[TopazStone]

I have medicated patients q4h for cancer pain, I have snowed patients, I have advocated for stronger pain meds, but I feel that the term "drug-seeker" is valid. I have an elderly patient who greets me with "Hi honey! Can I have my pain pill?" I have watched her outside, walking fine, begging for cigs; when she sees me, she hunches over and shuffles. She is unable to rate or describe her pain-- when asked, she takes a long time to decide on the site and how it feels. This woman also suffers from constipation and frequent falls-- wonder why? (Darvocet q4-6h PRN). She goes to one of our local "pill pushers" that will prescribe 6 NSAIDs, pain killers and ASA . . . Yes, she is an abuser, but the doc won't change her to a non-addictive pain med.

[Ellen in Ont]

I agree that we should be aware of the possibility of addiction in patients who constantly ask for pain medication. This has never stopped me from treating all requests for pain meds as legitimate, only allowed me to use my assessment skills in dealing with pain. Pain is one of my priorities and I treat it aggressively. However, I have seen a few cases where I believe they were misrepresenting their symptoms in order to get the meds. I work in an ICU/CCU and only last month we had a patient admitted with chest pain. He watched TV, read, joked with family etc when he didn't think we were looking. As soon as he saw us approaching his room, he turned off the TV, hid the book, stopped talking to family etc and started rubbing his chest and looking distressed. There were no change in his vitals, no ECG or enzyme changes. After treating his pain aggressively for about three days with IV Morphine, Nitro gtt etc.with no change in his complaints, the doctor ordered the IV Morphine changed to Tylenol #3. When I told the patient this, he became very angry, refused the Tylenol #3, stated he had "better stuff than that at home", also said "why didn't you tell me that the doctor was going to D/C the Morphine this afternoon - I've wasted hours here", and signed himself out. I still aggressively treat all complaints of pain but I also use my assessment skills to assess other reasons for frequent requests for narcotics.

[fergus51]

I just have to say that I don't know how I can determine if someone is genuinely a drug seeker. Behavior like joking or walking around doesn't mean someone doesn't have pain. I had back injuries from a car accident and that is how I coped with my pain and stress. I think we tend to believe that unless someone is grimacing and staying in bed all day they aren't in pain. It forces patients to act like that if they want their pain treated. Then they look like phonies and can be labelled drug seekers. I just don't know the answer to this problem...

[mustangsheba]

If you knew the answer Fergus, you would be standing before some committee on the Hill. This is an enormous problem. I will continue to treat pain aggressively. However, I would notice if a patient such as Ellen describes and talk to him about his behavior. However, outside of substance abuse treatment centers, the addiction that has been most prevalent in my experience is ETOH. Personally, I don't care if my LOL's are addicted as long as they are comfortable and the drug isn't causing falls. I have seen too many others who couldn't move and were depressed because no one addressed their pain. With pain relief, their quality of life improved immeasurably. As has been mentioned before and is a true story, bottom line is individual assessment.

[majic65]

Just a couple of thoughts on this HARD issue. the first--we should all know that pain meds are more effective when they are given on a regular schedule, rather than PRN--especially post-op pain. So the pt. who asks for her meds on time is in fact helping us medicate her properly.
Second--has anyone else had patients who appeared to be drug users in the "outside world" who needed pain meds? I have,and I have also seen my peers refuse these patients meds, "because they are probably already addicted" or some other nonsense. In fact, a patient who has/is abusing drugs often needs more pain meds because of increased tolerance. In short, pain in pain and our goal as nurses is to help the patient cope with all the ways the disease system is affecting his life--and pain is a big part of that. Who are we to judge what hurts???

[mustangsheba]

Amen, Majic!

[diane1023]

I too say amen to majic Pain is Pain and is a subjective and individualized. I have fought many times with Surgeons who feel that their pts. don't have pain post-op! I also get angered at co-workers that feel the pt. can wait, It is a PRN correct?

[night owl]

I too have always believed that if a pt states that he has pain and would like his "pain pill," then I give his pain medication without any hesitation. The only question I have is, "What number is your pain On a scale of 1-10, 10 being the worst?" then promptly return with the medication which on my LTC unit is usually Tylenol, Tylenol#3, Percocet, or Hydrocodone. Once in a while maybe MSContin. We had an resident admitted at the end of April. Dx: PTSD, depression, schizophrenia- chronic undiff. type, alcohol dependency, Post-op (surgery in Dec.2000) for hydradenitis axillary and groin regions and also diabetes Mellitis. His surgical areas were slow in healing. Axcillary completely healed, groin area, still has some weeping drainage. The res. is 51 y/o, does own ADL's,and does his own TX which is intrasite gel with DSD, OD. He has a MS04 30 mg IM q6 h prn for pain which he has been receiving since his surgery in Dec/'00. He transfers to his w/c by himself and once he's in it, he's gone off the unit. He returns for his meals and his MS04, then off he goes again. If he is sleeping during the night,obviously he can't be in that much pain. When he wakes up, the first thing he asks for is MS04 and gets angry when staff dosen't wake him up for it and of course we explain that we won't wake him up to give him a prn med. He must ask for it. The only weaning of this medication since his arrival was changing the time from q6hrs to q7hrs. His pain level is always a 10, and has always been a "10" since the surgery. Should he have been weaned from this alot sooner, say like a week after the surgery??? He was admitted directly from the hospital where he stayed for 4 months and received all of this MS04. Now he's with us in LTC where the Dr. continues to give him this drug, but only one hour later. His history shows that he's been in and out of the Psych Unit for flashbacks of vietnam, hearing voices telling him to "hurt other people" which he says that he would never act upon, he's been admitted in detox for alcohol abuse. He is presently on Clonazepam, Resperdol, Zoloft, Nph insulin with coverage, and a few others that I can't even remember. He knows that as long as he has MS04 ordered, he is allowed to have it. Now I ask you all...Is he a "drug seeker," or someone who is just in alot of pain? Pain from post-op surgery or pain from being delt a bad hand in life and would rather be "numb" to all of it??? Eventually he wants to be d/c'd and go back to his apartment. Then what? If he continues to receive MS04 in some shape or form AND starts to drink again, he'll probably kill himself! I feel so frustrated on why his real problems aren't being addressed. Now social service is trying to get him an electric w/c to go home with. Sometimes it sucks being a nurse when you don't have any answers...

night owl

[MollyJ]

Nightowl, your alcohol abusing/addicted client is likely cross addicted to the morphine you're giving him. Now, I don't know the patient and there is alot I don't know about the situation so _my first statement is very brazen_, but nurses need to be aware of the risk of cross addiction to other substances. That means that when an addict's chemical of choice is not available they will use other chemicals and become addicted to other chemicals.

A consult by a physician who specializes in pain management and has experience in working with addicts would be useful. I think there are many relevant perspectives here. Does the client and/or his family WANT the addiction addressed? How do you folks feel about professional enabling? Are you willing to treat this as a harm reduction situation? (In face of the fact that no one is willing to address the addiction, are you willing to help him use his chemical in the least harmful/safest way?) The latter question may be your best case framework for the whole situation. I personally would be reluctant to enter into a power struggle with a patient when no one else (the patient, his family, his doctor) was concerned about his usage. You could get real tired.

This is a real life incident of you can run but you cannot hide from addiction problems in your nursing practice. If addicts have learned that cutting themself to put blood in their urine and acting like a kidney stone will get them a single shot of morphine, do you think they can fail to learn that replying "10" to a pain scale will get them a shot of morphine? I am not saying he doesn't have pain. But I am very concerned that their is a co-existing addiction problem here.

Good luck.

[night owl]

Molly, Thank you first of all for responding to my post. This senario is a tricky one I must admit. This particular client has family, but they are not supportive in his care at all. As a matter of fact, they haven't had any contact with him in over a year.

Most nurses on our unit would rather just give him the medication because as they state,"who wants to hear him." It would be a very exhausting experience to try to wean him off at this point especially since he has not expressed his desire to do so. He becomes extremely agitated when he doesn't receive the morphine on time even though it is a prn order and yes it becomes a power struggle!

I'm sure that he has a certain amount of pain, but in my opinion, alot of it is coming from within and morphine is helping him to numb that pain just like alcohol did before he had the surgery for hydradenitis.

At this point he needs alot of intervention from a psychiatrist, a pain management physician, his physician, the staff and probably needs to be on a unit that manages drug addiction because a nursing home is not a place for that kind of intervention.

If and when they decide to discharge him and it is in the making, my best bet is that he'll either be admitted to the detox unit for alcohol abuse like he has so many times in the past, or to the county morgue for morphine overdose. I would love to help this man, but his problems are much deeper than I can handle and it seems that no one else is willing to give me or him the support that he really needs. It's a real shame...