Pain control in narcotic addicted pt

[dankimal]

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."?

[~Mi Vida Loca~RN, ASN, RN]

I also wanted to touch on Leslies story.

I had a patient about 30 years old that was in for PID and possible other things going on. She had an order for Q2hr Dilaudid 1 mg and a percocet order that wasn't used. She had uncontrollable abdominal pain.

She was labeled a drug seeker, she seemed pretty high and was on the call light right on the 2 hr mark asking for more pain meds. She had been admitted for 2 days when I took over her care and she wasn't getting much pain relief at all. In fact, another nurse got the doctor to change the order to Q3hrs because they felt she was drug seeking. So I asked her if she ever had Toradol since she described the pain as a deep cramping pain. She said heat made it worse. Anyway she had never had Toradol before and had no kidney issues. So I called the doc and got an order for Toradol. I told her we would try the Toradol and the Percocet. She went from a constant 6-7 the 2 days she was in to a 3 and the next day she was a different person. In fact it was nice to see how personable she was when she wasn't high and in so much pain. By that time the docs figured out something else that was going on and she was given a lot of IV Abx and she was doing great.

Sometimes Nurses just have to step back from the instant judgements (I know they are easy to do and I know I am guilty of it) and we have to use that critical thinking that was pounded into our head and work from there. In doing so we might find out that our patient really was in a lot of pain and they weren't simply drug seeking.

[~Mi Vida Loca~RN, ASN, RN]

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......

LOL There has been many of days when I was hurting bad but I looked at how many pain pills I had out and new I had to ration it out so I tried to just tough it out and maybe OD on Motrin and stuff Now we do sound like addicts. LOL

[xtxrn, ASN, RN]

LOL There has been many of days when I was hurting bad but I looked at how many pain pills I had out and new I had to ration it out so I tried to just tough it out and maybe OD on Motrin and stuff Now we do sound like addicts. LOL

Just sadly lumped together...... :heartbeat

[~Mi Vida Loca~RN, ASN, RN]

Is it the 16th yet? I need a refill.

[xtxrn, ASN, RN]

I had a youngish female patient with off-the-charts lab work w/pancreatitis.... no issue with a "real" diagnosis. Her nurse came and told me that she said the pain meds weren't holding her...so I go down to talk to her before calling the doc. Lots of drama, loud crying, etc. OK... I'll call the doc. I paged him, and right when he calls back, I see her bopping down to the lounge to get coffee...and tell him that, BUT that she says the pain is at least a 20 (out of 10).

Physiologically, her pain was "justified"....behaviorally, she looked like an idiot. But it wasn't my call to say if she was really hurting. She wasn't a frequent flier. She didn't come from the ER with a "bad rap". She just didn't act like my ideas 'preferred' her to...but that's on me. Maybe she was just a drama queen in general, and the pain made it worse- IDK ..... But after getting the booster dose (1x order), she went to bed and wasn't heard from the rest of the shift (and yes, she lived- ). I told her the next night that if she hurt, she just had to tell me- the 'show' wasn't necessary.....but more diplomatic than that

Pain is one of those things that the patient can seldom "win" with- if they don't complain enough, they must not hurt....if they complain too much, they're seeking drugs.... What is acceptable???? And it's true that addicts have tainted views for everyone....and they're the vast minority of those who are looking for pain relief. What are the stats- something like 1% of those who take prescribed narcotics become addicted (not dependent or tolerant- but actually addicted)....the 99% get 100% of the grief for that 1%.

[~Mi Vida Loca~RN, ASN, RN]

That's pretty much it in a nutshell. I know in school we learned that the rate of opiate addiction from someone that took it when they really had pain was very low. Maybe they do enjoy the "high" but maybe it's the "high" that masks the pain so it does help with the pain. It's a no win situation.

I just know it's not my job to toy with people for my own hangups and judgements. If they are completely snowed and I can physically harm them by giving them more drugs, then that's a different story. But from what I have seen that is HARDLY the case. It's more so the nurses or doctors feeling the person isn't really in pain because they look fine or because they can't find the cause so they want to hold the medication or give less and stuff to boost their own egos. You will see these nurses singing their own praises in report about how they weren't going to feed into the drug seeker and did this or that.

Frankly I would rather give "drugs" to the "perceived" addict then have to watch the mom of my little kiddo act like she could completely care less about her child that is very sick.

[applewhitern, BSN, RN]

@Mi Vida Loca: Hi, this is "off-topic" but you mentioned the tempur-pedic bed. Well I bought one for my 34 year old daughter who has severe pain from fibro and arthritis, and she hates it. When she would try to sleep on it, she would wake up sore all over! I finally put the darn thing in a guest bedroom, but nobody likes it. Just be sure to actually try it out several times, for more than a minute or two, before you invest in one. Ours is kinda hard, and it is the name brand one.

[~Mi Vida Loca~RN, ASN, RN]

That is weird. I have heard a lot of good reviews on it. I figure it would ease some of the pressure when I lie on my side. I used to have a tempurpedic mattress topper and that helped but it got tossed in our move.

I will make sure there is a return policy or something if I ever get one. Thanks for the heads up.

[linearthinker, DNP, RN]

I will never understand why come nurses care so much if patients are addicts, etc. Just give them the bloody drugs. Either they're an addict and their life is hell, or they're in pain and their life is hell. Either way, it's their hell and not yours. Why waste your time begrudging them their interventions? Implement valid orders and move on.

[carolmaccas66, BSN, RN]

This is an extremely difficult situation to deal with.

I've cared for psych patients in the mental health unit admitted with narc addiction (plus alcohol addiction & other problems usually). Psych patients also have major surgeries, and have narc pumps attached to them after surgery, as per protocol.

The bottom line, in Australia anyway, is that you cannot deny someone in pain pain medications, especially after surgery. They must be given pain relief.

However, having said that, I've also had patients who were obviously addicted to narcs, whom the doctors wrote up other medications for; doc would write on med chart, ie: try such-and-such medication FIRST before others), then we could give them narcs as a last resort. Of course, the family would interfere and INSIST that mama get the narcs first, even though we tried to explain that the DOCTOR (ie: God) was trying to wean said patient off of the narcs. But the nurses would give in to the family's and the patient's pain who would say we were cruel, get called all the names under the sun, etc. So on the wards, we try to deal with narc addiction as best as we can, but down under, we can't lie and say a patient hasn't been prescribed narcs.

So the whole situation puts nurses b/ween a rock & a hard place.

I have actually complained as shift coordinator sometimes, and rung the pain service for some demanding, pain patients. The pain service needs to be involved with the patients you describe.

So it's not only patients who complain, we get families and spouses, in-laws, kids AND friends complaining if patients don't get their narcs, so most nurses just give in. Narc addicted patients will do ANYTHING to get their drugs as well; they are highly manipulative, selfish individuals in most cases. Some are just at the end of their rope and can't survive w/out their narcs.

Talk more to the docs, and try to get other meds written up. Also call your pain service team to have the patient reviewed.

I agree we do enable patients, but sometimes, you can't refuse pain medications - unless a specialist pain doctor orders this, and the patient must also be under strict observations due to the risk of descending into sometimes life threatening delirium tremens.

[Esme12, ASN, BSN, RN]

That is weird. I have heard a lot of good reviews on it. I figure it would ease some of the pressure when I lie on my side. I used to have a tempurpedic mattress topper and that helped but it got tossed in our move.

I will make sure there is a return policy or something if I ever get one. Thanks for the heads up.

Off subject.......think about a soft sides water bed. I hated the tempurpedic bed but the "soft sides" water bed I LOVED. It looks like any other be, uses regular deep pocket sheets but the key for me was the warmth AND support........

I'm now one with terrible pain......and I am one who never says how much pain because I would die if I ever got labeled a "seeker" just because I have chronic pain. NOR would I EVER go to the emergency room for pain unless I have suffered an amputation of a limb because I know first hand what the nurses thinK and say. I was never one to judge one's pain as valid or false unless abundantly obvious AND I had cared for them multiple times and/or saw them at other hospitals at my per diem jobs. I once saw a patient medicated at one ED and triaged the same patient at another ED a few hours later...imagine their surprise...

I am in the process of looking for another MD because I recently asked if I could take more that one Vicodin (that's right one tab) at night, and I got a lecture about addiction and chronic narcotic use..... WHAT A JERK! I think we need to stop generalizing, judging, and categorizing our patients and really LOOK at them.....I mean really see AND hear them before we snap to judgement.

An "admitted addict" CAN have real pain that requires "real meds" and relief that isn't necessarily "seeking" anything but relief............and someone with "chroinc pain" isn't automatically an addict even when they require larger amounts of meds that require treatment. JM:twocents:

[xtxrn, ASN, RN]

Off subject.......think about a soft sides water bed. I hated the tempurpedic bed but the "soft sides" water bed I LOVED. It looks like any other be, uses regular deep pocket sheets but the key for me was the warmth AND support........

I'm now one with terrible pain......and I am one who never says how much pain because I would die if I ever got labeled a "seeker" just because I have chronic pain. NOR would I EVER go to the emergency room for pain unless I have suffered an amputation of a limb because I know first hand what the nurses thinK and say. I was never one to judge one's pain as valid or false unless abundantly obvious AND I had cared for them multiple times and/or saw them at other hospitals at my per diem jobs. I once saw a patient medicated at one ED and triaged the same patient at another ED a few hours later...imagine their surprise...

I am in the process of looking for another MD because I recently asked if I could take more that one Vicodin (that's right one tab) at night, and I got a lecture about addiction and chronic narcotic use..... WHAT A JERK! I think we need to stop generalizing, judging, and categorizing our patients and really LOOK at them.....I mean really see AND hear them before we snap to judgement.

An "admitted addict" CAN have real pain that requires "real meds" and relief that isn't necessarily "seeking" anything but relief............and someone with "chroinc pain" isn't automatically an addict even when they require larger amounts of meds that require treatment. JM:twocents:

All horrible situations to be in because of the very few that make the most waves.... Also, when someone says they hurt, it is harmful to ram their leg into a 90 degree angle no matter what- then insult the person for the slobber running down their face... a torn ACL and medial meniscus were made much worse because of that...still haven't been able to have surgery....