Accidental Pill Pusher - page 3

Accidental Pill Pusher In the early 80’s nursing education about pain management took a turn. Gone were the days of observing the patient for non-verbal signs of pain or of watching the clock to... Read More

  1. by   jeastridge
    Quote from jeastridge
    Studies show that initial dependency often happens after surgery for orthopedic problems, wisdom teeth or other "routine" procedures.
    Could you provide links to those studies?
    http://www.uky.edu/~pjsamm1/Dentists...id%20Abuse.pdf
    Data Overview | Drug Overdose | CDC Injury Center
  2. by   jeastridge
    Quote from macawake
    Well, I think that most people agree that pain negatively effects quality of life and as nurses we know that it has many physiologically detrimental effects on the human body. So yes, I agree with thinking of pain as an enemy. It's only really useful in the ultra-short term when it signals to us that we should pull away from/stop doing whatever's causing the pain in order to protect us from sustaining further injury. Beyond that, it's just one huge stressor on the body.



    Could you provide links to those studies?





    (my bold)

    While I have no doubt that you are well-intentioned I always worry when I read posts like yours, describing the problematic "opioid epidemic" and suggesting that the solution to it can be found in the acute care setting, and in how we manage postsurgical pain. I think that this fear (sometimes bordering on hysteria/moral panic in my opinion) of causing addiction negatively affects many patients, both individuals who suffer from chronic pain and patients who have recently had surgery.

    There's nothing wrong with a multimodal approach to pain treatment for postsurgical patients (the same goes for chronic pain) and I'm not saying that many of your suggestions don't have merit. They do. But opioids often (almost always, unless the surgery is very minor) have to be the first choice in the immediate period following surgery. You will not cure the opioid epidemic in the acute care setting. It's not the time nor the place.

    Pain isn't "innocent", it isn't a mere nuisance that we can stoically suffer through without any ill effects.

    Undertreated postsurgical pain results in needless suffering for the patient. The sustained stress response that is the result of undertreated pain causes elevated catecholamines, cortisol and increased catabolism. That is not beneficial. It increases anxiety, leads to poor sleep, limits mobility, increases risk of thrombosis, pulmonary morbidity (both pneumonia and embolus), suppresses the immune system, delays wound healing and increases the risk of infection and also increases the risk of the pain becoming chronic (persistent postsurgical pain).

    Please don't let your fear of opioids make you undertreat your patient's pain. It will hurt them.

    Before I became a nurse I've had half a dozen surgeries, several of them traumas. Fortunately I had nurses and physicians who weren't in the least bit scared of opioids and they treated my postsurgical pain to as close to zero as they could come. That allowed me to heal and do my physiotherapy and recover fully with no sequelae. I never needed opioids for much more than a week after any surgery and sometimes just days, but they would have treated me for as long as it was necessary. I'm glad I had knowledgeable healthcare professionals.

    These days, I make sure that my patients are as pain-free as I can make them.




    "Old-ish" but still relevant:

    Improving the Quality of Care Through Pain Assessment and Management - Patient Safety and Quality - NCBI Bookshelf

    Understanding the physiological effects of unrelieved pain | Practice | Nursing Times
    Thank you so much for your thoughtful comments. The intent of the article is not to "fuel hysteria" or even to suggest that the problem is a simple one. Of course, pain needs to be treated. Of course the addiction problem is a systemic societal problem and there are not simple solutions or easy answers. We need to work together to improve mental health, youth mentoring, family health, counseling services, addiction treatment, job availability, and the list goes on. The intent here is simply to say that as professional nurses we have a role to play. A role. Not the only role. But we can all do something to help. Joy
  3. by   MrNurse(x2)
    My brother was a heroin addict because of chronic pain from hip misalignment, something requiring hip replacements at 48. He needed a pain consult because he was on suboxone. He only took Tylenol for the last three years because of other health issues. This doctor spoke to me very candidly about the issue. Dilaudid, the main go to in ER's across the country, not only resets the body's tolerance (even marijuana does that), but, scarier, resets the pain perception, so what was once perceived as 2/10 may now feel like 4 or 5/10. The real horror, he said, was research shows that as little as one dose of Dilaudid may do this. I. too. live with chronic pain. My understanding of the practice act keeps me from taking any pain med, save a few Motrin when it gets really bad.
  4. by   3ringnursing
    Quote from MrNurse(x2)
    Timely delivery. I am a school nurse in a K-8 of only 125 students. Even at this young age, very few will endure a little inconvenience of pain. I have one today with a gum ulcer who has been in 5 times for Oragel. He then returned because it wasn't working. The look when I told him he may have to live with this discomfort was priceless. Where do they get this? Parents. Assessments ask what tolerable pain level a pt can withstand, my most common answer was zero, even after an attempt to clarify. We are a coddled society that demands comfort above even safety.
    I had ulcers in my mouth and throat a few years ago - I was surprised it was so painful that I didn't even want to swallow my saliva. I was so surprised how painful they really were that I quickly became dehydrated.

    That was a a shocker. You learn something new even when you are an old fart like me.

    Of course the Oragel didn't work after a while. He became tolerant to it's effects (it's also surprising how quickly we as humans become tolerant to any medication to ease our suffering - even ibuprofen).

    Poor guy. He learned an important lesson that day: pain sucks. Too bad no one taught him about the use of a simp!e black tea bag for that darned screaming ulcer. Works every time on mucosal ulcers no matter where they are, or what causes them.

    There are very few modalities available that enable one to out run pain, but eventually none work forever. If you don't have pain you really can't possibly understand what it is like, especially if it never goes away. Learning to live with it isn't always possible, depending on the nature of it. Many chronic pain suffers have a wide variety of things they use to tolerate it, from hot packs, cold packs, counterirritants, whirlpool spas (if they are lucky), inversion tables ... and the next new thing to add to one's arsenal is always being searched for (Magnets? Floating in warm salt water? Let's do it!). There is always one eye open for the next new thing that can bring a modicum of relief, even for a little while.

    Pain can be a sentinel being with a vile temper, which at times will not be ignored. Just you try - it laughs in your face!
    Last edit by 3ringnursing on Oct 16
  5. by   subee
    Check out last night's 60 Minutes segment on the cozy relationships between Republican lawmakers and the drug distribution companies. I don't think that Jarrod gonna be able to fix this one.
  6. by   jeastridge
    Quote from 3ringnursing
    I had ulcers in my mouth and throat a few years ago - I was surprised it was so painful that I didn't even want to swallow my saliva. I was so surprised how painful they really were that I quickly became dehydrated.

    That was a a shocker. You learn something new even when you are an old fart like me.

    Of course the Oragel didn't work after a while. He became tolerant to it's effects (it's also surprising how quickly we as humans become tolerant to any medication to ease our suffering - even ibuprofen).

    Poor guy. He learned an important lesson that day: pain sucks. Too bad no one taught him about the use of a simp!e black tea bag for that darned screaming ulcer. Works every time on mucosal ulcers no matter where they are, or what causes them.

    There are very few modalities available that enable one to out run pain, but eventually none work forever. If you don't have pain you really can't possibly understand what it is like, especially if it never goes away. Learning to live with it isn't always possible, depending on the nature of it. Many chronic pain suffers have a wide variety of things they use to tolerate it, from hot packs, cold packs, counterirritants, whirlpool spas (if they are lucky), inversion tables ... and the next new thing to add to one's arsenal is always being searched for (Magnets? Floating in warm salt water? Let's do it!). There is always one eye open for the next new thing that can bring a modicum of relief, even for a little while.

    Pain can be a sentinel being with a vile temper, which at times will not be ignored. Just you try - it laughs in your face!
    Well said. Pain can be nearly impossible to live with and can easily take over our lives. Looking for the next thing to help is always out there. If we have come up with opioids--who knows?--we could come up with something even better. Nice thought. Thanks for sharing. Joy
  7. by   d_eRN2017
    How do we make hospital management get this? When I try to explain to my acute pain patients that I don't want to over-sedate them with too many narcotics after they've called for pain meds and then fallen back asleep by the time I get to their room, I get belittled and complained about during AM rounds and end up in my director's office due to low patient satisfaction. Everyone has to be on board for things to change - but not at the expense of pt's with chronic pain.
  8. by   BostonFNP
    Quote from d_eRN2017
    How do we make hospital management get this? When I try to explain to my acute pain patients that I don't want to over-sedate them with too many narcotics after they've called for pain meds and then fallen back asleep by the time I get to their room, I get belittled and complained about during AM rounds and end up in my director's office due to low patient satisfaction. Everyone has to be on board for things to change - but not at the expense of pt's with chronic pain.
    Well we all know that PG scores are inversely correlated with both cost and mortality, so makes ure administration knows

    There is also the issue of personal bias we all have to consider. Is the patient truly dangerously over-sedated by narcotics or is the patient asking for more medication then we think they should need or were they rude or do we think they might be a "seeker". Bias can convince us of a lot.

    How many patients do you think are under-treated for pain vs how many times are patient's given Narcan for nurse administered meds?
  9. by   jdub6
    Quote from macawake
    Well, I think that most people agree that pain negatively effects quality of life and as nurses we know that it has many physiologically detrimental effects on the human body. So yes, I agree with thinking of pain as an enemy....
    There's nothing wrong with a multimodal approach to pain treatment for postsurgical patients (the same goes for chronic pain) and I'm not saying that many of your suggestions don't have merit. They do. But opioids often (almost always, unless the surgery is very minor) have to be the first choice in the immediate period following surgery. You will not cure the opioid epidemic in the acute care setting. It's not the time nor the place.

    Pain isn't "innocent", it isn't a mere nuisance that we can stoically suffer through without any ill effects.

    Undertreated postsurgical pain results in needless suffering for the patient. The sustained stress response that is the result of undertreated pain causes elevated catecholamines, cortisol and increased catabolism. That is not beneficial. It increases anxiety, leads to poor sleep, limits mobility, increases risk of thrombosis, pulmonary morbidity (both pneumonia and embolus), suppresses the immune system, delays wound healing and increases the risk of infection and also increases the risk of the pain becoming chronic (persistent postsurgical pain).

    Please don't let your fear of opioids make you undertreat your patient's pain. It will hurt them.

    Before I became a nurse I've had half a dozen surgeries, several of them traumas. Fortunately I had nurses and physicians who weren't in the least bit scared of opioids and they treated my postsurgical pain to as close to zero as they could come. That allowed me to heal and do my physiotherapy and recover fully with no sequelae. I never needed opioids for much more than a week after any surgery and sometimes just days, but they would have treated me for as long as it was necessary. I'm glad I had knowledgeable healthcare professionals.

    These days, I make sure that my patients are as pain-free as I can make them.

    "Old-ish" but still relevant...

    Some of the "old-ish- articles and studies and texts (including what some of us were given in school) were funded and influenced by the manufacturers of opiate drugs. Sadly the public and The Joint Commission and other "official" sources parroted this contaminated info for years before the corruption came to light.

    IMO the problem with seeing pain as an enemy to be eliminated is that it leads many to the conclusion that pain CAN be eliminated, especially chronic pain. The CDC now states that there is insufficient evidence to treat chronic pain from headaches and fibromyalgia and chronic low back pain with opiates AT ALL. Not because it isn't noble to relieve suffering and not because these peoples' pain isn't real but because opiates are not effective in improving many of the things you cite as consequences of pain (namely function which is what leads to many of the physical consequences you listed like PE. The studies that show some improvement in average pain rating also show that this does not have the same effect with inproving function.)

    I don't think anyone wants to revert to not treating pain. But per the CDC while prescriptions for opiates have quadrupled over the past years the number of patients reporting chronic pain and the average pain level and functional measures (employment, mobility) have NOT improved. Perhaps throwing opiates at pain when there is only anecdotal evidence ("I have chronic pain and it works for me and I'm not an addict" is an anecdote) for effect isn't the answer either? Perhaps we don't HAVE a good answer, but this scares us so we refuse to see the evidence about the lack of effect of opiates or any modality? Perhaps we want to believe we can eliminate pain when really we can't in most cases? As the morphine equivalent unit dose of chronic opiates increases the pain level doesn't decrease and especially function doesnt improve...but we don't want to tell people we can't help so we sell them ineffective therapies?
  10. by   jdub6
    Quote from MrNurse(x2)
    My brother was a heroin addict because of chronic pain from hip misalignment, something requiring hip replacements at 48. He needed a pain consult because he was on suboxone. He only took Tylenol for the last three years because of other health issues. This doctor spoke to me very candidly about the issue. Dilaudid, the main go to in ER's across the country, not only resets the body's tolerance (even marijuana does that), but, scarier, resets the pain perception, so what was once perceived as 2/10 may now feel like 4 or 5/10. The real horror, he said, was research shows that as little as one dose of Dilaudid may do this. I. too. live with chronic pain. My understanding of the practice act keeps me from taking any pain med, save a few Motrin when it gets really bad.
    This is the thing...we ignore the bad effects of opiates (and there is evidence to support them) in favor of the thought that opiates are powerful and therefore must work.

    We don't have good evidence for opiates for a lot of pain conditions. We DO know that somewhere from 5-20% (depending on your source) of people treated with them are biologically wired to become addicted with repeat use. saying that you or people you know use opiates responsibly for their pain is rather arrogant really. The fact is we have no way of knowing we are susceptible to addiction (and maybe to having poor effect of opiates ie increased pain or increased euphoria/craving) until it happens. the majority who escape it aren't generally showing responsibility, they are showing that they do not have the genes and temperament to be addicts.

    This is NOT a statement that people don't have pain or that chronic pain sufferers should just suck it up. It's a statement that opiates aren't the magic bullet no matter how badly we want them to be. They don't work in general...and for a substantial minority they lead to addiction. why risk that over something with minimal to no proven benefit?
  11. by   ItsThatJenGirl
    Quote from subee
    Check out last night's 60 Minutes segment on the cozy relationships between Republican lawmakers and the drug distribution companies. I don't think that Jarrod gonna be able to fix this one.
    I saw that - it was really interesting. I hadn't considered the distributors being part of the problem.
  12. by   subee
    Quote from ItsThatJenGirl
    I saw that - it was really interesting. I hadn't considered the distributors being part of the problem.
    Yes, I didn't either. What was I thinking? Hard to believe that any entity involved in patient care is so blatantly evil. Of course, I thought I already KNEW that but guess I was still a naif.
  13. by   OCNRN63
    Articles like this scare me. I'm afraid the day may come when I'll just be given bullets to bite for my chronic pain from cancer.

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