Drug seeking or real pain? How do you tell?

I love my cat! · May 3, 2008

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.

I think inadequate pain relief will turn a "normal" person into one that appears to be an addict.

The description of this has been labeled PSEUDO ADDICTION. Here is a brief article describing the behaviors.

Pseudoaddictions

From the article:

Signs and symptoms of a person diagnosed with pseudo-addiction are usually associated with the behaviours displayed by drug addicts seeking to receive superfluous analgesia.

Typical behaviours include the constant request for pain relief, knowing exactly when pain relief is due or can be taken, even causing clock-watching and knowing in-depth information about different types of pain relief. These patients often moan, groan and overtly verbalise their pain in an effort to receive further pain relief. In the case of pseudo-addiction, the patient is actually experiencing high levels of pain, but due to their behaviours, staff are often reluctant to administer pain relief as they do not want to encourage drug use by what they believe to be an addict, often exacerbating the situation.

nanacarol · May 5, 2008

Josh, You took the initial assessment piece to its basic beginning. Thanks. I agree with you completely. nanacarol

10MG-IV · May 5, 2008

, yes, my hubbie big joe paramedic, deep sea diver dude, rn man, had a cervical herniated disc and went through the same thing. he could not believe the pain. now his thought process has totally changed. he never never uttered the words "suicide and i understand why people do it", untill he had this amount of pain. i was in shock when i heard that come out of his mouth.

he said he knows why people seek drugs now if they have that much pain,l give them the drugs! needless to say, this was a 180 turnaround.

lortab made him have night terrors. flexeril made him insane..... robaxin was like drinking a glass of water, untill i shoved a 5yr old soma saved from pulling my back out gardening, he did not get relief. had to get an rx stat for him too because of the drug testing they do @ his work. doctors were soooo leary at first. getting past the front desk bulldog is impossible. if you are in pain pray you have a stash, hoard meds because you won't get em when you need em and save your bottles with your name on them for when you get the p test. surgery was a success, no meds except for nsaids. i am sure there is a law somewhere how long i can have my narcotics. where do you go though, dental pain, chronic pain, mental pain, ..........the er.......then all these people drive all over the place on all these drugs... holy cow.

Dragonnurse1, ASN, RN · May 5, 2008

10MG-IV 6 months before I found out that I had C3-4-5 discs herniated I could to to the ER get the following, 100mg Demerol, 50 mg, phenergan and 100 mg of pentobarbitol; then drive home try to find something to feed my 4 kids and approx 1 - 1 1/2 hours post injection finally pass out. MD thought I was haveing really severe migraines (hx of same) but pain was not the same. Now I have plates holding c 5-6 together, neuro guy will not touch neck again, too many allergies:banghead: Today I find out that L1,2,3,4,5 and S1 are all ***** and collapsing Here I go again for the pain problems. :crying2:

Dragonnurse

alwayslearnin · Jul 2, 2008

First of all, thank you to all of the posters. I have learned and have been given resources for continued growth.That being said, I wonder, "what about the intuitive" side of nursing that we use. The one that, in the ER we use when we look at our patient and know the all important question, "sick or not sick" It's that gut sense when a nurse is working with a post op patient and think, "somethings just not right" and yet she doesn't have alot of physical data (i.e. changes in vital signs, exessive bleeding, change in mentation etc.) to point to yet. This is a recognized part of nursing and medicine. So when I am dealing with someone in pain, I can't use that part???? I still listen to that intuition when I have someone tell me about their pain.

We are talking about different synarios (sp) with pain. For the Drug addict in withdrawl-yes lets treat him for goodness sakes, but for the addicts that is just seeking (sorry, you can't tell me it don't happen and it does ALOT in the ER) why give them medication? It is enabling the behavior.What happened to the Hippicratic oath and the Florance Nightengale oath? What about REALLY treating our patients and being honest with them and sitting down and talking about the 60 ER visits this year for pain related issues that were dental,and abd pain that all scans and test done were negative. Why don't we talk to people and ask them what they are really needing. If it is addiction, do they want help we can get them help. If they are lonely-let social work helop them find some resources. It hurts when you bust your butt to help people and then you have this group of people that you know are playing the game-how because you overhear them talking in the hall about the "score" from the doc after discharge.l Because of the pharmacy calls from the patient that just left the er that tried to alter their perscription, or the pharmacist who called to say, did you know that patient just refilled another perscription from x doctor for that med 2days ago? Yes these people need help, but throwing pain medication at them is not the answer-getting clean and sober and dealing with whatever else issues are. And to just say that anyone who says people exhibiting these behaviors "drug seeking" are judgemental-no I would say we are probably seeing the reality and saying"lets really help them " We use objective pain indicators at other times- i.e when a person is on a vent (including vital signs) Why is it all of a sudden thats not vallid just because a person can talk now. I am not being adversarial, but these are things I have wondered over the years.

Dragonnurse1, ASN, RN · Jul 2, 2008

Alwayslearnin

This is a very good post and you have made some really good points. I always had fun in triage when the pt. had "chest pain radiating, N/V, sweating". Pts v/s are stone cold by the book normal. I would ask where the pain was radiating to and watch as the patient would close their eyes and try to remember the TV commercial and then tell me "down my right leg". Wrong answer, you do not pass go and you do not collect $200 dollars. Here give me a urine sample - watch the patient bypass the bathroom and head out the door. Get call from other ER in town - had pt come in with cheat pain, their name is ******, known cocaine dealer/addict. Thanks but he just left without giving urine for drug screen. Chalk up 1 for the good guys. :yeah:

On the other hand someone comes in with REAL chest pain and still very young get them to the chest pain area. I know, too young to fit AMI but a cocaine induced heart attack is quite another problem to treat and very tricky.:uhoh21: Oh and do not assume like 99% of ER Docs do, that women of all ages can not have a heart attack. :nono: We had a patient in Chest pain center c/o just not feeling right. The Doc had seen her the night before in the other ER - came in and told her "I saw you last night - you were not having MI last night and you are not having one now so I am sending you home." :angryfire I had protocal and followed it and I waited on the discharge until cardiac markers came back. The numbers were through the roof. Doc had to appoligize, patient sent to cath lab and I had the satisfaction of knowing that I had keep the Doc from having a real problem and that the patient received the right treatment. Why did I not follow Doc's orders? Because her "pain" and how she presented I had a gut feeling that something was wrong. :banghead:

Trust your instincts as a rule they will not let you down. :cool: I am so glad to know that there are nurses like you that will give the care the patient NEEDS and not nessearly the ones the patient wants. :yeah:

dbmc · Jul 12, 2008

As a nurse and a chronic pain sufferer, this topic is very interesting to me. Ladies and Gentlemen, the way that we treat chronic pain patients is unforgiveable. I have been made to feel like a felon for going to the ER for pain relief, asking my doctor for a stronger analgesic and for not "sucking it (pain) up. It's difficult for those who have never suffered with pain 24/7 to appreciate exactly what chronic pain can do to a patient's life. Family members are compassionate to a degree, but eventually they're worn out and don't want to hear about it anymore. The pain consumes the patient, so it is difficult for the patient to focus on anything other than the pain that they're experiencing. It is our job as nurses to be a strong, level-headed advocates for the patient. It's pathetic that we treat our pets better than we treat our humans, in that we don't let them suffer. :confused:

leslie :-D · Jul 13, 2008

chronic pain is very challenging.

while there is an evident need for aggressive and creative pharm mgmt, this still does not negate the fact that many still, become addicts.

i'm not talking about tolerance levels.

i'm talking about those who need the narcs for their physical pain, yet have become psychologically addicted.

and it happens, w/o a doubt.

i truly believe those w/cp, need to only see a pain mgmt doc, if available.

otherwise, it can turn into a crap shoot...

where they're either being undertreated or being prescribed enough meds to kill an elephant.

there has to be a middle ground.

leslie:twocents:

nanacarol · Jul 13, 2008

I may not have written it well, but that is the point I was making. It begins with the health care provider (nurse and doctor) completing an accurate assessment and referring the patient to the appropriate provider. Pain specialists are the appropriate provider to prescribe pain meds for chronic pain. The attending needs to maintain close communication with the Pain specialist so there is less chance of double medicating. The new medication reconciliation process (when implemented correctly) is designed to identify patients who go from dr to dr, Er to ER seeking medications. The process requires that the various providers review the med liist, that the nurse and social worker engage family and significant others about home meds and that the pharmacist review the list for duplicates and dosage problems. nanacarol:twocents:

ssouthernyankee · Jul 21, 2008

I am having questions about pts. with facticious disorder/Munchausen I didn't know how to start a new topic so I am gonna try here. My family have been informed that our mother may be faking illness. Said that she was putting feces into her bladder and giving herself skin abcess by inecting feces into herself. How on earth could she do this? And how can we know for sure that is what is going on. I don't want to accuse her of this if she is truly ill. Any thoughts on this type situation and does this really happen in other pts.? Thanks

oldnewnurse46 · Oct 9, 2008

OK, I'm going to be honest. They are under 40 years old with no serious medical dx excepting "back pain". They call 911 themselves. They convince the EMTs to run a line and request dilaudid the milisecond they are in the hospital. They are "allergic" to Ibuprofen and Tylenol. They are have "nausea" and request Phenergan yet wolf down a full meal. They are sickingly sweet to the RN until you hesitate giving them more narcs, and then they turn toxic and call you names such as "*****". They tell you which vein is best for the IV. Every new face on the unit will get sucked up to in their perseverative effort to get narcs. They split staff. When you get a MD to run an Rx check they have shopped pharmacies and doctors. Their pain MD has told them they are no longer welcome as pts due to non-compliance. Their tox screen is positive for drugs they didn't tell you about. They are still on disability from a workman's comp injury from 5 years ago. When you search their bags, you find empty pill bottles that should have lasted them for two more months. They are not interested in physical therapy. When you check their medical records, they've presented to the ER for "chest pain" then "neck pain" then "back pain" then "stomach pain" over and over, with no physical cause found despite batteries of tests. "Chest pain" get you morphine stat:twocents:.

nanacarol · Oct 10, 2008

I don't understand your point. The physician writes and order for pain medication, the last time I checked with my Board of Nursing, I am required to either provide the physician with real assessment data that indicates the current orders are not in the patient's best interest or carry out those orders. I am not familiar with the nurse practice acts of other States so I defer to each of you. Yes, as a nurse you can make suggestions/recommendations to the patient concerning alternative treatment modalities but in the end, the physician's order takes precedent, at least in my State. Your open and accurate communication with the prescriber is critical in making a change. JCAHO indicates that a patient's statement of pain is true and accurate and should be acknowledged and acted on. I am merely the messenger, please, don't shoot me. Just tonight, I had 2 pts I am sure in my noer, were seeking medications, they answered my questions correctly, became angry when I suggested they wait a while longer, reported me to the charge, I held off as long as I could but finally gave the medication, left a message for the doctor about my concerns. I then moved away from the issue, I had done all that is within my scope. Think about it. Nanacarol