Pain control in narcotic addicted pt

FancypantsRN · Aug 30, 2011

You make them suffer. Then you can feel self-righteous when you deny them pain meds.

I would hope that nobody really feels that way.

xtxrn, ASN, RN · Aug 30, 2011

i agree that those addicted need specific intervention, which is not more of the very drug for which they are addicted. doctors are becoming smarter and prescribing far fewer narcotics through the er, and many hospitals in my area have developed new policies with stringent rules on the type, quantity and uses for certain narcotics in the emergent setting.
i completely agree that pain is subjective. as the matter of fact...patients don't have to say a word. as part of a study i did in a statistics class, we evaluated patients coming into an er with complaints of pain. statistically, regardless of the type of complaint approx 90% of patients told the er md their pain was a 9 or greater using the 0-10 pain scale when asked. when flacc was used with these patients, the average score was a 4 or 5. when the smiling to crying faces were used the average number decreased further to a 3 or 4, with almost no 9 or 10's. (duh... i'm not crying or grimacing...i'm smiling... the doctor can see that...i better not choose the grimacing or crying face or they might know i'm lying!!" this study shows there are issues with a 0-10 scale. other evaluators tend to be of higher accuracy with use in the adult general public. still subjective. pts are saying what their pain level is. they are just using a different type of communication. they can still indicate they have pain and whatever their "pain is"...we just need to provide these adults with a more accurate way to do so.

http://www.childcancerpain.org/content.cfm?content=assess08

down at the bottom, you'll notice that flacc was designed for use in young children- those whose verbal skills don't allow them to express pain well enough to treat them adequately.... flacc is not an accurate scale for adults. but, yes- we do need a way for adults to convey pain to healthcare professionals who refuse to listen to their descriptions. definitely :)

LuxCalidaNP · Aug 30, 2011

Wow! I think there was a misunderstanding...I'm talking about the ones whose pain is NEVER under control because we've amped up the doses and overrun their mu and kappa receptors for 20+ years. When it still hurts on hydromorphone, vicodin and percocet for breakthrough pain, it's time to look for other solutions.

I was in no way doubting the legitimacy of their pain! They're crabby because their life hurts! And IMO, they're hooked because of us!

RNperdiem, RN · Aug 30, 2011

Luckily if you work in an area such as burns or SICU, you will have no trouble believing there is a real physical cause for pain.

Getting hit by a truck while riding your modped hurts. Femur fractures are painful.

Addict or not, I will be bringing on the pain meds.

xtxrn, ASN, RN · Aug 30, 2011

Wow! I think there was a misunderstanding...I'm talking about the ones whose pain is NEVER under control because we've amped up the doses and overrun their mu and kappa receptors for 20+ years. When it still hurts on hydromorphine, vicodin and percocet for breakthrough pain, it's time to look for other solutions.
I was in no way doubting the legitimacy of their pain! They're crabby because their life hurts! And IMO, they're hooked because of us!

I don't think that was it- at least that's not how I read it :) We used Buprenex during detox for some addicts, and it does work well for getting people off of drugs- I don't have any experience with it for pain control. And, yes- I would agree, when those other narcs don't work, something else is needed. Maybe not addicted- but high tolerance and dependence :)

WolfpackRed · Aug 30, 2011

ketamine, an NMDA receptor antagonist, can be used as an adjunct (in theory) for chronic pain in high dose opioids; even at low doses I have given as part of an anesthetic plan for a patient on 150mg methadone po daily. if used in a pain clinic, you can make the argument that you are trading one addiction for another, but it could be a possibility

leslie :-D · Aug 30, 2011

When it still hurts on hydromorphone, vicodin and percocet for breakthrough pain, it's time to look for other solutions.
I was in no way doubting the legitimacy of their pain! They're crabby because their life hurts! And IMO, they're hooked because of us!

so...you're doubting the legitimacy of their pain relief?

i apologize for those who've heard this story before, but it bears repeating.

when i was hospitalized, they gave me iv dilaudid, fentanyl, and morphine.

while i didn't complain, when the nurse came in and asked how i was, i did complain that i was high...but the pain was there.

and i honestly was in pain, but feared 'they' would think i was seeking increase in dosage and frequency.

when she offered toradol, i accepted...and it took care of my pain completely.

i even asked the nurse if i could only have that for pain mgmt...it didn't happen for whatever reason.

but it is very true, that just because it's an opiate, doesn't mean it's going to be effective.

this goes for addicts, too.

not all addicts are manipulative, sleazy people from the dregs of life.

i would bet they're not even the majority.

many addicts are aware of their addiction and wish it wasn't so, but lack the strength to seek help.

these people are wealthy, mid-income, and poor.

they are professionals with college degrees...and not.

they legitimately feel pain.

i would much rather err on the side of caution, versus even letting one person (needlessly) suffer.

sometimes i wonder what others would say about 'us'...you know, we who are so judgmental and self-righteous.

really...what would others say...and would we be offended for being insensitively judged...just like we do with addicts.

it's always different when shoe's on the other foot, i do believe.

leslie

~Mi Vida Loca~RN, ASN, RN · Aug 30, 2011

Hello all:
In my practice I have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. May I make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. They will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds.
My question/comment is this: After all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain?
Perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?

Except that there are many things that can cause pain that might not be something Physically obvious. People that also have chronic pain are good at looking normal while in pain because it's just what they have to do. They have to function and since their baseline is already at like a 3-4 they just learn to deal and to someone that hasn't had to deal with it the person might seem like they are fine when they are really hurting.

If someone told you they are a narcotic addict why would they be going through faking symptoms for more narcotics? It would seem they already admitted what they were doing so it would be pointless for them to play up their pain.

xtxrn, ASN, RN · Aug 31, 2011

Except that there are many things that can cause pain that might not be something Physically obvious. People that also have chronic pain are good at looking normal while in pain because it's just what they have to do. They have to function and since their baseline is already at like a 3-4 they just learn to deal and to someone that hasn't had to deal with it the person might seem like they are fine when they are really hurting.
If someone told you they are a narcotic addict why would they be going through faking symptoms for more narcotics? It would seem they already admitted what they were doing so it would be pointless for them to play up their pain.

YES !!!

People with chronic pain find it frustrating to use the 0-10 scale because they're never at a 0... on a good day, they might start out at a 3-4...I've heard this many times. I personally never use 10, because to me (and this is jme), that just redefines 9- lol...:) Plus, different people have different pain tolerances- if someone isn't used to pain at all, a "routine" lab draw hurts more than a little.... for someone who is in pain a lot, that same lab draw is like 'what?...something happen?'....doesn't phase them. And for some, the idea of pain causes so much anxiety that they may need more meds to deal with the increased muscle tension adding to the original pain... it's ALL so individualized. A family member had a lap choley and thought he was dying - he'd never had surgery before, so didn't know that the 3 bandaids were an improvement over the 5 inch scar :) A patient who had had all sorts of surgery was up and around without any problems the night of surgery. A laminectomy patient would get so much relief from the pre-op pain, that post-op he was thrilled- 4 inch incision and all :)

With the faces scale, someone with chronic pain will be totally misrepresented with that- they can sit there with mind numbing pain, and a totally neutral expression on their face- so they shouldn't get any relief???? :down:

Like I couldn't work with a patient who was not adequately medicated, maybe an option for those who don't like to take the chance that they're giving pain meds to an addict would be to not work with them- just sayin' it's an option :) And that's not intended as snarky- there are things that most of us just can't stand to do- fortunately, nursing has options.... :twocents:

allnurses Guide · Aug 31, 2011

. . . Yeah- nobody wants to enable an addict. But who wants to be a party to someone NOT getting some sort of relief for pain? We can't always know who is or isn't being manipulative-- sometimes the fear of the pain can make folks sound pretty desperate, and that is judged by healthcare professionals as "proof" they're just looking for drugs....

This is pretty much the bottom line for me . . visiting a patient who weighed about 50 pounds whose spine was twisted like a corkscrew (necessitating long-term opiate use) in the throes of pain and withdrawal because her PCP decided she was being an enabler to a manipulative patient and cut her off abruptly - that's a sight I never hope to see again --- and yeah she could be a pain in the *** but anxiety and fear of pain without treatment can make people pretty shrill sounding at times.

This is an area where my attitude has definitely evolved - I'm angry at the people who lie, cheat and manipulate too - but I guess I'd rather have some of those slide through than have somebody exhaust themselves trying to prove they have a legitimate need of pain relief while their pain is continuing to be untreated.

imintrouble, BSN, RN · Aug 31, 2011

You make them suffer. Then you can feel self-righteous when you deny them pain meds.

:eek: This kind of thread makes you angry. Pain meds/seekers/narcotics/addicts are guaranteed topics to polarize the thread. It's generally why I choose to just read these posts instead of commenting.

Trekfan · Aug 31, 2011

so...you're doubting the legitimacy of their pain relief?
i apologize for those who've heard this story before, but it bears repeating.
when i was hospitalized, they gave me iv dilaudid, fentanyl, and morphine.
while i didn't complain, when the nurse came in and asked how i was, i did complain that i was high...but the pain was there.
and i honestly was in pain, but feared 'they' would think i was seeking increase in dosage and frequency.
when she offered toradol, i accepted...and it took care of my pain completely.
i even asked the nurse if i could only have that for pain mgmt...it didn't happen for whatever reason.
but it is very true, that just because it's an opiate, doesn't mean it's going to be effective.
this goes for addicts, too.
not all addicts are manipulative, sleazy people from the dregs of life.
i would bet they're not even the majority.
many addicts are aware of their addiction and wish it wasn't so, but lack the strength to seek help.
these people are wealthy, mid-income, and poor.
they are professionals with college degrees...and not.
they legitimately feel pain.
i would much rather err on the side of caution, versus even letting one person (needlessly) suffer.
sometimes i wonder what others would say about 'us'...you know, we who are so judgmental and self-righteous.
really...what would others say...and would we be offended for being insensitively judged...just like we do with addicts.
it's always different when shoe's on the other foot, i do believe.
leslie

that is true years ago i was being treated at a big hospital for bleading peoblems and mensterl cramps i was given all kinds of narcs and nothing worked i was stoned but still in pain . i got a new doctor and she told yah narcs do not work well on cramp she gave me flexerll oh my god it was so much better with just that and two tylenol :)