In the hospital I work if a patient does not recover per the established schedule, or requires more pain meds than usual they are labelled "spleeny" or a drug seeker. So I was wondering what practises, formal or informal other nurses use to determine if someone is "truely" in pain.
For example, if a person is asleep can we assume they are not in pain? What if they appear to be fighting sleep?
Mar 4, '01
Pain is what the person says it is. Period. The research shows that addiction is not an issue for hospital patients and that their recovery is slowed when they don't receive adequate analgesics. You can't judge a person's pain by anything other than what they tell you. Just because someone is sleeping, joking, laughing or walking around doesn't mean that they aren't in pain. People cope differently.
This is my personal pet peeve because I think the percentage of people actually drug seeking is minute compared to the amount of people we force to be in pain because of our own beliefs about pain and drugs.
Mar 4, '01
This is one of my biggest pet peeves. With all the research and data out there on pain control vs addition that people will still withold medication. If a pt is in the hospital and under our care it is up to us to take care of their pain, not judge them. Part of our ability as RNs is to properly assess and control the pain. Elderly tend to underreport pain and often will state they "can't get comfortable" or "can't fall to sleep." If that pain med is ordered q 2hr prn, then use it and don't wait for the pt to ask, make your assessments and follow through.
Mar 4, '01
How about someone admitted for abd pain who has been worked up to the nth degree with no cause of pain found. Reports that nothing (imagery, relaxation) but narcotics help. Comes in every two-three months with the same problem. We want to do something besides keep admitting her and medicating her unconcious. She does not report relief unless she is literally knocked out with drugs. Stays about a week then gets better when we taper to po meds. What now?
Mar 4, '01
Sadly a lot of people with pain don't have a diagnosis, or don't get one for years. My mother was complaining for 6 years before they finally found out she had endometriosis so bad she needed a hysterectomy at 34. I would say to keep looking for a cause but treat her pain until you can find it, don't make her suffer because you don't know why she's suffering. Medicine hasn't solved all the worlds mysteries yet.
If she was a drug seeker I would think she would be in more than once every few months, ours were! I also think that when someone says things like imagery don't work but narcotics do we think they're drug seeking. Maybe they just know their own bodies and what works for them.
Mar 6, '01
Just because this patient comes into that facility every few months doesn't mean the patient isn't at another facility, doing the same thing. It also doesn't mean that the patient is a drug seeker. I agree that pain is what the person experiencing it percieves it to be. I think we fall into the myth of people who require few pain meds being "strong" and tough and courageous. It takes courage to show up at a facility every few months and continue to aks for help even when this patient knows that probably no one believes her.
I used to work in 2 different ED's, 50 miles apart and was amazed at the number of people who would come to one ED, get a script for percs and be in the other ED the next day, asking for Percs. Those people are real drug seekers, they don't tend to hang around in the hospital- too many rules.
Have you taken the time to sit down with this patient and ask them to tell you what their life is like- whats really going on for them? I don't think that will make this pt's pain go away (there's a cause for it somewhere), but it will let the pt know that you are committed to helping the pt conquer this pain.
Mar 6, '01
Lots of great replies. Amen to patient report being the gold standard for pain measurement. Nothing else compares. Vitals tell you nothing about a patients pain and don't let anyone tell you otherwise. Pain is an individual and completely subjective phenomenon.
As for "drug seeking" behaviour I agree with the previous poster in that these pts aren't likely to stay around. We have a few "frequent flyers" that get really bad pain episodes every few months with no good Dx. You really can see that these people are in pain and do need the narcotics to control it. It really bugs me when people make negative comments that they are just looking for drugs.
Sleeping people can have pain too. Look for stiff body posture, grimacing and restlessness. In unresponsive pts these can all be signs they're having pain.
Mar 6, '01
If drug seekers exist how do you pick them out? And how do you deal with them as a nurse?
I must say that an occasional hospital admission would certainly bolster a drug seeker's argument for pain meds while he/she is an outpatient. An admission that included narcotics on demand sounds pretty worthwhile to me. So I don't buy that all seekers are seen in the ER.
I originally posted to find out how I could prove the validity of pain claims to doubters in the nursing staff, so if anyone has ideas on that, or articles I would be interested. The fact that people show pain while sleeping with moaning and grimacing was good information for me to pass on. Thanks.
Mar 6, '01
I think the "pain is what a patient reports it to be" has great applicability in a post op or acute pain setting. I am less certain that it applies as well in chronic pain or ED settings. And, please, I am not saying that it never applies. However, drug seeking behavior exists. Canoehead, I don't have any hard and fast rules about detecting drug seeking behaviors, but people raise my level concern for drug seeking when they doctor hop, when they rush to tell me that Percodan or Demerol works best for them, that they are allergic to Stadol. And yet all of these can be very legitimate statements. The point is that drug seeking can hide poorly controlled chronic pain, depression, undiagnosed problems or addiction or "professional patienthood". Either way, an ED or office frequent flyer with these types of concerns may merit a referral to the ED case management or social work staff. I also have a bias that these kinds of folks are best managed by one doctor with good follow up. I think that 100% buying the patients report of pain may cause us to overlook OTHER patient problems. If you have a concern about someone's pain usage, make sure your unit based team is comparing notes and include the patient in your problem solving. COMPLEX PROBLEM.
Mar 6, '01
This is a topic dear to my heart. I suffered from chronic pelvic pain for many years(and I'm only 31!). Thank heaven's sthat this undiagnosd, no reason for having pain just up an left! I'm not going to worry about WHY it left. I never was hospitalized for it, but did have a tube and ovary out on one side...and the pain still persisted.I did not think it was in my head. Patient's who "drug seek" for real are ADDICTS and the other "drug seekers" are truly in pain. Are any of us capable of feeling another's pain (or reading their mind, etc)? In both cases, THEY are the pt in the hospital bed,not us. In both cases, they are ill. Addiction is an illness as well as a choice. I'm not supporting addicts, but I don't want to be the judge here. We nurses do enough already. We assess, document, intervene and evaluate. I don't have time to play social worker or god or doctor!
Thanks for letting me go nuts here. I hope that I didn't insult anyone..none intended.We are all here for the same ultimate goal, to be patient advocates.
Mar 7, '01
Even if you do give drugs to a drug seeker you think is in pain, what is the worst thing that will happen? They'll take more of the drugs they've been taking for years. On the other hand, the consequences to undermedicating someone in real pain are much worse. I would rather err on the side of caution. Too many people are made to suffer because a health care "professional" decides they're lying. I swear, the first time you are in that situation your views on pain control will REALLY change. It's sad but that is what I think it would take to get us to really show compassion for our patients.
Mar 7, '01
I totally agree with the last few posters. While I don't have a lot of knowledge base or experience with drug seeking patients, most of the literature on pain identifies health care workers as one of the most common barriers to good pain control. Only the patient knows what their pain is like. Throughout pain studies and literature this is the single-most important and valuable theme. Chronic pain is no different than post-op. If anything it is often much more difficult and complex to manage and requires a consistant, careful approach with constant re-assessment and evaluation.
Mar 7, '01
I am going to print up these replies and post them at work. You have brought up some good points. Thank you everyone.
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