[mustangsheba]

I didn't mean to imply that you were preaching to us, Honey. Just not to sound that way when approaching the doc. Probably didn't need to say that, did I? Sorry.

[sis]

I know that we all have heard the term "drug seeking patient". Until Nov. of last year, I had never had myself or family treated like a drug seeker. My sister age 36 had been fighting breast cancer for 4 years. I won't go into details. She was supposedly in remission when she started haveing sever headaches and vomiting. Was hospitalized for a week on morphin IV. All scans wee neg. Spinal fluid neg. except for very high pressure. Dc'd home. We made it for 4 days. Pain became worse. Went to ED at a regional size hospital. She had never ben through the ED befor. The nurses drug their feet. I could tell by their atitude what they were thinking. I had to stay on them to get her meds all the while my sis is crying and begging for a shot. Scans still neg. Admitted and put on morphin PCA pump.. The next night, while she was sleeping we went for dinner. When we returned, kThe neurologist had dc'd her pump because of change in level of consciouness. We could here her screaming when we got off the elevator. We found out that there were Ca cells in her spinal fluid. She was confused and disoriented. Pulling at everything. A "nurse" was telling her to quit pulling at things. We finally got morphine restarted several hours later. Do you have any idea how difficult is is to watch your sis screaming and crying in pain? Karla died 18 hours later. I have never been so disappointed and disgusted by some of my fellow nurses. I hope never to see that again. My point is to be very careful how you treat patients. One day you or someone you love may be in that situation. Tricia

[mustangsheba]

Tricia: I am so sorry your sister suffered. One more case history to support the argument for treating pain as reported by the patient. It is better to medicate an addict than to NOT medicate a patient who is suffering. The picture of a loved one suffering stays with us forever.

[MollyJ]

A difficult situation and we are sorry for you, your sister and her family. Again, the problem of the severe pain vs drug seeking dilemma is that these are not black and white situations and being with people that are in unalleviated pain is very difficult for those that have to be there.

I am sorry.

[suzannasue]

Hello yall,

I find the discussion about pain management very interesting. Pain is indeed the 5th vital sign and I have always acted as patient advocate even before it was mandated by any of our governing commissions.
We have all had those patients who seem to be seeking instant gratification from our pharmceutical resources and we have seen the suffering of those who have had less than adequate pain management.
This past weekend I was a pt in the ED where I work. I had fallen and twisted my foot. I could not touch my foot to the floor without screaming with pain nor could I even take the bumps in the road on the ride to the hospital due to the agony it caused. The wait was not long in actual time however my foot told me we had been there a week or more!!!!!!
My foot was x-rayed and luckily there were no fractures. I was seen by a P.A. and in his opinion and past experiences "sprains don't hurt that bad"...I described the pain on a scale of 1-10 as a 10 consistently...told him that I was having muscle spasms and if he didn't believe me all he had to do was look at my toes flexing and twitching...the vascular system of my foot was visibly throbbing. He gave me a prescription for an NSAID and would not listen to me when I tried to tell him that I have a sensitive GI system,in fact he just walked away from me. My husband asked for me to be given something for the pain and the P.A. raised his voice and said "we don't give narcotics for sprains".
Well...then he turned on his heels and said "you're welcome"
The next 36 hours were horrible and I experienced a lot of pain ....a LOT of pain. Oh yes,I applied ice packs and elevated the extremity and did all of the pallative measures I knew to do.
I cannot really express how this experience has made me feel.
No,I did not have cancer! No,I did not have a GSW! BUT...I was having pain...I presented with "10" and I left with the same "10"!!!
No medication was given to me for pain control in the ED. The prescription he gave me caused nausea and vomiting.
I feel the pain management guidelines and assessment tools are a farce until there is a seminar that dwells on the meaning of the word "subjective".
My health care plan does not pay a lot when used at another facility...HOWEVER.......due to the fact that I was not treated as a human being, I will not subject myself to this inhumane person who rates pain on his "personal experience" of pain. I will gladly pay 80% of the costs if I can find a facility that has personell who use the JCAOH mandated subjectivity to any discomfort or injury I may have.
Thank you for letting me vent...the shoe was really"on the other foot"this weekend and I have been livid that I recieved less than adequate care where I work. Geesh!!!!!!!!!
I have filed a complaint through the proper channels. We shall see what the outcome may be.


Gimpily your colleague!!!!!!
suzannasue

[P_RN]

Hi y'all? Hey another southerner? Wow. I'm not usually in this forum, but boy a nerve got tweaked when I saw this thread.

Most of my career has been in adult orthopaedics in a major teaching hospital. Our patients had PAIN!!!! Try having the top part of your femur sawed off and a new hip pounded in there!

On the other hand, because we were so skilled in pain med management and epidural and PCA management, we got many, many sickle cell crisis patients. Have you ever SEEN what SSC does to a person? It is agonizing. It's a constant TEN . Unfortunately the meds that make it bearable also make for addiction.

Our folks were "frequent flyers," but I seriously doubt they sold their pills after discharge. A slight change in the weather, a gals period, or even stress could set off a vaso-occlusive crisis. They asked, I gave. Most of the time it was for agonizing pain. Let me tell you a "10" can't usually do anything but scream!

Now *I* became a pain patient myself after my work injury. I can't say that I had a 10 with the herniated disks, but I surely had a "9." I finally went to a pain management doctor because......yes *I* was drug seeking! I was IN PAIN!!!! Fortunately he believed me and gave me a short course of narcotics including fentanyl patches. Only 3 weeks to get me out of pain so I could cooperate in therapy.

You say that folks walking and talking and laughing CAN'T be in pain? Haven't y'all heard of DISTRACTION?? I would get up at night and walk and lean on walls to try to forget about my leg that was on fire. I said I had PAIN. The doc believed me. The pharmacist even delivered the med to me.

Believe me. PAIN should be the FIRST vital sign! BTW I still hurt some, but not like before. I still get up at night. I am never going to be able to work as a hospital nurse again. But if I went back, I tell you now that when someone SAYS they have pain, it's not going to be ME who denies them the med.

And I have lost family members to alcohol and drugs too so I am not immune to what that feels like. I also watched my sister in law with terminal diabetic kidney disease and pathological fractures NOT be prescribed anything but Tylenol because the renologist didn't want her to get ADDICTED!! She died at age 34!!

OH and just because someone OD's and has oxycodone in their blood, it doesn't mean that Oxycontin is to blame. There are at least 10 other meds that have the same ingredient. The same company that makes Oxy tried to get a sustained release Dilaudid on the market....guess what.....nope, no can do.....because of the Oxy stories. It's OK in most of the world, and available right there in Canada though.

[misti_z]

Very interesting thread we have going here...
I, too, believe it is better to medicate a addict than to not medicate a pt in pain. Pain is very subjective. What's a 10 for me maybe a 8-9 to you.
But sometimes I do not feel comfortable giving the desired (by pt and MD) dosages. For example, right now there is a pt where I work that has been with us for 3 wk almost 4. She is in with sickle cell crisis. I know she is hurting. Her expressions, verbal and nonverbal, indicate pain as do her lab values. She is receiving 150mg Demerol q2h scheduled. And it is proven that >800mg/day can cause renal failure and/or seizures. She is getting 1800mg/day and has been for 3 wks now. Now that her labs are resolving her pain is still a 10, and I believe her but I also believe she is addicted. One of the few reasons I think she is addicted is because she demands that you give it IV push through her femoral TLC, a nurse tried to use the syringe as a secondary on the IV pump because she had 6 other pt to get meds to. The pt yelled and cursed so loud she was scaring other pts, so she demands the push. The 'Pain management doctors' refuse to see her anymore because they do not believe she is in pain, and her doctors will not attempt to taper the dosage at all.
I just hope she does not seiz and code from all the Demerol she is <25 yo.

[JillR]

I hate the term "drug seekers" because it implies that the person who is seeking pain relief is addicted or abuses drug in one form or another.

I do know that some people do seek drugs for recreational use, and I hate that, it gives people who suffer from Migraines, back pain or any other form of chronic pain a bad name.

The whole oxycontin thing is terrible. The people who have misused this drug have taken a very useful, safe and effective medication and gave it a bad name, and that stinks. I work in an emergency room and I (almost) always refuse to give out oxycintin to patients, I will give them an alternative to take home (if ordered by the Doctor) with them until they can get a refill of their oxy from their PCP, but I have refused to send people home with the med. The reason I do this is because, unless the person has a well documented reason for taking the medication on file, I tend to think that if someone comes in to the ER and asks for oxy there is a very good possibility that they are either abusing it themselves, or want to sell it.

On another point, I have a tendacy to twist and sprain my right ankle periodically and I usually live with it. However one time I sprained it so bad that the size doubled immediately and the pain was excrutiating, like nothing I ever felt before, a definate 10. The doctor in the ER gave me Torodol IM and sent me home on Vicodin and the torodol worked better than the vicodin, but I doubt very much that Ibuprofen would have even touched it. So, to anyone who has never experienced a real bad sprain, they are very painful. I broke my elbow a few years ago and that pain was nothing compared to the sprain.

People who seek drugs, do so for many reasons. They may be seeking because they have real pain, emotional pain that it showing itself as physical pain, they may be afraid that they are not going to have enough pain meds and in fear that the pain may come back, or the may be addicted ( which is, by the way 1% of patients who take narcotics). They may have become tolerant and need more meds more frequently to control the pain, tolerance does not equal addiction.

I also want to add that there is a big difference between physical dependancy, addiction, and abuse.

Also, just because someone asks for pain at the exact time they can get it does not mean that they are "seeking" as many people think of seeking, they are probably seeking pain control and maybe augmenting the percoset (or whatever) with ibuprofen or another NSAID, antidepressants, anticonvulsants or other classes would be more useful, I have found this to be very useful with my pain, as I then have to take less of the narcotics. One other thing I try to do is to get the person off IM,SC, or IV meds ASAP and go the oral route. I simply explain to the patient that the oral meds work longer and that one of the goals of pain control is to get them to take only oral medications.

A suggestion for the man in the LTC facility would be a transdermal fentanyl patch or MS contin or even oxycontin with something oral for breakthrough. I would have a tendancy to stay away from the oxy with him though because of the risks for abuse.

I don't think we can exclusively judge someones pain by how they are acting, but when I have suspicions, I document their behavior before and after the medication administration, I use quotes alot. For example I had a patient come in the other day with chest pain, stated she was allergic to all nsaids and such and NTG was not working for her pain, then she had a HA after the NTG. Refused an IV, wanted IM meds, when I told her I could not give her anything IM with chest pain, she then wanted the IV. With the chest pain better, wanted something for her HA, MD ordered Tylenol. Pt made the statement "If all you will give me is tylenol, I will go home then". Pt checked out AMA. I documented this in quotes, along with other statements she had made. If the doctor would have ordered a narcotic for the meds after she threatened to go home (which he didn't) I would have had her rate the pain given her the med and documented the conversations with her and the reaction of the patient. I will not refuse to give pain meds, but I will document when I have suspisions of seeking behavior.

[nurse T]

I just went to a seminar called 'Pain, The fifth vital sign'. Put on by VA. Due to JCAHO 2000 revised standards for pain assess and management. It was reported that hospital ER's will be expected to relieve pain immediately rather than waiting for assessment to be completed. Through research, JCAHO discovered severe health problems resulting from unrelieved pain. Too lengthy to write here but as ex: Severe acute pain is a major risk factor for chronic neuropathic pain,, unrelived acute herpes zoster pain WILL develope post herpetic neuralgia 6months to 9years later unless pt recieves aggressive analgesic TX in the acute phase. Also pts with more severe pain before amputation are at greater risk for more severe phantom limb pain, can be avoided with preop epidural blockade. I work in hospice and must teach pts pain management: take meds routinely to prevent pain from getting out of control, it's too difficult to play catch up if pain is already too severe. I find many of my pts with chronc pain have already discovered this on their own however have done so without the benefit of nurse education. This results in pts scrambling to take whatever they can get their hands on without the knowledge of the medication's expected effects, onset, duration etc. This would appear to other professionals as drug seeking behavior, I call it pain relief seeking behavior. Many physicians are in a hurry to meet JCAHO standards and prescribe without assessing the duration, quality and intensity of the pain. Nerve type pain will not be relieved with opioids, some antideppressants such as elavil and antiepileptics such as neurontin have proven to be very effective at nerve pain relief. We changed our nursing assessment form to include all aspects of pain in the vital sign section for all pts, not just hospice.

[P_RN]

I totally agree about the meperidine. We had one guy sieze in the bathroom, hit his head on the sink and had a cva as a result.

Another time we had a patient who went into status from meperidine and died!

Both were SSC patients and both were patients of the same doc. He then started using dilaudid. No bad effects that I can remember, except having to give 5 or 6 amps at a time. The straight push into the central line of demerol gives a "rush" you don't get from many other narcotics. I'm sure that's why some ask for it that way.

The docs would usually leave the IV fluids on the total admission time (usually about a week) mainly to help the nurses but also to avoid any excess heparin from flushing so often.

P