or need more pain drugs, I just want some phenergan so I can keep some fluids down because I'm feeling dehydrated it gets rehashed yet again that I am "on all these drugs".

    Sheeesh, given how much hassle is involved in getting drugs from an ER for the buzz I am amazed that people go thru it ...it is a whole h3ll of a lot easier to pick up oxycodone or Vicodin on the street corner (but then again, you got to pay for it there).

    I feel slightly better now, thank you.
  2. by   RainbowSkye
    Thank you so much for your post, kids-r-fun. I absolutely agree with you even though it may not have seemed so in my post. You are doing what I would like all the chronic pain patients I've worked with to do: take advantage of a pain management program. And I do understand that people with chronic pain have break-through episodes. I want to apologize for the rotten treatment you've received as well.
    However, I'm talking about patients I see on at least a weekly basis and sometimes a daily basis in our little er. People who are truly drug seeking and have an addiction problem (in the past few months I've had one patient nearly die from an opiate od and another patient's teenage son committed suicide using Lorcet this patient had gotten from several emergency rooms and docs). Just last week I saw a patient going through withdrawl because she had not been able to get someone to give her opiates and barbituates - thankfully, she chose to go to rehab.
    I had one patient come to the er with back pain so stoned she couldn't talk. She didn't recognize our er doc whom she had just seen the day before in his office (where she signed an agreement not to seek drugs at any other facility - he requires it before prescribing oxycodone). Another woman was discharged from one er then drove 20 minutes to ours to get another Demerol shot.
    And so it goes. How do we appropriately treat folks with pain while not facilitating others' addictions? I'm not sure that there is an answer.
    BTW, the hydrocodone available on the street corner in my neighborhood is most likely being sold by someone who got it for their "back pain" at our er. I've had more than one patient tell me that's how they got their medication in the past.
    Sometimes I think it would be a good idea to sell Lorcet on the counter next to the Advil at Wal-mart.
    And thank you for introducing me to Margo McCaffery, I'm going to look her up.
  3. by   flashpoint
    Pain management is a hot topic right now. Our hospital is on a kick where we are considering pain to be the "5th vital sign" and we are required to question every patient we see regarding pain. I guess that makes sense to an extent becasue most patients come into the ER with some sort of pain...everything from an earashe to a sore throat to back pain. I have to admit, I get pretty frustrated when I see people jumping around and playing "keep-away" with the toys in the waiting room and then one of them requests a wheelchair to get from waiting to exam because their pain is so bad. I can't help but be suspicious when a lot of the above situations are mentioned? If someone is in constant, chronic pain, how can they not take the time to establish with a local doctor? How can they always forget to get their refills or always have someone steal their meds or lose their meds? Do people sit around at parties discussing their back pain and decide as a group that they are all in such severe pain they need to go to the ER? We had a paitient in a few days ago who was visiting family for the holidays. He had his lorcet, duragesic, methadone, soma, flexeril, and whatever else refilled on December 18...according to the label he had 30 days worth of each, but on the 26th, somehow all of his meds were gone. 30 days of meds gone in 9? He said he didn't know what happened to all of his meds...maybe someone stole them. So we called the police (a crime was committed) and the guy left. Couple hours later, we get a call from an ER about 60 miles away wanting to know if we could send them this guy's medical records...sigh.

    It's people like that who make us all a bit cynical. It's people like that who make us all a little suspicious of people who want pain meds. People like that make us doubt how much pain our patients are really in.
  4. by   fab4fan
    I agree with not facilitating addiction; but it is dificult to diagnose true addiction, and requires extensive eval. by someone trained in that field.

    Also agree that w/ chronic pain, you do need to have a PCP; guess I just get a little touchy b/c usually when people talk about "bogus" ED visitors, they talk about people with migraines. I'm an ED RN, and have gotten migraines since I was about 5y, so maybe my POV is a bit different.:spin:
  5. by   teeituptom
    Howdy ya'll
    from deep in the heart of texas

    The key to working with these pts in the ER is to remember its not up to us to judge what motivates these patients. All we can do is assess and intervene appropiately. Anyhting else gives you grey hairs and aint worth it.
    Ive been in [ain for a decade and half now with 3 ruptured lumbar discs. I control my weight, I exercise. I stretch, and I live without using narcotics. I also pray a helluve lot.
    If I should ever awaken pain free then I will know I have died in my sleep.
    But I refuse to let mind altering agents rule my life, pain does good enough on its own without me giving it a helping hand.



    doo wah ditty
  6. by   RN2B2005
    Hmm...

    1.Ask the nurse as soon as she comes with the med...what is that?
    2. followed by ...how much am l getting?
    I guess I'd be labelled a drug-seeker, then, since I ask EVERYONE administering medication to me in an ED what they are about to administer, and in what dose.

    7.present to ther ER asking which MD is on duty
    Yup, I'd definitely be kicked to the curb. I always ask the name of the physician on duty. Not because I'm concerned about getting a script, but because I want to refer to the ER doc by name should anything go wrong...but I guess in your world that wouldn't matter, since OBVIOUSLY any assertive patient is drug-seeking.

    9.do not have a PMD
    10.vary your ER visits between different local ER's
    Gosh, I've had FOUR different primary physicians since 1998...and three of them are no longer practicing, which you wouldn't know from looking at the records (and apparently wouldn't believe if I told you). One retired and three moved. That number doesn't include my OB/GYN (3 since 1998; one stopped doing OB care, one moved, and the last one I just didn't mesh with) and of course, I saw six different doctors (my PMD, two neurologists with slightly different specializationns, and a team of neurosurgeons) after being dx'd with a brain tumour in 2000.

    And of course, I do vary my ER visits...for asthma exacerbations, I go to one hospital, and for the strokelike symptoms I experience when my brain tumour bleeds out (yes, it does that, and I don't need a "tattered MRI report"...any idiot can see the blood from twenty feet on a CT scan) I go across the street to the community hospital where I work. Why? Well, the ED at the major medical centre I go to for asthma problems happens to be the ED my pulmonologist admits through--he doesn't have privileges at the community hospital, so I go to the hospital he DOES have privileges at if I think I may need to be admitted. On the other hand, my PMD admits to the community hospital, and she'd be in charge of ordering supportive care if the headache from the tumour was bad enough to require admission.

    And I usually know when I need to be admitted...I've had asthma since I was four...but again, as an assertive patient, you'd just write me off. Not to mention the fact that the three times I've been seen in the ER for severe headaches related to the brain tumour (a cavernous hemangioma), I've been very specific in my medication requests--IV fluids, IV Phenergan, and IV pain med of the doc's choice, but not Demerol. I must be seeking, right? I mean, why else would I care what meds I received?

    Sure, I had a spectacularly bad reaction (not an allergy, just an adverse reaction) to Demerol the one time I had it (puking every twenty minutes for 36 hours), but any patient who is specific in his or her pain med requests must be a druggie, right?

    Last, I'm usually in a hurry to leave. Sure, I've got a toddler and a husband at home and a healthy aversion to hanging out in ER's, but in YOUR world, a hurry to leave (and free up a bed and personnel for other patients) signals a hurry to fill an Rx.

    I haven't worked in the ED, and I know that there are drug seekers out there...but pain IS very subjective, and everyone has different ways of dealing with it. I can be very matter-of-fact when I'm so dehydrated or in so much pain that I can't stand up...so it might look to YOU like I'm reading, when in fact I'm focussing on the words on the page in order to distract myself from the numbness on my right side and the rising nausea in my stomach.

    Judge not, that ye be not judged...oh, well, nevermind. Your judgement is quite clearly beyond dispute.
  7. by   ernurse728
    RN2B....I think that unfortunately unitl you have worked in the setting that we all work in on a daily basis you can't understand our position. I agree that pain is subjective...nobody is disputing that. I agree that under normal circumstances that yes you have every right to know which doc is on duty and you should ask what med you are getting and how much. These are not things that i have a problem with. What I do get angry about like I said earlier is the patient who comes into our ED atleast 4-5 times a week minimum...and also does the same to the surrounding ED's in the area. There complaint is always "migraine" , they want to know who the doc's are that are on duty only for the fact that they know who will give them narcotics and who won't. They want to know what they are getting b/c if is not the drug of choice for them they will refuse it. As well as if it is not a high enough dose for them. And after that have received their "fix" they can't wait to leave because they were never sick to begin with. These people never follow up with the doc's that they are referred to because there is nothing wrong with them except that they are ADDICTS!!! Plain and simple, I see them take up beds everyday. Beds that could be used for actual sick patients and it disgusts me! If these comments make a bad person in your mind...so be it!
  8. by   l.rae
    Originally posted by RN2B2005
    Hmm...



    Judge not, that ye be not judged...oh, well, nevermind. Your judgement is quite clearly beyond dispute.


    once had the county prosecuter tell me that ER nurses were his favorite ppl to get on a jury......why?....cause, "They have an uncanny sense of ppl's character....recognise BS in an instant. RN2b....not only have you NOT walked a step in an ER nurses clogs, you haven't any experience as a nurse what-so-ever. The next time you are ill and sitting in the waiting room of ther ER cause no beds are available ...please know that there are probably 2/3 of the patients there that DO NOT require ER treatment, chances are good that more than one of those beds likely have a drug seeking addict sucking up valuable time and space. My pt's lives depend on my "judgement"........been at this 22+ yrs and l am quit good at it...........LR
  9. by   berry
    some of my favs......

    I am allergic to lortab 5s but I can take the 7.5s

    no i need atleast 50mg of drug x

    if i wanted just an advil i could have stayed at home

    or the ones you wake up checking v/s and they tell you thay are a 10/10 on a pain scale and they fall back asleep before the bp cuff finishes its cycle


    My er has group of 13 docs and you can bet the seekers want to know who is on duty...my fav is a frequent who has been instucted by group he will recieve no meds until a uds is back and if he is + for coke (is 10 out of 10 times) he gets no meds. some of the frequent fliers are learning no to present with abd pain and N cause now they get phenergan supp LOL
  10. by   AngelGirl
    I work as an RN in a California County Medical Center Emergency Dept. We are told by the Administration that the budget is in the red by 2 million dollars. This is only February. A decifit in excess of 10 million dollars is expected by the end of this year. My concern is this: we receive and treat people on a daily basis for pain control. The cost to the County is enormous. They have no private doctor, however, we are not their only source of medical care. Those of us who work in more than one facility see these folks sometimes daily in any number of medical settings. Sometimes they arrive by ambulance, receive a prescription and walk out. Sometimes they return after being home for only a few hours, by ambulance, because they had no ride to the drug store to get the prescription filled. We see and treat them again. One woman who comes in frequently for pain medicines, presents at the door with her order: "Just a hundred of Demerol and a six pack tonight." She comes in with similar requests night after night after night after night. One night she came in just to let us know that she wouldn't be coming in that night. She's been denied injectable drugs and now seeks pills. She has taken to bringing in her father and her son. It is believed that they share whatever prescription one of them receives until it is depleted. Then they return. They have no money, so the County foots the bill. I believe that she and her family have greatly added to our hospital debt. Such patients are not uncommon.....Has anyone found a workable system to deal with such cases? Please advise!
  11. by   l.rae
    Originally posted by AngelGirl
    I work as an RN in a California County Medical Center Emergency Dept. We are told by the Administration that the budget is in the red by 2 million dollars. This is only February. A decifit in excess of 10 million dollars is expected by the end of this year. My concern is this: we receive and treat people on a daily basis for pain control. The cost to the County is enormous. They have no private doctor, however, we are not their only source of medical care. Those of us who work in more than one facility see these folks sometimes daily in any number of medical settings. Sometimes they arrive by ambulance, receive a prescription and walk out. Sometimes they return after being home for only a few hours, by ambulance, because they had no ride to the drug store to get the prescription filled. We see and treat them again. One woman who comes in frequently for pain medicines, presents at the door with her order: "Just a hundred of Demerol and a six pack tonight." She comes in with similar requests night after night after night after night. One night she came in just to let us know that she wouldn't be coming in that night. She's been denied injectable drugs and now seeks pills. She has taken to bringing in her father and her son. It is believed that they share whatever prescription one of them receives until it is depleted. Then they return. They have no money, so the County foots the bill. I believe that she and her family have greatly added to our hospital debt. Such patients are not uncommon.....Has anyone found a workable system to deal with such cases? Please advise!

    untill the ER docs start writing her a RX for Motrin......you might as well suck it up.....it's up to the docs......good luck!
  12. by   caroladybelle
    It happens in all departments.

    We kept having a terminal cancer pt, come in with issues related indirectly to uncontrolled pain. As our physicians' are pretty good with giving good pain control care, we wondered why.

    Found that the patient's husband was stealing the drugs, calling the MDs for replacements, whenever a different one was on duty, and selling the drugs on the street.

    Also, a favorite, the patient that asks me for a sleeping pill, and I return with it, to find he and his buddies with white powder up their noses, and his BP through the roof.
  13. by   AngelGirl
    Thanks, I.rae and caroladybelle, for the input. I suggest that ER's develop a central database, listing inappropriate "frequent flyers," and documenting the treatment they've received. If we offer them the same advice and treatment uniformly, (including a psych eval) which will obviously not be to their liking, they will hopefully lose interest in the what we have to offer them and leave the few remaining resources for those who are really in need.

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