Is current thinking on pain control creating drug addicts? - page 7

The current approach to pain control has been to believe the pt's self report of pain no matter what. Is this creating drug dependency, and or addiction, in emotionallly susceptible people? Should we... Read More

  1. by   subee
    Quote from olderthandirt
    I think it's the same as with guns, guns don't kill people, people kill people. Drug addicts create drug addicts. My doctor will only give me Darvocet for my chronic pain. I have herniated discs, sciatica, degenerating spine, several pieces of metal (plates) and he says after taking this medication for 6 years that I am becoming used to narcotics; NO MY PAIN HAS GOTTEN WORSE!!!!

    Please get thee to a pain specialist. Darvocet went out with Dodge Darts.
  2. by   NiteNurz79
    I work on a psych/substance abuse unit - I don't know the answer to the problem of people with genuine chronic pain developing addictions, but I do know for certain that an increasing number of people who intentionally abuse drugs are learning to take advantage of the current attitudes about pain management. I get patients all the time who use IV oxycontin for the high then demand their "rights" and want opiates prescribed while they are in the hospital. One client actually quoted a line from a pain article to me, saying " I have a right to pain meds and I don't have to prove my pain to anyone. My pain is whatever I say it is!" How exactly do you document medicating a patient like that ( the quote itself is probably right out of a nursing magazine, and it's hard to describe the smirk on her face in medical terms!) It's frustrating....
    Last edit by NiteNurz79 on Jan 12, '07
  3. by   Warpster
    They studied this in Boston in the mid 1980s. They followed 10,800+ patients who had been given narcotics in hospital. Guess how many new addictions they found!

    Wait for it.

    Got a guess?

    FOUR.

    If your patient says he is in pain, he is. Even if he's a drug addict. Even if you think he's taking too much pain med. Even if you think he's a whining crybaby. Even if he's exhibiting classic drug seeking behavior, something I've seen in every post op patient I've cared for after Nurse Tylenol reported off to me.

    The statistics are with him that he won't develop an addiction.
  4. by   GardenDove
    You know, I agree totally about that. When I started the thread though, I was more thinking about the whole chronic pain movement and the fact that there are people who take advantage of the liberal attitudes regarding prescriptions. I wasn't really talking about acute pain, to tell you the truth.

    I think the ER sees alot of this behaviour, where drugseekers come with general abd pain, labs are normal, and the scruffy looking pt is carrying on in a melodramatic demanding way. They always know all about the pain scale and they are always a 10/10.
  5. by   heron
    I don't have any easy answers for this one. I've been interested in pain management since the early 70's ... worked in acute medicine taking care of many folks with sickle-cell, pancreatitis, cancer and such-like. Back then, I was appalled at the power struggles that would occur between patients and docs re pain control. An example: a 34 year old sickle cell pt maintained on dilaudid 8mg q4h at home being forced to go to demerol 50 IM q4 DURING A CRISIS!!! I could hear her screaming at the other end of a 50ft hallway with her door closed! The intern wouldn't modify the order ... he didn't want to get her addicted! 25 years later, I took care of an end-stage AIDS pt on a morphine drip (around 160mg/hr at the time) who was lying rigid in the bed with the pain of neuropathy, various CNS infections and spinal TB ... the attending refused to allow escalation of medication and, in fact, REDUCED the dose!!! He felt the pt was "drug-seeking". The poor b-----d was actively dying ... luckily this idiot only covered us for a weekend and when our regular attending came in, we were able to address the pain rationally and do something about it. These are 2 fairly extreme examples of the way we often get tangled up in conflict over whether we are treating pain or treating an addiction. I agree with something I read years ago ... in order to do effective pain management, we have to accept the fact that some addicts are going to "get over". It is reasonable and necessary to try to screen out addictive drug-seeking ... but we also need to hold to the fact that addiction and pain are two different problems and decide which is the priority. My personal opinion is that our society has placed a higher priority on making sure addicts don't get high than on relieving pain...but that's just me.
    Working with addicts who are also in pain is the greatest challenge of all ... I don't think anyone is expert at it ... I just know that there is no 100% accurate objective measure of pain ... pts with chronic pain have nl vitals and look/act normal (my partner a case in point ... chronic pain @ 8/10 for years from arthritis and scoliosis ... couldn't tell from looking at her) So ... until someone invents a God-pill that will let me read minds, I still have to treat the pain the pt reports ... if I think there's addicitve drug-seeking going on, that's what psych consults are for.
  6. by   donormom
    Quote from heron
    I don't have any easy answers for this one. I've been interested in pain management since the early 70's ... worked in acute medicine taking care of many folks with sickle-cell, pancreatitis, cancer and such-like. Back then, I was appalled at the power struggles that would occur between patients and docs re pain control. An example: a 34 year old sickle cell pt maintained on dilaudid 8mg q4h at home being forced to go to demerol 50 IM q4 DURING A CRISIS!!! I could hear her screaming at the other end of a 50ft hallway with her door closed! The intern wouldn't modify the order ... he didn't want to get her addicted! 25 years later, I took care of an end-stage AIDS pt on a morphine drip (around 160mg/hr at the time) who was lying rigid in the bed with the pain of neuropathy, various CNS infections and spinal TB ... the attending refused to allow escalation of medication and, in fact, REDUCED the dose!!! He felt the pt was "drug-seeking". The poor b-----d was actively dying ... luckily this idiot only covered us for a weekend and when our regular attending came in, we were able to address the pain rationally and do something about it. These are 2 fairly extreme examples of the way we often get tangled up in conflict over whether we are treating pain or treating an addiction. I agree with something I read years ago ... in order to do effective pain management, we have to accept the fact that some addicts are going to "get over". It is reasonable and necessary to try to screen out addictive drug-seeking ... but we also need to hold to the fact that addiction and pain are two different problems and decide which is the priority. My personal opinion is that our society has placed a higher priority on making sure addicts don't get high than on relieving pain...but that's just me.
    Working with addicts who are also in pain is the greatest challenge of all ... I don't think anyone is expert at it ... I just know that there is no 100% accurate objective measure of pain ... pts with chronic pain have nl vitals and look/act normal (my partner a case in point ... chronic pain @ 8/10 for years from arthritis and scoliosis ... couldn't tell from looking at her) So ... until someone invents a God-pill that will let me read minds, I still have to treat the pain the pt reports ... if I think there's addicitve drug-seeking going on, that's what psych consults are for.
    From a chronic pain sufferer, I thank you for your input. I am going to print out your posting and give it to the ER where I work. They are more concerned with addiction than pain control. I was appalled at their attitudes before my pain escalated, but now I have a much better understanding.

    You have a very caring and empathetic personality.

    Karen
  7. by   scarta105
    I find it extremely sad that patients, along with their families and some healthcare workers, must resort to forming organizations in order to educate and bring attention to the crisis of under treatment/non-treatment of pain. Our society has been bombarded with so much anti-opiate propaganda over the last century that we blindly accept it as gospel. Anyone who dares even question the validity or the effectiveness of the drug war is immediately suspect. Doctors and nurses are caught in the middle of this war when governmental policies are written that oftentimes requires these licensed professionals to become pseudo detectives by interrogating patients to make sure that they are not seeking drugs. What a mess we have created for ourselves.

    I am copying a letter written by Siobhan Reynolds (we could all learn alot from her) of one of the organizations that was created to address the problem of pain management in our country. I found it interesting and thought that I would share it with you. You can read more about this subject at her web address:
    www.painreliefnetwork.org . I do hope that we begin to really study this problem, to learn about addiction and pain, and to learn to recognize in ourselves our ability to love and care for our human brothers and sisters without false assumptions.

    Nov 13, 2005
    Press Release
    Painreliefnetwork.org
    Constitutional Claim on Behalf of Americans In Pain
    Presented By Siobhan Reynolds
    President, Pain Relief Network
    "Men feared witches and burnt women."
    Justice Louis D. Brandeis 1927
    The Problem
    People in severe pain are unable to mobilize to defend their rights. Chronic pain is a disease and when left untreated sufferers often find it beyond their power to place telephone calls or use computers. These people cannot work, attend to their families, enjoy social or sexual relationships, or participate in holiday celebrations. When pain is overwhelming, they cannot think clearly or even sleep. 50 to 70 million Americans live in chronic disabling pain. According to a 1999 survey, one third described their pain as "almost the worst pain one can possibly imagine.1"
    Over the past twenty years the medical community, in concert with policy makers, worked in good faith within the current legal paradigm attempting to get pain treated. Safe harbor laws were enacted, medical board guidelines drafted, and for a short while, a few doctors began to treat chronic pain with opioids.
    In 2001, the United States Department of Justice unleashed a torrent of criminal prosecutions against physicians and called this crackdown the "Oxycontin Action Plan." All over the United States conscientious physicians have been prosecuted, jailed, or have lost their licenses to practice medicine. Dr. William Hurwitz, a pioneering pain physician, was tried and convicted of violating the Controlled Substances Act. He is presently serving a 25-year term in federal prison. Dr. Ronald McIver is serving 30 years, and Dr. Freddie Williams is serving a life sentence. There are countless other examples.
    Medical Abandonment Feeds the Prosecutorial Machine
    Frightened by this brutal display of executive power, most doctors, including those in the field of pain management, have simply abandoned this sickest and most vulnerable segment of our population. Patients suffering from mild to moderate pain, and requiring low dosages of opioids may still find care, but those patients with high dosage requirements are increasingly shut out of care altogether.
    Due to this public health disaster and humanitarian catastrophe, untold numbers of our trusting citizens have been unable to recover from injuries or illnesses that would, with proper treatment, be entirely manageable. Unable to find relief, these pain victims are often driven to suicide. Countless other patients have been provoked by their doctor's meager dosages to visit more than one physician looking for enough medication to allow them a measure of normal functioning, only to find themselves arrested for "doctor shopping." These unintentional criminals are often coerced into confessing to drug crimes and/or providing false testimony against alleged co- conspirators. To avoid long prison sentences, they may be forced to submit to ineffectual and inappropriate treatment for addiction, and face the prospect of unrelieved pain for the rest of their lives.
    Civil Rights of Americans in Pain Destroyed
    In 2004 it was estimated that there were less than 5000 pain specialists in the United States,2 many of whom would not, as a matter of policy, prescribe opioids. Those few medical practices which do treat chronic pain with opioids impose severe restrictions on patients' freedoms.
    Patients are routinely required to sign unilateral "pain contracts," promising to see only the designated physician for care, relinquishing their rights to visit emergency rooms, and to use more than one pharmacy. Often the patient must agree to waive his right to medical privacy, and permit government agents unlimited review of his medical records in order to be eligible for
    opioid therapy. One such "contract" required that the patient not "anger any county employee."
    Violation of these contractual provisions may result in draconian sanctions imposed by the physician, including the cessation of pain treatment. Patients are forced to sell businesses, give up jobs, and to relinquish custody of their children. As a consequence of being labeled "non-compliant," the abandoned patient will find it nearly impossible to procure replacement care.
    Spectral Evidence
    The root of the problem is the Controlled Substances Act, which defines addiction in a manner that renders willful substance abusers indistinguishable from undertreated pain patients.
    The term "addict" means any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare, or who is so far addicted to the use of narcotic drugs as to have lost the power of self-control with reference to his addiction. 21 USCS Section 802 (1996)
    The law's apparent aim is to keep substance abusers from being maintained on opioids by physicians who are not in possession of a special maintenance license. Under this scheme, should the pain treating physician fail to divine the true character of a patient's opioid dependency and inadvertently provide maintenance to a substance abuser, this failure may subject the physician to Federal accusation of drug dealing and all that it implies, including forfeiture proceedings, personal ruin, and decades in prison. At trial, patients in pain are obliged to confess addiction and to testify that their doctor "addicted them" in order to provide substantial assistance to the prosecution and thereby escape a lengthy prison term. No corroborating medical testimony is required to establish a patient's self-diagnosis of addiction in a Federal courtroom.
    Witchmarks
    In response to the enforcement of the CSA, physicians who treat pain have invented a system to ferret out "legitimate patients" from addicts. Common behaviors such as losing a prescription, or asking for more medication are considered "aberrant" and have become self-evident indications of addiction. A patient's display of any of these behaviors is sanctionable by withdrawal of medical care. This system provides the pain-treating physician a way out of continuing treatment that he perceives to threaten his professional and personal existence.
    The ability of patients to remain in care is threatened at every turn. Patients in pain are required to attempt to prove to their physicians that they are not addicts or criminals. Patients who have
    any encounter with law enforcement, or who are turned in to their doctors by spouses or coworkers for taking what these lay associates believe to be too much medicine, find themselves severed from their medications as the doctor attempts to protect himself from potentially damaging future testimony.
    The results are discriminatory and racist. Minorities, people with psychiatric disorders, poor people, and Americans who have a history of substance abuse are virtually unable to find care.
    Simply put, the Controlled Substances Act is, by every meaningful definition, arbitrary power enforcing its edicts to the injury of persons and property; the very sort of thing the 5th Amendment was enacted to prevent.
    The Structure of The CSA is Unconstitutional
    The Controlled Substances Act prohibits opioid possession and distribution, and allows for harsh criminal sanctions. Possession and distribution of controlled substances is permissible only when the Attorney General of the United States authorizes such activity.
    This criminalizes the pain patient and the physician, requiring both to prove their conduct is authorized. The very structure of the law, therefore, denies people in pain the traditional presumption of innocence that free people enjoy and lifts the burden of proof off of the government and puts it squarely on citizens in pain and those who would treat them.
    The Solution
    Because the Controlled Substances Act unjustly prejudices the due process rights of patients suffering from chronic pain, the Pain Relief Network seeks to enjoin the DEA from enforcing the
    Controlled Substances Act against physicians. We anticipate having the CSA declared unconstitutional by arguing that patients in pain have an important liberty interest in not having their "state of being" (opioid dependency) de facto criminalized. The argument is not that people in pain have any fundamental right to pain treatment or health care. Rather, it is that the majority may not criminalize the activities of an unpopular minority simply because they find a behavior morally offensive.3 A bare desire to harm a politically unpopular group cannot constitute a legitimate governmental interest.4
    Once the lack of available pain treatment in the United States is perceived as a consequence, however unintended, of the Controlled Substances Act, it will become clear that we cannot continue to further harm sick people and their relationships with their physicians in this manner.
    A Patient In Need
    Pain Relief Network (PRN) has identified an ideal plaintiff. He is a patient who lives in agony.
    He is a 30 year-old father of three, a former highly paid executive, who cannot obtain effective pain treatment in Massachusetts or surrounding states. He is so obviously disabled that he was awarded Medicare and Medicaid without the help of an attorney. We have located a physician who would like to treat this patient, but refuses out of fear of Federal prosecution. Were the DEA enjoined, this physician would treat this patient's pain.
    Having closed his practice to new patients since Dr. Hurwitz was convicted, this physician is unwilling to incur the additional personal risk represented by taking one more patient who requires opioid therapy. If necessary, several doctors will testify that they refused to see this patient for the same reason.
    Pain Relief Network
    Pain Relief Network is a not-for-profit organization devoted solely to making effective pain care accessible to the citizens of the United States. To this end, we are participating in the appeals of eight wrongly convicted physicians who are victims of the Controlled Substances Act.
    Through our work in these appeals we've discovered that the United States government does not acknowledge that they must prove mens rea to convict a physician of drug trafficking, nor do they concede that there is a difference between civil and criminal law in these cases.
    We have drawn a great deal of media attention to the issue, and recently participated in a CATO Institute forum addressing the pain issue. This may be viewed at the following link: http://cato.org/events/050909pf.html
    We are currently working with 60 Minutes on a piece profiling wheelchair-bound multiple sclerosis patient Richard Paey who is serving 25 years in a Florida prison for "trafficking" 1/2 gram of oxycodone. Even the prosecutor concedes that Mr. Paey didn't sell any of the medications in question.
    PRN will prepare the attorneys who enjoin the U.S. with all the materials they will need to accomplish this action. In the interests of our plaintiff's safety, and the interest of all the other vulnerable patients who are also unable to access effective treatment, it is important that we move with haste.
    Contact: Siobhan Reynolds
    President Pain Relief Network
    1
    Chronic Pain In America: Roadblocks to Relief
    http://www.ampainsoc.erg/whatsnew/conclude_road.htm
    2
    Libby, Ronald T.,"Treating Doctors As Drug Dealers: The DEA's War on Prescription Painkillers," Cato
    Policy Analysis No.545, June 16,2005 http://www.cato.org/pubs/pas/pa545.pdf
    3
    Lawrence v. Texas 000 U.S. 02-102 (2003)
    4
    Department of Agriculture v Moreno, 413 U.S. 528 (1973)
    Last edit by scarta105 on Jan 14, '07
  8. by   hecete
    i work in a snf rehab center. for the most part they are maintained on "narcs" thru the first week or two after therapy begins. then they are weaned off to a non-narcotic. my biggest problem is other staff members. i work 12 shifts 5 days/wk and know my patients pain levels. the weekend staff, and they only work wekends, are great for putting pts. back on "narcs". i have a pt. that sits in bed and paints pictures all day, no signs of pai, but every monday she is on sched. vicodin. i've asked the nurse not to put her on vicodin, but this has fallen on deaf ears. i finally had to get a order from the attending, not the on-call doc, not to call for a vicodin order. that took care of that problem. now she has moved on to 2 other pts. anything to shut them up so you don't have to deal with them.:flamesonb
  9. by   jane_4855
    I don't believe that we create drug addicts. In some cases, though, we awaken the addict. I have had a smiling teenager tell me that her pain level was 10 (then she popped her bubblegum). An explanation of the pain rating system didn't change her mind. Having raisd teenagers myself, I was angry at the lax and liberal manner in which narcotics are prescribed for dental pain. I had lots of orthodontia as a child and never got anything other than Aspirin or Tylenol and don't recall being in severe pain. I do not believe that narcotics are the best way to relieve pain, either. After all, Ibuprofen and other antiinflammatories also work by alleviating pain and inflammation. For some people, 50 mg of Demeral is about the same as two Aspirins so why give the narcotics in the first place? Pain is subjective and I would never advocate witholding medication to anyone with severe, intractable pain. However, as a profession, we need to develop better assessment tools, and not only alleviate the pain of those suffering but also identify those persons who have a propensity for abuse. We , as a country, are an addictive society with relatively low threshold for pain, also. "Evidence based" practice is the mantra these days. Let's see the evidence on how well we are doing with these issues.
  10. by   clee1
    Quote from jane_4855
    ...However, as a profession, we need to develop better assessment tools, and not only alleviate the pain of those suffering but also identify those persons who have a propensity for abuse.
    I'm all for better assessment tools/techniques, but our job is to alleviate suffering. The DOCTOR prescribes the meds, and we give them. It is not our role to beat the bushes looking for undiagnosed addicts. I refuse to watch my pt deal with pain when I have an order that will allow me to alleviate it. Period; end of story.

    We , as a country, are an addictive society with relatively low threshold for pain, also. "Evidence based" practice is the mantra these days. Let's see the evidence on how well we are doing with these issues.
    No; We, as a country, are a puritanical society that would rather see someone in pain than to think they might be enjoying a "high" from pain killers. THAT is a crying shame!

    Based on "personal evidence", root canals, broken bones, and surgical incisions HURT. I have taken opioids for pain and I am not an addict. I will continue to treat my pt's per doctor's order and will advocate for them as appropriate.
  11. by   Myxel67
    I wore braces on my teeth from age 30 to 33. Every time they were adjusted pain was intense for 3 days. 1 or 2 Percocet tablets usually helped. (I didn't get dizzy, slur my speech, or feel high.) The dentist who referred me for orthodontia told me "you have to expect and accept some level of discomfort" He changed his tune however when he got braces himself a year later. He told me his pain was so bad that he would never question a pts complaint of pain again.

    Dental pain can be so intense that it seems to radiate causing severe headache, earache, eye pain, and neck & shoulder pain.
    Last edit by Myxel67 on Jan 28, '07 : Reason: addition
  12. by   LilRedRN1973
    God, do I agree with dental pain being severe. Over the last 2 years, I've had my 4 front bottom teeth pulled, tissue sliced from my hard palate and stitched to my gums below, then a few months later, a procedure called crown-lengthening, which is just a fancy way of saying, we're going to scrape away your gum tissue with a sharp object and then throw a few stitches in for good measure. After about a year, along came 4 root canals, more tissue grafting (the tissue from the hard palate being stitched onto your gums) and more gum cutting. It seems with each procedure, my tolerance to pain is becoming less and less, instead of the other way around.

    I have found a combination that works wonderfully. I normally take 100mg of Celebrex BID for my rheumatoid arthritis, but after my oral procedures, I throw in an extra 100mg for good measure, along with the 7.5mg/500mg vicodin given to me by my periodontist. The pain medication helps the acute, current pain and the celebrex helps to bring down the swelling to prevent further pain.

    I've had so much done in my mouth that a root canal alone is like someone else going for a routine cleaning....LOL. I showed up for my 12-hour night shift one time about 3 hours after a root canal and some of my co-workers were aghast that I was up and about, let alone at work. They stared at me in horror, saying they would be at home, laid up in bed....lol! Nah, a root canal is nothing....I much prefer my 4 hour long visits in the dentist's chair, followed by several hours in the periodontist's chair, and being sent home with gums full of stitches, looking like I'm ready for Halloween!!!

    On a more serious note, I fully understand and emphathize with anyone who suffers from chronic pain. When in nursing school, one of my patients was a woman in her early 40's that took quite a bit of pain medication for rheumatoid arthritis and a myriad of other afflictions. I couldn't understand or grasp her pain because to me, it wasn't visible, like a bruise, broken bone, etc. Then, within a month of graduating nursing school, I received a cruel gift.....diagnosis of RA myself. After having lived with it for several years now and experienced quite a few "flare ups", I will never again underestimate a person's pain nor will I judge a person by how they appear on the outside, especially when they live with a chronic illness. I can appear completely pain-free and comfortable on the outside, when inside, I am crying. I've learned to live with a certain amount of pain and have accepted it. I'm embarrassed when I think back to how skeptical I was of this woman's pain. I can now say I have walked a day in her shoes.

    Melanie = )
  13. by   twotrees2
    Quote from grandee3
    I think I failed to mention that I work in an LTAC, our length of stay can be anywhere from 10 days to 45 days. We get a lot of 30 something's who have old injuries from either work related or sometimes from their long addiction to pain meds, ie falls, broken bones etc.
    They come to us a few days post op or post hospital for long term care. I know these pts can still experience some severe pain, but when they are c/o nausea and eating fried chicken at the same time and want a push of Phenegan, I have a problem with that. And then, they want the med pushed real fast and not diluted, to me that's a problem.
    When I said they can go out to smoke, I am referring to a pt we had who took her Dem?phen push then went outside with her cig and was fould asleep in her wheelchair with a lit cig burning her gown! What would have happened it the pt was injured by setting herself on fire because she was medicated? What happens to that nurse in court? Does her license survive? Please, advise.
    being a smoker- and having gone out and was so out of it i was luckyi had someone with me lol - first off - you should have anyone go out sign a AMA form simply because even if we do smoke we all know that it is proven to be bad for us and doing it is against medical advice- second i would be sure that that person either had a nurse or family /friend with them. if not then refer to number 1 - the AMA form should cover our butts especially if we document in the notes how beligerent i can be to go out and have one AMA -

    as for eating when nauseated - well - been there too -lately ( hahvent figured out why yet and no im not pregnant lol) i have been nauseated daily most of day - one gets hungry and needs to eat - the unfortunante part is it rarely stays down but its kinda a rock and hard place - get rid of the hunger and throw up or feel hungry and throw up

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