Pain control in narcotic addicted pt

Nurses General Nursing

Published

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."?

Specializes in Emergency/Trauma.

well there are a lot of things to consider. i am only a student so i am not as wise as the experienced nurses here of course, this is just what i learned when we were discussing this topic in class and reviewing The American Society of Pain Management Nurses views on addiction.

1) addicts can suffer from things that cause pain. if you believe they are truly addicted, they should be given a non-narcotic pain reliever.

2) addicts will require a lot more medication to relieve pain as they have a tolerance

3) a lot of addicts are actually pseudo-addicts- they appear to be drug seeking because they have chronic pain that has never been adequately managed. an addict will continue to exhibit drug seeking behaviors after receiving the meds, while a non addicted person will not exhibit any of these behaviors while the medication is in effect.

4) some patients will be talking on the phone or laughing and report their pain at an 8. their vitals will be normal. those with chronic pain conditions will have normal VS, because the sympathetic response to pain diminishes due to the parasympathetic rebound effect.

well there are a lot of things to consider. i am only a student so i am not as wise as the experienced nurses here of course, this is just what i learned when we were discussing this topic in class and reviewing The American Society of Pain Management Nurses views on addiction.

1) addicts can suffer from things that cause pain. if you believe they are truly addicted, they should be given a non-narcotic pain reliever.

2) addicts will require a lot more medication to relieve pain as they have a tolerance

3) a lot of addicts are actually pseudo-addicts- they appear to be drug seeking because they have chronic pain that has never been adequately managed. an addict will continue to exhibit drug seeking behaviors after receiving the meds, while a non addicted person will not exhibit any of these behaviors while the medication is in effect.

4) some patients will be talking on the phone or laughing and report their pain at an 8. their vitals will be normal. those with chronic pain conditions will have normal VS, because the sympathetic response to pain diminishes due to the parasympathetic rebound effect.

OK- so someone who needs more meds should be given something that isn't as strong???? :confused::eek:

Yes- if a non-narcotic works, then it should be used....but an addict with severe pain isn't going to get by on Talwin or Ultram..... It was an everyday thing to have someone come into detox who took 70 Vicodin per DAY.... add a couple of root canals, and what, give them an ibuprofen the first day? They would get 4-6 Vicodin at a time (this was before the whole acetaminophen limit business) for 2-3 days- they were still in detox, so not going 'back' to that level...then naproxen or ibuprofen after that.... and they were less likely to bolt from treatment because of inadequate pain control....

The rest of those items make sense (whoever came up with them- doesn't matter to me :)). # 3 and # 4 are the ones that seem to throw people into a tizzy.... there's no differentiation between addict behavior, and fear of pain.

And it's good to hear from students :)

Specializes in Emergency/Trauma.
OK- so someone who needs more meds should be given something that isn't as strong???? :confused::eek:

Yes- if a non-narcotic works, then it should be used....but an addict with severe pain isn't going to get by on Talwin or Ultram..... It was an everyday thing to have someone come into detox who took 70 Vicodin per DAY.... add a couple of root canals, and what, give them an ibuprofen the first day? They would get 4-6 Vicodin at a time (this was before the whole acetaminophen limit business) for 2-3 days- they were still in detox, so not going 'back' to that level...then naproxen or ibuprofen after that.... and they were less likely to bolt from treatment because of inadequate pain control....

The rest of those items make sense (whoever came up with them- doesn't matter to me :)). # 3 and # 4 are the ones that seem to throw people into a tizzy.... there's no differentiation between addict behavior, and fear of pain.

And it's good to hear from students :)

i know the real world is far different from school... that was just what the ASPNM guidelines say in my acute care book. however, although not clear, it seems like they're saying that is for med seeking that is not pain related. which is where the problem comes in again of how do you really know? :confused:

i know the real world is far different from school... that was just what the ASPNM guidelines say in my acute care book. however, although not clear, it seems like they're saying that is for med seeking that is not pain related. which is where the problem comes in again of how do you really know? :confused:

What you posted was good :) And you really don't know- I think that's where some of us get upset at the idea that patients should have to 'prove' pain somehow- it's not possible to prove something, especially if there are already preconceived ideas. Some bonafide addict drug-seeking patients sound like they're dying from some acute pain and give very little overt signs of being hooked. And, some hardcore chronic pain patients will put off taking pain meds when they shouldn't . Kind of like watching the TLC show "A Baby Story" and some 90lb woman delivers some 10 pound kid with a mild wimpier, when some larger woman delivers a 5 pound kid, and they know about it first hand 3 counties away :D

There are a lot of types of pain that will never be adequately relieved- but my feeling is that we should at least try. As long as the doc isn't prescribing crazy amounts of meds (which is also individualized)- or some boneheaded thing like giving someone propyfol (?sp) at home :uhoh3: , then erring on the side of the patient will do a couple of things- it gives some relief, and like you posted, the behaviors will show themselves- if pain is relieved, the 'seeking' stops. :)

Manipulative patients are annoying. Aggravating. Down right ran me off from my last job. (When you're on a dilaudid PCA for pancreatitis and everytime your enzyme levels drop you sneak down to the snack machine to shoot them back up again, ARGH!)

But here's my thing:

I'd rather overtreat a million patients, than have one patient needlessly suffer because I didn't believe them.

Specializes in Emergency Dept. Trauma. Pediatrics.
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:

I agree, I deal with chronic pain. I have a high pain tolerance. My baseline is probably a 3. So on a good day I still have pain. But no one would no looking at me. I don't show any signs of being in pain. It's because I am used to it and it's always there. I was diagnosed with fibromyalgia last year. (like the worse diagnoses one can get since there is so much negative stigma about it already, might as well be an ADHD diagnoses on a kid) I have chronic back pain that is not the same as the Fibro pain, the fibro pain is more sensitivity to pressure. In fact I never realized the pain I was feeling on some things WASN'T normal. I figured it's like that for everyone. The doctor is the one that brought up when he was doing manipulations on me that it shouldn't be hurting.

I have a monthly script for percocet for flair ups of my back pain. Massages help with my fibro well but it's bitter sweet because massages are painful for me. They offer relief after and if I stay consistent with them they help a lot. But there is NO WAY I could get through a massage without taking a percocet prior. The percocet doesn't take away my pain at all. It just helps take the edge off for me to better deal with it.

So anyway, the script I have for percocet isn't really enough to get me through the month. I have to take 2 of them and they are 7.5 mg each, and about 5 hrs later I have to take another 2. So I have enough to last for 5 flare-ups. The massages weekly take up 4 of those 5 days. That leaves me one day of a flareup for the rest of the month. BUT because of so many judgements made on people that use narcotics I don't say anything. I work on this side, I come to these boards, I see how people are regarded with "chronic" pain and how they are drug seeking and so on. So I just deal with it. I have never been to the ER for my pain. I have been to Urgent Care twice in my life for a migraine. I see a PCP for my pain. Believe me, I am calling for my refill the day of the month I can have it again. Because more likely then not I have already ran out and have had nothing for relief for a while. I am sure the gals in the doctors office look at me as a seeker since I am right there calling in my refill the day I can have it.

I am in no way a weenie, my own doctor has told me that I have a really high tolerance to pain when he does my muscle work and manipulations. He can feel me tense up or jerk sometimes but I don't say a word. I understand the phrase "no pain no gain" so I know although getting his manipulations or the massages is going to hurt, I know that it will give me longer relief on the constant pain. One time when he was done I got up and had tears in my eyes because I had been holding it in the whole time and it hurt so bad. I know when he saw that he felt terrible but I told him it was OK because I know I will be thanking him later. He made a comment that he can't believe how much I can tolerate. Even with that, I still wouldn't ask him for more pain medicine for the month or a higher dose to keep the same quantity. I just say what I have is fine.

It's sad that in this day and age stuff like this have to happen. People have to be afraid to get pain control because they are so worried about the judgements they will receive.

ETA- The FLACC scale would be a complete waste for someone like me. I have dealt with my pain for so long that you aren't going to see my vitals elevated, I won't be moving around and stuff. I can tell you I am a 3 and laughing and stuff with my friends because I use mind over matter and just try to ignore the constant buzz of the pain I am in. You might see me shift a little or try to stretch to try and lesson the pain or might see me fidget a bit to try and get in a more comfortable position. But in your 30 second assessment I am going to appear to be just fine. I am just not a dramatic person when I am in pain. When I had my kiddos (outside of the first one) you give me a focal point and I will do my deep breathing and get through it and I can assure you I was probably on a 10 out of a 10 during that time. It was one of those things that you think this is the worst pain of your life and then it gets worse.

I hear ya- people don't understand that contact with a bed hurts- and it's not THE bed- it's ANY bed...:down: And if you tell someone you hurt, you get "the look".... it stinks.

I know it is unethical, but sometimes I wish I could give Placebo to certain patients :p

Specializes in Emergency Dept. Trauma. Pediatrics.
I hear ya- people don't understand that contact with a bed hurts- and it's not THE bed- it's ANY bed...:down: And if you tell someone you hurt, you get "the look".... it stinks.

I so badly want to get a Temperpedic bed. I can only sleep on my side but it hurts my hips so bad from the pressure. I have tried numerous beds and it doesn't matter, that pressure is still there and man it hurts. I would say my pelvis and hip bones are the ones that hurt the most. When the Doc would try to see if my hips were aligned he barely put pressure and I wasn't expecting the shooting pain and about jumped off the bed it hurt so flipping bad. Like if is had just stabbed me with knives on those bones. He looked shocked that what he did hurt. That is when they thought to look into other things and tested me for Fibro. I was testing positive for every pressure point they tried. I was almost embarrassed and asked was it not normal for that to hurt and he said NO it wasn't normal. The CPR simulations I will be in pain for days in my hands from holding the pressure of one hand over the other for those 2 minutes. Or like using the WOW. I have to take the mouse and put it on the counter because having my forearm resting on the top of the WOW I will be in pain in my forearm the next day. I asked my co-workers not thinking it was my fibro if their arms will hurt from it and they looked at me like I was crazy. That is when I realized it was my fibro causing the pain.

I just want to add my own experience as a way for others to maybe learn....Several years ago I fractured my coccyx, it was not seen on x-ray at first but was suspected...I went back to the ER a couple of days later because my PCP could not schedule me in a timely manner and told me to go....I was considered a drug seeking patient and left on my own...I could barely walk, had to have my husband unbutton my pants so I could use a bathroom, three hours after trying to get off of the couch...I was in absolute agony...My husband made an appointment for the Ortho doc, sure enough spiral fracture to the coccyx seen obvious on x-ray

Recently I had my gallbladder out, upon waking up from surgery I had the usual dose of morphine...When asked my pain scale I said 7, was told no I was definitely a 10, my face says everything....After my dose of morphine was up, I was told I was being given Toradil.....Never felt better in my life...

I took my boards 5 days later, staples and all with only taking Motrin and Toradil at night....I have never been one to take pain meds but if I tell you I am in pain, I am...Look at your patients, I know I do

I know it is unethical, but sometimes I wish I could give Placebo to certain patients :p

I got orders to give one ONCE, but not for pain..... a lady was convinced from a day before a cerebral arteriogram that she wouldn't be able to hold still for the 6 hours (back in 1988- don't know if they have to hold still that long anymore) after the test. She'd made it for over 5 hours, but was getting REALLY antsy...so I called the doc. HE wanted to give her Restoril (at 4pm)... I asked if I could try some normal saline IVP - and he said ok, but if it didn't work, put her to sleep :eek: Geez- I just wanted her still for less than an hour, not wait for an hour for the Restoril to kick in and then be out cold just to wake up at midnight.... So, I gave it. Told her the doc said she could have it- she didn't ask what "it" was....and was snoozing before I got the syringe out of the IV (back when we used needles- LOL). Her daughter looked at me a little funny, and I motioned with my head towards the hall- she followed me, and I told her what "it" was.... she smiled and said thanks...:) The lady probably would have been fine moving around that long after the test- but back then, we stuck to the time thing pretty tightly- maybe still do.

I've tried things myself that may or may not have some physiological basis for how they work (one was a migraine tablet that worked like a charm- for a bonafide migraine- used to get it at Walgreens....they don't carry it anymore). I didn't CARE if it was a placebo effect as long as the pain (or whatever) went away- though with the migraine med, I don't see those going away with placebos..

:twocents: :)

I so badly want to get a Temperpedic bed. I can only sleep on my side but it hurts my hips so bad from the pressure. I have tried numerous beds and it doesn't matter, that pressure is still there and man it hurts. I would say my pelvis and hip bones are the ones that hurt the most. When the Doc would try to see if my hips were aligned he barely put pressure and I wasn't expecting the shooting pain and about jumped off the bed it hurt so flipping bad. Like if is had just stabbed me with knives on those bones. He looked shocked that what he did hurt. That is when they thought to look into other things and tested me for Fibro. I was testing positive for every pressure point they tried. I was almost embarrassed and asked was it not normal for that to hurt and he said NO it wasn't normal. The CPR simulations I will be in pain for days in my hands from holding the pressure of one hand over the other for those 2 minutes. Or like using the WOW. I have to take the mouse and put it on the counter because having my forearm resting on the top of the WOW I will be in pain in my forearm the next day. I asked my co-workers not thinking it was my fibro if their arms will hurt from it and they looked at me like I was crazy. That is when I realized it was my fibro causing the pain.

Yep-- and grocery shopping is the only thing I can do in a day, and hurt the rest of that day, and the next. It's not "oh, gee, that's a bit sore", it's 'change all plans' kind of pain..... and that's stuff I don't medicate, so I don't "waste" the pain meds...because it can get much worse. But I LOOK fine......

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