Drug seeking or real pain? How do you tell?

[JudyPRN]

I'm a new nurse on the list so please pardon my ignorance. I was quite interested in the pain links and explored several and probably will use some for staff training. I did not see any mention of dealing with chemically dependant people who may or may not be having pain. I work in a mental health facility which also serves chemically dependant people. We have a constant struggle with determining who is in pain and who is drug-seeking. We have isolated a few cues, but over-all are probably treating the wrong patients. Does anyone on this list have ideas on this subject, who can steer me to a few resources? I appreciate all the help offered.

[nanacarol]

You are right, religionand or faith do not negate the reality of pain. It is unfortunate that some encourage others to feel it is the lack of faith and trust in God that hinders pain relief or healing. Pain is real and should be treated, faith is an adjunct to treatment and has a place in refocusingaway from self, but Pain is very, very real. nanacarol

[luvyluvy]

My specialty has been in subtance abuse for 8yrs and whether they are seekers or not they are in pain, withdraw does cause a patient to go into immediate pain as soon as the pain med wears off so yes now they are seeking, intentionnally or not, the patient may not be aware that they have developed a problem or that they are developing a problem, I have to say that it is up to the M.D. to determine what the patient needs are all we can do is continue to educate ourselves in the field we specialize in, so that we can educate our patients, and pray for the patients we work for, there are alot of excellent sites you can look up in regards to addictions and recognizing withdraw Sx, in order to differentiate the seeker from a new patient, who can be taught other ways of pain management, because once addicted to pills, I have learned that it is a long road to freedom. Some withdraw symptoms are chills, dialated pupils, muscle aches, their back and leg hurt the most, sweats, yawning, teary eyes, runny nose and difficulty sleeping, but most commonly you will find the patient over medicating or switching doctors alot, some patient frequent the E.R. so they can get an immediate script for pain medication these are definite tell tail signs. But they are still patients none the less and they still have a sickness that needs to be treated.:redbeathe

[KarenGeorgeBSRN]

Good Morning!

I have run a network for almost 10 years for those in NIP (nonmalignant intractable pain), and the true victory was the definition of PAIN as a disorder; not just a symptom. As another nurse mentioned FM and CFS are still not scientifically diagnosed but by subjective statements and objective criteria, but the pain experienced by such clients is extreme.

We have found (statistics) that when QOL (quality of life) is addressed, and clients are treated for NIP there are benefits to society as a whole. Less time lost from work, less family dysfunction and divorce, less psychiatric outcomes although most who suffer NIP do have "depression" as an outcome of nontreated pain, and some pain disorders which affect the SNS and ultimately destroy REMs sleep or what we can simply term restorative sleep; where healing can occur in "normals."

There are legal and ethical considerations. As an Adminstrative nurse it is imperative to me when I take on a position that my staff understands pain as a disorder and a symptom of a disease process. Just as years ago the extremes in developmental stage (infant and elderly) were thought "to not have pain perception" and we would operate on premature infants who would "collapse" on the table due to the pain perception (go into shock). Can even one of us imagine not being able to verbalize, move away from, scream out something to stop the scalpel from cutting our wee chest?

The elderly suffer deterioration of normal function not just "pain disorders" and to keep mobility, ROM, and ambulation (so that further deterioration does not occur) their pain should be treated. I have worked with many seniors who live a very good existence on a LA (long acting) medication such as Oxycontin, MS Contin, or Duragesic without negative (but positive) outcomes.

The DEA however is practicing medicine. With all research in place we see DEA busting good physicians and even clients of the same. I personally have helped thousands around the country with referrals, follow up, case management and support, and right now pain is a political statement for many practicing medicine, and those of us who care for their clients.

Opiods are the safest method overall of treating NIP. I always in teaching about pain give the example to nurses "if you have a heroin addict come in with a bad appendicts do you administer his or her morphine?" Many will balk, and the look of disgust is evident (think of what that poor individual feels when they see our experession), but the answer is "yes" and along with that we better make sure that order is high enough to meet the needs of tolerance for their daily habit. Yes we do treat their pain, and if they are lucky perhaps get some help for them (a referral) for some therapy, and addiction interventions.

Another example in practice which bends more to DNR mandates is "If Mrs. Jones (terminal end stage pancreatic cancer) who is a DNR is eating lunch, having a good day with her pain chokes do we intervene?" Many not few have answered "no she is a DNR!" and the truth is "yes we do; she is in house for her uncontrolled pain in OP hospice and stabilization--her choking episode is and has nothing to do with her end stage disease."

For the new nurse good topic! I wish more nurses coming into practice would ask and not remain confused. It takes a lot of courage to say "I do not know" about important parts of practice, rather than the energy wasted on ignorance. There is in some cases no right or wrong answer, but as you gain time in working you will see many nurses, many environements, and gain what we call a good instinct. We must also remember though that "our instinct in isolation from our peers" leaves us sadly uneducated.

What is wonderful about our profession is the constant change and learning; each day!

Have a great week!

Karen G.

[Templedoll]

Thankyou Karen for your great post.

[KarenGeorgeBSRN]

Dear Temple,

Thank you for reading; this is one of the most difficult parts of modern medicine today and when they state "pain kills" it is truth.

Peace out!

Karen G.

Thankyou Karen for your great post.

[KarenGeorgeBSRN]

Good Morning!

One of the most difficult concepts for a nursing professional who is brainwashed into thinking of "drug seeking" as a medical term is the differentiation between "tolerance" and "addiction." The physical symptoms are the same for either person; yes they are both viable clients with overtly different diagnoses and outcomes!!

Over and over I read posts on this topic in the year 2008 where modern research has shown that "tolerance" and "addiction" appear the same physically, when indeed the only similarity is the symptoms physically that occur between a person who is legally prescribed medication for pain, and someone with a serious disorder which is entirely different; this disorder is termed "addiction."

Physical withdrawal can occur between the "pain patient" and "the addict" with the same result; an uneducated physician or nurse can infer by value system (not by the subjective verbal report of the client) that a person is in fact "drug seeking" and one of the top pain specialists in the United States told me "at some point a patient not treated for his or her pain will be RIGHTFULLY drug-seeking at some point if not treated, for he or she cannot tolerate the suicidal level of pain they experience."

Nursing professionals are in the role of advocate by the nature of our profession; with or without a value system in place; putting ourselves as "God" does nothing for the client in need, makes us look like idiots, and furthermore negates the value of our very comprehensive education. I do not care whether you are a LVN, two year or diploma RN, or four year RN--you know through clinical experience if not through text book knowledge the truth.

Reply after reply show nurses who have years "in the trenches" learning from their own misconceptions about the term "drug seeking." When I tell you that stating such in an ER with a client in true need is malpractive for a physician and the nurse involved I mean this. If any of you who use this term freely or believe somehow that you know better than the client experiencing pain "his experience" then you are wrong. Lack of objectivity will keep you miserable in your role as a potential advocate, and then when someone you know and love, even yourself falls through the cracks, and is attacked or mistreated in thousands of ER's (in particular) throughout the United States you might change.

We have an obligation to continue the learning process throughout our lifetime. I know of no other profession where it is encouraged, applauded, and complimented. Our profession can make a difference in the lives of many; this particular concept of "drug seeking" needs to be trashed along with foul language, abuse, and a thousand other crimes of a medical nature that occur with frequency today.

I ask all of you in disbelief to further educate yourself; get your nurse managers or DON's (such as myself) to arrange inservices, really make yourself an open book when you approach any new client, and "stop the violence." One day it might be you so labeled and suffering, please do this for your client's and for yourself.

There is no "seeker" this is a disgusting judgement. An addict is also suffering a serious disease process; one that is incurable, but a psychiatrist is in the role to truly determine if a person fits into that diagnostic criteria; not a one shot five minute analysis rendered by a value statement.

Thank you,

Karen G.

My specialty has been in subtance abuse for 8yrs and whether they are seekers or not they are in pain, withdraw does cause a patient to go into immediate pain as soon as the pain med wears off so yes now they are seeking, intentionnally or not, the patient may not be aware that they have developed a problem or that they are developing a problem, I have to say that it is up to the M.D. to determine what the patient needs are all we can do is continue to educate ourselves in the field we specialize in, so that we can educate our patients, and pray for the patients we work for, there are alot of excellent sites you can look up in regards to addictions and recognizing withdraw Sx, in order to differentiate the seeker from a new patient, who can be taught other ways of pain management, because once addicted to pills, I have learned that it is a long road to freedom. Some withdraw symptoms are chills, dialated pupils, muscle aches, their back and leg hurt the most, sweats, yawning, teary eyes, runny nose and difficulty sleeping, but most commonly you will find the patient over medicating or switching doctors alot, some patient frequent the E.R. so they can get an immediate script for pain medication these are definite tell tail signs. But they are still patients none the less and they still have a sickness that needs to be treated.:redbeathe

[vamedic4, EMT-P]

Karen you really should post more!! Those two posts were some of the best I've read on pain management. It is truly appalling the ignorance that pervades the medical and nursing professions on the topic of pain management. Too afraid of making their patients addicted, I suppose. Perhaps they don't realize the negative quality of life that those who suffer from chronic pain endure on a day to day basis.

What's sad is that so many people know just how to work the system. Like teeituptom says - they could be sitting there eating potato chips (or, in the case of my facility- fries and a coke), and tell us their pain is a 5/5. Do the fries make it better? :nuke: These are the people who make providers jaded, the ones who make us doubt their claim because we can't feel what's going on inside their bodies. Because they "look" fine, they "sound" fine. It's a shame people just can't be honest...but that would be too much to ask.

vamedic4

[twotrees2]

Ten years in the ER and I saw both types of patients. Drug seekers and those with chronic problems that really hurt.

Yes, we are taught that the patient is always telling the truth about the pain. Around here the favorite chronic complaint is a migraine. After 11PM we always got lots of migrainers. Why? Because we usually had one of three MD's at night = 2 who placated and 1 who would not play the game. If one came in and found that Dr NO was on they would leave.....in fact all the migrainers in the er waiting room would leave. I don't know about you but I have a hard time believing that someone is in agony if they can get up and walk out without tx.

But let the 2 Dr. Feelgoods be on and I promise you on any given Friday night we "medicated" between 5 and 10 pain patients. Why did I say "medicated"? If a patient is given meds and is in fact a seeker - then you have just become a dealer.

You will learn to tell the difference - if you have to wake up a patient that is snoring up a storm and ask are you still hurting and they say yes after you have had to shake them in order to wake them up. They are not hurting.

If you go into a migrainers room and the light is on and they are chitchating with family and sneaking and eating some chips. They are not hurting.

You go and ask the diabetic patient if they are having chest pain and they say no, or you ask if their feet hurt and they say no(etc) you had better check all of these areas out - diabetics do not feel pain like others do. And if your senior patient complains of nausea make sure that the MD is notified and you start with 6.25 of phenergan (unless you want to support their BP until it wears off)

You will learn as you go - ask questions -observe the patients and soon you will be able to distingush between real and really acting. I swear the oscar people should see some of the performances we see.

And before anyone gets in a snit - I have suffered with migraines for 34 years and have 2 kids with migraines. We all have different triggers, we all require different med's, and we all handle the pain differently. the 23 yo gets dizzy, the 15 yo (male) vomits just as I do. He and I require narc. but the 23 yo can generally sleep hers off. (Lucky girl).

Post Script:

Many times migrainers can in and asked for me - even the seekers - because I was so understanding and took care of them so fast, never hurt them with their shots, was able to work around the styrofoam in their rearends and finally I gave each one the same instructions. The only difference I showed between them was that I knew the seekers allergies as well as they could and they did not have to list them for me.

living with chronic pain i disagree with you on the "if you have to shake em to wak em or thier snoring" etc comments- - when my body gets in the best position i can zonk out quite soundly - not really sleeping but my body wore out type sleep - but when i awake i am in so much pain it isnt even funny - i snore even when i am not sound asleep with sleep apnea - dont assume i am sleeping just cause i am snoring. also during a acute pain episode i was given demerol - it took care of the edge of the pain allowing me to sleep between spasms of pain- teh spasms of pain would wake me right up screaming - -

[twotrees2]

Here's what's confusing to me about people who have genuine chronic pain conditions for which they are under the care of a chronic pain specialist, and have an agreed to (often signed) treatment plan, including a narcotic or two.

Why would they ever have to go to an ER (particularly to get refills of those prescribed narcotics) in the FIRST place? Just like diabetics or asthmatics or any other patient with a chronic disease, they HAVE (or SHOULD have, if they are willing partners in their own health care) a physician managing their treament plan and prescribing their narcotics according to a fixed schedule. Why should they ever be caught in a position where they have run out, and have to go to an ER where people don't even know them, their hx, or how their pain has been managed, since they have no access to their outpatient charts?

I mean--if you have chronic back pain, or chronic migraines, you have a doc managing that chronic pain; a chronic pain specialist, if you've gone to the trouble to seek one out and have worked out a mutually agreed to treatment plan and are compliant with it--and that means keeping your scheduled appointments and getting your narcotic prescription refills as ordered and as agreed to in your treatment plan.

If you've done that, then you have the meds you need and should be using them as prescribed. Why would you ever be caught in a situation where you have run out and have to visit an ER, essentially behind your doctor's back, for more of the same meds, or the same meds, but in IM or IV form? To me, that's non-compliance and in violation of your agreed to treament plan.

I am anything but judgemental, and I, too, agree with the adage that "the patient's pain is whatever he says it is" but that adage is referrring to ACUTE pain----not chronic pain.

Chronic pain is a whole different ball game, and needs to be managed by chronic pain specialists. Chronic pain patients should know better than to be using emergency rooms as drop-in clinics--they need to be compliant with their own agreed to treatment plans, and I am betting those treatment plans have detailed instructions as to how to avoid running out of medication before a weekend (which includes taking the prescribed meds ONLY according to the schedule prescribed) and therefore having to drop into the friendly neighborhood ER, expecting them to become a partner in a chronic pain treatment plan to which they don't have access, and are therefore reluctant to interfere with.

For those of you ER nurses who frequently hear the story, "My meds fell down the sink" (or the toilet) check out http://www.placebojournal.com

There is an amusing animated picture called "Narcotic Mystery--just click on it.

people who have chronic pain can have acute pain also - i dont see any reason they should NOT go to the er if they end up with other pain - one because with our chronic pain we know whats causing it and what fixes it - i sure am not gonna have severe abd pain and just medicate myself with my pain meds and perhaps have a ruptured appendix opr whatever -

oh and i have seen somone who ran out of the pills ( not thinking to refill them as they werent scheduled )- and he tried hard to not take em - and he let it go so far he went toget some and had only a few pills left - not enough to get through the weekend to get to doc on mon. it happens.

[twotrees2]

There are drug seekers, without a doubt, as long as the doctor has ordered pain meds for that patient we have to give them whether or not we believe they are really in pain. I try really hard not to make judgements but sometimes you just find yourself being human. We have one doc that will tell us to give NS IV if he suspects drug seeking going on. Anytime I've ever given NS IV for pain it has worked the same as if I had given the good stuff. Makes me wonder if endorphins come into play here because they believe they got the good stuff or are they just satisfied by thinking they got the good stuff? You will run into patients that will speed up their IV rate (yes, they figure out the pumps) right after you leave the room so they can get a buzz. I've had many hold their hands up and say "here you can put it in this first port, the stinging doesn't bother me." I didn't fall off of a coconut tree yesterday I'm thinking. I always dilute narcotics with NS and push slowly over 2-4 minutes. Some mind, some don't. I have to do what I think is acceptable.

no , we do NOT have to give what a dr ordered if we have valid issues and proof at hand- if i suspected strongly ( not just whimsica) that i had a drug seeker r i would before giving anything call my supervisoer or tell the doc to give it himself then. ourlicense is on the line - it is our responsibility to question an unnacceptable order - if we dont in the court we are held as responsible as the doc.

as for speeding up the narcs then those patients are idiots as its more than likely in there- it isnt like the dose is in the bag- and if your doing over 4 min the amount you wuld give diluted would be already run into the vein.

[krisssy]

Good Morning!

One of the most difficult concepts for a nursing professional who is brainwashed into thinking of "drug seeking" as a medical term is the differentiation between "tolerance" and "addiction." The physical symptoms are the same for either person; yes they are both viable clients with overtly different diagnoses and outcomes!!

Over and over I read posts on this topic in the year 2008 where modern research has shown that "tolerance" and "addiction" appear the same physically, when indeed the only similarity is the symptoms physically that occur between a person who is legally prescribed medication for pain, and someone with a serious disorder which is entirely different; this disorder is termed "addiction."

Physical withdrawal can occur between the "pain patient" and "the addict" with the same result; an uneducated physician or nurse can infer by value system (not by the subjective verbal report of the client) that a person is in fact "drug seeking" and one of the top pain specialists in the United States told me "at some point a patient not treated for his or her pain will be RIGHTFULLY drug-seeking at some point if not treated, for he or she cannot tolerate the suicidal level of pain they experience."

Nursing professionals are in the role of advocate by the nature of our profession; with or without a value system in place; putting ourselves as "God" does nothing for the client in need, makes us look like idiots, and furthermore negates the value of our very comprehensive education. I do not care whether you are a LVN, two year or diploma RN, or four year RN--you know through clinical experience if not through text book knowledge the truth.

Reply after reply show nurses who have years "in the trenches" learning from their own misconceptions about the term "drug seeking." When I tell you that stating such in an ER with a client in true need is malpractive for a physician and the nurse involved I mean this. If any of you who use this term freely or believe somehow that you know better than the client experiencing pain "his experience" then you are wrong. Lack of objectivity will keep you miserable in your role as a potential advocate, and then when someone you know and love, even yourself falls through the cracks, and is attacked or mistreated in thousands of ER's (in particular) throughout the United States you might change.

We have an obligation to continue the learning process throughout our lifetime. I know of no other profession where it is encouraged, applauded, and complimented. Our profession can make a difference in the lives of many; this particular concept of "drug seeking" needs to be trashed along with foul language, abuse, and a thousand other crimes of a medical nature that occur with frequency today.

I ask all of you in disbelief to further educate yourself; get your nurse managers or DON's (such as myself) to arrange inservices, really make yourself an open book when you approach any new client, and "stop the violence." One day it might be you so labeled and suffering, please do this for your client's and for yourself.

There is no "seeker" this is a disgusting judgement. An addict is also suffering a serious disease process; one that is incurable, but a psychiatrist is in the role to truly determine if a person fits into that diagnostic criteria; not a one shot five minute analysis rendered by a value statement.

Thank you,

Karen G.

Karen George I really support,with great humility and respect, everything you say. I couldn't begin to express it as beautifully as you did.

When a patient is in pain, we as nurses need to use our critical thinking skills, read the doc's diagnosis, read the labs and other test results and figure out what is going on here. One writer at the very beginning of this thread wrote that bowel obstructions are caused by constipation due to narcs. That may be true for SOME, but for a nurse to decide that that is the problem is cruel. I had two emergency surgeries for bowel obstructions due to adhesions, from a previous surgery, wrapping themselves around my colon causing the blood supply to my colon to be cut off. The pain was excrutiating, and I would have died without surgery. Imagine if a nurse said to herself, "this is just a drug seeker constipated and on narcotics?" The ED treated me with IV narcotics, but the floor nurse would not give me my pain meds before the surgery. My husband went to the DON and nearly got her fired. The surgeon had written an order for narcotics, and she refused to give it to me??????????????? How could a nurse think I was a drug seeker in the condition I was in? She obviolusly didn't read my chart and didn't even know what was going on with me? As a patient and a nurse I was shocked.

I also agree, Karen, that drug addiction is a DISEASE. When blood levels drop on a narcotic user, they are in real PAIN. They have a disease, and they have the right to medical care. Addiction and alcoholism are recognized by the AMA as a DISEASE. There are detox centers, rehabs, and all sorts of places that social services can get for patients with a DISEASE who are withdrawing emotionally, mentally and physically and need help. Why is it that some nurses still don't get it? You can turn away a person in withdrawal and they can get their narcotic off the street and overdose. It does not matter and it is not up to us to judge why they use these pain killers. It is our job to help our patients with compassion and understanding and not judge them by what kind of disease they have.

Sorry if I am ranting, but like Karen the words "drug seeker" makes me very angry.

Krisssy RN MA

[KarenGeorgeBSRN]

Dear ?

This is not about you but is about what is medically ordered.

How would you know what happens? Have you mainlined please

give yourself some dignity when you reply in regards to a proper

medical order. A client can be responding normally and be in pain

this is not a judgement call.

I am frequently amazed at nurses who "know it all" but really are

just thinking or replaying what they do know. Substance abuse

is high in medical professionals and the tone of this post makes

me wonder!

Karen G.

no , we do NOT have to give what a dr ordered if we have valid issues and proof at hand- if i suspected strongly ( not just whimsica) that i had a drug seeker r i would before giving anything call my supervisoer or tell the doc to give it himself then. ourlicense is on the line - it is our responsibility to question an unnacceptable order - if we dont in the court we are held as responsible as the doc.

as for speeding up the narcs then those patients are idiots as its more than likely in there- it isnt like the dose is in the bag- and if your doing over 4 min the amount you wuld give diluted would be already run into the vein.