[MollyJ]

Pappy,
To me "doctor shopping" is when a patient is getting narcs from 2 or more doctors and those doctors DO NOT know that another doctor is prescribing narcs for that patient. This is how addicts keep a ready and complete supply of narcs on hand: multiple sources. Complex care patients often have multiple specialties involved and ideally they all know about each other and interact and, for the outpatient, only one of the those docs does the pain management.

[fab4fan]

There was nothing in my post that stated that addicts don't exist; what I was saying was that many of the things nurses use to label someone a "seeker" are not accurate measurements.

For that matter, to call someone an "addict" is to make a medical diagnosis...nurses do not make medical diagnoses. Usually, the term is used arbitrarily and in a derogatory manner.

Pts. with chronic non-malignant pain usually try very hard to look "normal". This winds up being a double edged sword: Look too good, and no one believes your pain is that severe...look bad and you're overdramatizing your symptoms.

Even "doctor shopping" may not be a hallmark of an addict. People with chronic pain have usually tried multiple doctors and multiple meds...I prefer to think of them as being "pain relief seeking", something that I don't believe is a crime.

I work in the ED, and yes, there are people that are looking for their fix. But I don't believe it's my job to determine if someone is an addict or not...there's not enough time to do the kind of evaluation that's needed, and again, this is a medical determination.

I live with a chronic pain condition, too; unless you have had these labels tossed at you, you will never be able to understand how truly devastating it is. I am so very thankful that after 15 years of suffering (in silence, a good deal of the time, since no one wants to hear about your pain) I was able to find a doctor who had the intelligence and compassion to realize that I needed relief.

If you have any doubts about someone requesting pain meds, ask yourself this question: Will providing pain medication improve this person's quality of life. It won't, in an addict. In someone with chronic pain, it usually does...it lets them get out of the house, go back to work, socialize, etc.

Pts. with chronic pain don't usually experience a "high" like an addict does...pain pts. will usually have no idea what you're talking about when you refer to it. That's because the drug is relieving their pain...there's nothing left over to give a "buzz."

True addiction rarely occurs in pts with chronic pain. Tolerance does occur, over time, but tolerance is a physiologial reaction, it is not addiction. So when someone says that his/her pain med no longer works, please don't assume addiction.

Obviously, this is a topic that stirs a lot of emotion. I would just ask that we use care and discretion when suspecting addiction; it is a complex illness that cannot be made in a cursory eval.

[pappyRN]

Molly J and fab4fan- thanks for the discussion. I have enjoyed the opportunity to share thoughts with all who have replied.

Fab4fan I totally understand when you say nobody wants to hear about your pain. It sure is a good way to see who your real friends are. The ones who can't take it or don't know how to be supportive bolt like lightening.

Fab4fan, I am so sorry that you also endure a chronic pain problem. I hope you are getting the relief that you need and I will keep you in my prayers. I know you completely relate about how it feels to be accused of making it up.

Just one more thing before I end my post. About 1.5 yrs ago while being treated for the inevitable depression I was seeing a psychiatrist for my antidepressants. In spite of all the above listed diagnosis he had the nerve to say to me "Shame on you for having to take pain medicine. Don't you know the human spirit is capable of tolerating great amounts of pain?" Go figure! It just blows my mind. He also accused me of possibly being an addict. He really hurt my feelings!

After him I started seeing a pain psychologist and a great PT who has done positional and myofascial release, body talk, facilitation of lymph drainage, cranial sacral work and taught me several cognitive behavioural techniques.

Again, thank you all for the discussion of this topic. Pain free lives to all.
Warm personal regards,
PappyRN

[thisnurse]

i dont care if my pts are seekers. yeah some of them are. if the doc orders the meds i give them as ordered. most times the docs know their pts are seeking. i can think of one pt in particular who was always coming in for pancreatitis until they cut his pain meds. he walked out AMA and we havent seen him since.

my job is to give my pts the meds they are ordered. what is the average length of a hospital stay? 2, maybe 3 days? none of my pts are going to get addicted in that amt of time. if they already addicts the drugs im giving arent going to make much of a difference one way or another. i dont have a judgemental attitude when i give the meds. i just give them and i treat everyone with respect...thats my job

i hate that so many nurses hold pain meds when they think someone is a seeker. i have argued with more than one nurse about this. i dont care what they do while they are on duty but im not taking the chance of not medicating someone in pain. ive had this done to me. i just wont do it.
equally, i hate that docs undermedicate the elderly. i cant tell you how many times i have had to FIGHT for morphine for my elderly pts with huge decubiti. i had a doc stop me from giving morphine to a pt they were debriding. "she doesnt need it, there arent many nerve endings under the dermis. it doesnt hurt"
pt was nonverbal...and yes it did hurt her. she flinched and moved all over the bed.
why on earth would this surgeon not want me to give her 2mgs of morphine while he debrided her woulds?
its just cruel

[MollyJ]

The problems of pain, chronic pain and drug seeking are very complex and I think the one thing that I do agree with is that it is hard to build sufficient knowledge of someone to legitimately confront addiction when it is present. I want to acknowlegde that many of us who work in ED's and have very rare patient contact with an individual; see a patient for a single hospitalization that lasts mere days; AND for those of us in the ED that cope with pain patients who don't have the financial wherewithal to have a doctor of any kind and hence are "unassigned" can have real problems with identifying a patient in trouble and finding a system with which to work in order to do a referral (either for appropriate pain management or addiction eval). On the other hand, for many clients the ED is the patient's last health advocate.

All of you are correct when you say that you cannot identify addicts on the strength of a short contact or a scattered ED visit. But when patients are repeaters, you can get a flavor of their issues, just as you get to know how Mrs. Smith's chest pain presents (in her elbow) or how Mr. Jones' drool turns purulent when he's got a pneumonia.

You know good care is always the combined efforts of patient, doctor and health care team, whether we are talking diabetes management, pain management or whatever. The responsibility of a patient is to be the best possible historian and to bring a list of all current meds (or the actual meds) to any health care visit. All of these "duties" fall especially hard upon the chronically ill patient, when they may have so many doctors involved in their care. This means that pain management clients must be up front about what meds, how often, who prescribes.

Recently my local hospital has seen a significant increase in pain mangement clients OD'ing on their pain meds and dying. They were all out-patients. Do you doubt these folks had contacts with nurses in the years, months and days leading up to their death?

Now many of you have posted that you feel terrible about neglecting someone's pain. No argument there. That is why I always say, sooner or later when we talk about this issue that the nurse must take very seriously her "power over" patients when she carries and controls the narcotic keys.

However....

Do any of you feel bad about feeding an addicts addiction?

Does the term "iatrogenic illness" mean something to you?

The first act of a nurse concerned about addiction is not to quit giving meds that are ordered (unless the patient is over-sedated and it is a matter of life or death). It is to start gathering data, just like you do when your floor patients start to show early PE signs. It is to communicate with the patient and the family and the health care team. The business of effective confrontation is not a flash in the pan. This may be a patient you refer to a case manager or psych nurse consultant that understands addiction.

Somewhere between the wasteland of "I never confront it" and "I just treat 'em ugly", there's got to be something else. That something else is awareness of the problem (it happens), index of suspicion, a willingness to get to know the patient and the family to see, hear and feel the impact of the issue on them, awareness of appropriate resources for referral and a willingness to be patient with what may happen next. (nothing/the status quo, slow change "This usage is costing me something", treatment, with potential for relapse or recovery). All of what I said also is true for your repeater drunks in the ED or in the hospital.

Remember, when you don't take the time to assess and intervene on addiction problems (and boy is it hard) you are writing off a significant and all too frequent problem.

Again, floor nurses and ED nurses may not have time to solve this problem, but they should act as case finders and know how to communicate with key people and encourage appropriate referrals.

[shygirl]

I believe in the patients. If they say they have pain, then they have pain. We have this one senior who askes for pain meds every time you look at her. "Can I have a pain pill"?, "Can I have a pain pill"? She is not able to identify pain anywhere. her blood pressure is 108/58,not indicative of pain, her pulse rate is 62, also not indicative of pain. She wears a duragesic patch that is changed q 3 days.
Her MD won't give her anything than extra-strength Tylenol!

She will be asleep and if you have to go in her room and she wakes up by accident, she says "Can I have a pain pill"! it is very exhausting telling her over and over she just had one, or she has to wait another hour or two hours. Any suggestions? Shygirl

[fab4fan]

"Power over patients"?? I've never felt this way; to my mind, it sets up an antagonistic relationship between nurse and pt. I've always felt that we needed to collaborate with our pts., not have power over them.

There is some very interesting information on the term "drug-seeker" in the latest pain mgmt. manual by Margo McCaffery. I was tempted to quote it here, but since I didn't ask her permission, let's just say that the pain mgmt. community takes a dim view of the term (and not just Ms. McCaffery).

We could probably go around in circles on this issue, but I doubt at this point that we're going to change each other's mind.

BTW, I did work in a substance abuse center, so I am familiar with seeing true addictive behavior; I can count on one hand the people I've seen in the ED who actually fit the diagnostic criteria.

Seeking relief from pain is not a criminal offense.

[Jen911]

Reading all your posts makes me wonder what you'd all do if I were your patient??

I have three bottles of narcotics sitting on my desk, all written by different physicians, different narcs, for different reasons.

My history... I have Benign Intracranial Hypertension (aka pseudotumor cerebri) causes severe headaches. I take Darvocet for breakthrough headaches when my Maxalt doesn't work. I also take Topamax and Verapamil for this.

I have also passed 13 kidney stones this year alone. I have hyperparathyroidism causing this. Therefore, I keep Lortab 7.5mg tabs on hand for the pain prn. Last script for 20 tabs was filled 2 months ago, still have 2 left, got the next one filled just in case....

Last week I had surgery for a ruptured ovarian cyst, thought it was my appendix, took care of both. Told my surgeon what I was already taking, so he was aware of my previous narcotic usage. He asked me if I wanted to take Darvocet at home post-op. I declined, stating I didn't want to build up a tolerance to the Darvocet, since this was what seemed to work for my headaches. He seemed to concur, as this was a chronic condition. He then wrote for Vicoprofen, stating there wouldn't be as much Tylenol running through my liver. He did seem to overdo it, tho...wrote for 50 tabs with 2 refills....seemed a bit much.... Wondering if the pharmacy reports back to him when I refill each of those and he's looking for me to be a seeker? Nope, didn't need the last bottle...LOL.. (however, I did need a few from the 2nd due to a raging wound infection, pus running out my incision..gross).

Anyway, it IS possible for some patients to need different narcotics from different physicians... My Darvocet is written by my neurologist... can't take the Viccodin for the headaches, just makes them worse (look it up, it's a contraindication to take it with elevated CSF pressure, which is when I'm having a headache).... yet I can't take the Darvocet for the kidney stones, it doesn't touch the pain.... And the Vicoprofen? Well, the was the Surgeon's choice, I just didn't need that much Tylenol this week, I guess...he didn't need to write for THAT many, tho!

Another comment I wanted to make... Yes, patients can laugh when they're in pain. When I went to the ER with my abdominal pain last week, I was able to laugh with my co-workers while I was being evaluated. That's just how I cope with pain. It doesn't mean I don't have pain! I've had chronic pain for so long, I'm able to hide it untill you have no clue I'm hurting so badly I can't see straight. Yes, my blood pressure, heart rate and temperature showed my pain, but I was still able to joke around. That's just how I work.

And no, I don't go to work under the influence of narcotics, in case you're wondering! LOL

Have a good one, and thanks for listening!

[MollyJ]

Originally posted by Jen911
....Last week I had surgery for a ruptured ovarian cyst, thought it was my appendix, took care of both. Told my surgeon what I was already taking, so he was aware of my previous narcotic usage....

Good communication with your docs is a key point when you are taking meds (any meds) from multiple sources.

[coleen]

"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"

Just a comment about the above statement - I wonder who the misusers are? The pain clinics that form lines around the block to just step up and get your oxy script, i actually went to a pain clinic- referred by my doc (2 herniated discs one in thoracic - inoperable) This pain clinic only required me to come once a year and they mailed me the # 90 oxycontin tabs and #90 lortabs faithfully the first of every month.

Also what a wonderful drug it is huh? I never abused my short acting narcs but as soon as I was changed to oxy - yikes - nobody can deny the intense euphoric feeling it gives! It is like potato chips - you can't keep your hand out of the sack. This is probably true for me because my family has a history of substance abuse - in the closet , too! Now I know I should have never started narcotic meds-family history too dangerous.

Next - add a full time job , night school 85 miles away, death of my best friend, 2 wks later the death of 53 year old Mom during her gall bladder surgery -a teenager with depression and yada yada yada - It's very easy to feel more pain than usual and YES to use them for mental pain, anguish, to stay awake and study and eventually - Oh it's Monday I better get a bottle. I am not a bad person. I was a sick person. And as far as drug seekers go - the withdrawing opiate addict is probably in more pain than you've ever imagined. I think sending them to treatment instead of giving touradol might work.

I never set out to ABUSE THAT GREAT DRUG which the "GOOD NORMAL" people with REAL illnesses need. If you asked me what the worst experience in my life has ever been - next to my Mom's death - Oxycontin DETOX- Yes the 180 pills a month i started on became 50 oxycontins a day 4 years later, 3 pain clinics going at once and I knew I was sick sick sick but I would have rather died than go through that detox.

as my md states - anybody would have gotten physically addicted to my very first rx'd amt - addicts or non addicts in less than 2 wks on the stuff.

Addiction has almost ruined my life, my marraige and my nursing career not to mention my self worth. But for the Grace of God I have been given another chance and now I am grateful . I am now the best nurse I can be because I 've felt real agony, defeat, humilty and yes courage and faith. I didn't have those things to give before. So I've turned it into a blessing and I pray I can keep sober one day at a time. Thanks for letting me vent.