Drug seeking or real pain? How do you tell?

NEC1970 · Apr 7, 2008

As the author of the original post, I , too, was unsure where this discussion ended up. There were many excellent responses that emphasized true advocacy and best practice. thanks.

andrew

Dragonnurse1, ASN, RN · Apr 7, 2008

i guess each of us has our own wayof deciding on real pain or drug seeking. The bits about normal bp, normal hr, normal breathing, no nausea, and they tell you that they can only get relief is mso4 or diluidid I would be on guard.

And we have have those that did fake by triage that got an int started and when we would go to get the meds the patient would bolt for the door. Talk about safe iv drug use!!!!!You will figure it out as you go. Medicine is a practice not an absolute.

If you do not learn something every day then you are not doing your job.

nanacarol · Apr 9, 2008

Dragonnurse, now, now, you and I both know that I said, nor did I imply that we should support drug dealers. My goodness the melodrama is emerging. I did say that as nurses we are to accept our patient's assessment of what is pain. I said, we were not deputized as drug police and if I did not I should have said that National Patient Safety Goal indicates we DO poorly in assessing, evaluating and managing our patients pain. I believe it is because we are so entwined in judging and less so in ministering to our patients. Now before the board blows up, I KNOW this is not true of every nurse! But to be real, there are a great many who feel as you describe. Our assessments should probe deeper into what is causing the diversion and make recommendations for the patient. nanacarol

Dragonnurse1, ASN, RN · Apr 10, 2008

Nanacarol, this is the last post I will make on this subject. The "tone" of your post pointed to a big problem in the medical field in general. We know that hospitals are forming "Pain assessment teams" trying to set goals to address pain needs. That is not what we are discussing - in the walk in triage setting how do you assess the pain level of the patient. Your complaint note states what they say 0 - 10 example 10. You note ten on your paperwork that will be forwarded to the doctors in the treatment area. But everyone of the people I worked with all formed dx with each patient. :down: Now you have 10 people all claiming to have pain of 10. You have one bed in the back. How do you decide which one goes back first. :uhoh3:

Your vital signs and the location of the pain. Now is it the 21 yo chest pain with a bp of 110/68,72,16, O2 sat 99% talking on the cell phone or the 35 yo chest pain with a bp of 166/99,89,24 O2 sat 96,holding his chest and sweating? The 21 yo came in first and both are males - who goes first?

the 35 yo is the one you choose - why. Because his appearance and vital signs indicate that he is possibly having an MI and he looks like he is in distress. You cannot be a good triage nurse if all you do is note the pain level and do not assess the patient for pain indicators. That is why we had a policy that no nurse with less than one year experiance could work triage. :nono:

That having been said and having worked in the ER like I did I can truly say that I never denied or "judged" people as to whether they were drug seekers or not because I had had that same Judgement leveled at me before I became a nurse. I mean when I would have to go and my "standing orders" were 100mg Demerol 50 mg phenergan and 100 mg pentobarbitol and I could tell by the burn of the injection if they had given me the correct med. and called the ER doc on it several times - than I an not going to do the same to my patients. If anything I was guilty of pushing the MD for more or different (stronger) pain meds depending on my patient. And when I was on at night I was sent to assess each migrainer when such was presented to see if they were "for real". 8 out of 10 times I would have seen the patient, found out what med worked best for them, drawn the meds from the pyxis, taken the chart put it in front of the MD and told him what I was going to give and how much. I can remember only one time I was vetoed and we ended up giving the patient my choice of meds and having to admit for intractable pain due the the slowness of receiving proper pain med. :banghead:

Sometimes only someone who has the experiance of intractable pain and mutiple medical problems all requiring pain meds can truly understand a patient with pain that cannot be "visualized".

:stone:heartbeat

nanacarol · Apr 10, 2008

This is my last response as well, if you do what you describe, then all of your patients will have been served well and you will really rank as an advocate. Kudos to you. nanacaroly

RN.38SPCL · Apr 10, 2008

1 How long have you been a nurse?
2 How long have you been a triage nurse?
3 How many times have patients come in and ask how is the doc on and leave
4 How many time have patients seen you sitting in triage and leave.
Don't quote pain problems unless you are ready to fix it:bow: I was found on a Monday to have C3,4,&5 Herniated well wedged into foramen on right side did not have much use of right arm. The nerve in my right are is permentaly damaged, they even tried to move ulnur nerve. I had C5&C6 fused and plated 2 years ago and it still hurts and I have stenosis at L1,2,herniated diskl3 and l4.
If your pain is that bad why do you not have surgery? Quick fix 2-4 weeks at home all better. Nerve damage in back you would have to explain.:typing
One other tidbit - Normal bp. normal heartrate, normal breating, not needing emesis basin and being able to tell the staff exactly what to give how much to give and that they are allergic or had problems with every other oain med except dilauid or mso4
something ain't right.
Post scriptone of our regulars (Sickle Cell) was caught selling her pain med on street.She on course fainted and they brought her back to er. no more meds, no passing go, nocollecting 200.00:lol2:
Remember it is the Doctors that order the meds not the nurses.

Yeehah dragonnurse!:bowingpur I work in a county jail now. I used to work hospice and pride myself at knowing how to help someone control their pain and other symptoms. I have a mildly herniated disk at L-5 and S-1. When it flares up...man, I am dying. Before we knew what was causing my pain, my FP made me an appt with an Ortho. It took 3 months to get in. I called and begged "Please, I'm in so much pain, squeeze me in" The secretary or bulldog I should say says, " Well I can get you in on this date", It was a month later than what I already had. My FP did not want to order an MRI, she wanted the ortho to order it. They all kept telling me Just go to the ER. We'll, yes I was suffering but the ER is for emergencies. This just needed Temporary TX until my 3 month down the road orth appt. I knew what worked in the past. I said, just give me 4 days worth of Naproxen and Flexeril and I'll be good to go. No NO NO from everyone. I gobbled 3 times the NAD of over the counters, Did stretching exercises, ice packs hot packs and went to work. How could I get time off? No doctor's note, no diagnosis etc. By the time my 3 months later appt rolled around, the flare up was over. I was in significant pain for 5 months. Waited 2 months before going to FP in the first place. So I went to my ortho appt and told them exactly what I thought of them and how I had drug dealers in my jail who were being treated by the same outfit with no Dx but "chronic pain". These addicts were selling their meds as well as playing with them. they got caught. So.. I was ****ed. The Doctor felt really bad about what happened to me and ordered a stat MRI. He read it right away. Even though I was not currently haveing a flare up, he rx'd me for naproxen and flexeril with 3 rflls. If I learned anything from an inmate, it was this....stock up on drugs. I'll never get stuck waiting 3 months without any relief again. that was 2 yrs ago. I kept those pills and when I have a flare up, if I treat it right away, at the first twinge, I can nip it in the bud. It takes one or 2 days of meds, ice and strething and I'm good to go. Any doctor today can plug your name and address inot a nationwide pharmacy system and see what you've been up to. It will list every doctor, every med that doctor prescribed, and every pharmacy you've been to. there is no reason any more for nurses and doctors to wonder if the patient is legit. Imagine yourself in a courtroom and the lawyer is asking you to explain why you continued to give rx to a known drug addict who ended up overdosing and died. Tx the cause and not the symptom.

vicky1964 · Apr 24, 2008

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.

"The number of those who undergo the fatigue of judging for themselves is very small indeed:yeah:

Home Health Columnist / Guide · Apr 24, 2008

just came across this info yesterday and added to pain mgmt links

from:

american society for pain management nursing

pain management in patients with addictive disease (pdf)

summary

patients with addictive disease have the right to be treated with respect and to receive the same quality of pain management as all other patients. providing this care addresses the potential for increased drug use or relapse associated with unrelieved pain. nurses are in an ideal position to advocate and intervene for these patients across all treatment setting...

** visit the aspmn web site (

www.aspmn.org

) for assessment tools for withdrawal, protocols for treatment of withdrawal, risks of unrelieved pain, treatment options for addictive disease, and therapeutic plans for relapse.

Templedoll · Apr 24, 2008

When I read a few of these posts I could just about feel the steam coming off the pages. Everyone who posts on here has a valued opinion an it deserves to be that. It is amazing what you can learn from reading these posts. :nuke: :nurse:

Josh L.Ac. · May 1, 2008

just came across this info yesterday and added to pain mgmt links
from:
american society for pain management nursing
pain management in patients with addictive disease (pdf)
summary

patients with addictive disease have the right to be treated with respect and to receive the same quality of pain management as all other patients. providing this care addresses the potential for increased drug use or relapse associated with unrelieved pain. nurses are in an ideal position to advocate and intervene for these patients across all treatment setting...
** visit the aspmn web site (
www.aspmn.org
) for assessment tools for withdrawal, protocols for treatment of withdrawal, risks of unrelieved pain, treatment options for addictive disease, and therapeutic plans for relapse.

this sounds great in theory for an inpatient setting but how do you safely give a chronic pain patient that is addicted to narcotics more narcotics in the outpatient setting? both the doctors i work with have narcotic contracts that the patients are required to sign. one of the stipulations is that they take their medications as prescribed and absolutely do not get more narcotics from other physicians. obviously, the addicted chronic pain patients have problems with this and eventually their ua comes up dirty.

so what are we supposed to do? if they are addicted, they will often take too many narcotics and develop hyperalgesia, which leads them to take even more narcotics without permission...which leads to more side effects.

as a patient advocate, how do you give the chronic pain addicted patient more meds without endangering their health? plus if they violate their narcotic contract, do you continue to write them scripts?

nanacarol · May 1, 2008

My response may seem like a copout, but adequately treating pain begins when the patient first presents, not after they have had to resort to inappropriately medicating themselves with whatever they can get legally and otherwise. The problem becomes a major challenge once the person is dependent and or addicted. And you are correct, contracts don't work, dependent and/or addicted individuals will do whatever is necessary to be medicated. I really don't have an answer other than to advise us to take the patient seriously when they first present in our health arenas. nanacarol

Josh L.Ac. · May 3, 2008

My response may seem like a copout, but adequately treating pain begins when the patient first presents, not after they have had to resort to inappropriately medicating themselves with whatever they can get legally and otherwise. The problem becomes a major challenge once the person is dependent and or addicted. And you are correct, contracts don't work, dependent and/or addicted individuals will do whatever is necessary to be medicated. I really don't have an answer other than to advise us to take the patient seriously when they first present in our health arenas. nanacarol

I am going to have to disagree a bit on your first point - I think there is a difference between a drug addicted patient and a patient that is receiving ineffective pain control.

One of the questions we ask new patients is if they have ever been treated for alcoholism, because an addict is an addict.

Let's say I go to the beer store and buy a case of my favorite stout [North Coast's Old Rasputin Imperial Stout]. Now there is zero chance I am going to go home and drink more than a few of them. One of my childhood friends, on the other hand, is a recovering alcoholic. There is a very good chance that once he starts with one he is going to continue until he is unable to drink anymore. My friend and I are pretty much in the same cohort - middle class upbringing, divorced parents that remarried, advanced degrees, BLAH BLAH BLAH. The major difference is that he is an addict for some reason, and I am not [for some reason].

I occasionally have neck and back pain with radicular symptoms. If I were to be put on narcotics for the pain, I would have no problem taking the ordered dose. If I was not getting enough pain relief, I would contact my pain doc and discuss increasing the dose, changing meds, or getting a procedural intervention. My friend, on the other hand, would probably start taking more meds even if he was not in excessive pain because he is an addict. That's the difference. Even if he got to the point where he was developing hyperalgesia, meaning he was in more pain with more meds, he would continue to take more meds.

I think the docs I work with would argue that inadequate pain relief will not turn a "normal" person into an addict, but inadequate pain relief will stress a patient with an addictive nature to the point where their addictive nature surfaces. But in those cases, the primary disease is addiction, not inadequate pain relief. If you switch meds or perform procedural interventions [to alleviate the pain] without addressing the addiction, then they are still in trouble.