Big pain management advocate here! Pain chain reacts in a way that hurts anything positive we are trying to achieve and therefore is contraindicated by the rules of having a person achieve their potential. Not only do I medicate well and in a knowledgable way, I educate my patients on how to do this effectively, the clear scoop vs the rumors, and that pain hurts all body systems and must be dealt with effectively and within REASON (not like snowing someone).
I am also a true believer in pain being like a snowball...once you get that snowball running down a hill (as in pain level), it picks up speed and soon you have a huge snow ball that can't be easily controlled. Hit it when it is starting down the hill...and looking into someones history of pain is the best way to guage that.
I ask my patients a few questions that help:
1. What was your worse pain ever? (we will rate that 10)
2. What level of pain do you think to yourself "OKAY NEED MEDS!"? (this will be tolerable pain level that signals the start of the snowball slope).
3. What do you use typically for this pain (hx of medicational use gives a guage).
4. Is what you take at home effective to you? (again hx)
5. What is your pain level now? (where on the slope are we).
Then it is up to you and the patient to choose what is in the MAR for pain and come up with a plan. Keep in mind the times and amounts so when they ask for more you can go over what has transpired and discuss changes.
Also, do NOT assume because someone is taking lots of pain meds at home that they need more! I have seen this cycle too many times, and what happens is you load them up...liver doesn't process well on the first pass, but second pass BOOM...but meanwhile you have medicated again for effect...now you have a potential probelm...especially in elderly! Look carefully at history and effect and think about what is in your MAR to use, and try what you think will be best routinely (even if it is PRN, best to keep on it) and trial and error will get you there as long as you are working with the patient (nonverbals/confused are harder...I use painad scale on them).
It is amazing to me how well pain management works if you actually involve the patient as much as possible...even the ones that seem like they are abusing pain meds...typically it is a cycle of anxiety along with pain that just keeps feeding eachother! Take out part of the anxiety...and part of pain follows! People have thought I was nuts before treating pain agressively for a 'drug seeker' (so they thought), and had to eat crow when the patient was no longer crying out for pain meds, responsible with them, understood the ones they are taking, and much easier to deal with!