Drug seeking or real pain? How do you tell?

Fgr8Out · Feb 2, 2004

I've been doing a good deal of thinking recently, in light of the numerous patient's I've cared for who were having difficulty attaining control of their pain. In many cases, their behavior pointed towards some sort of reliance on narcotics to alleviate their pain and the nursing staff had become very judgemental towards them.

My general routine with patient's, who are described as "seeking" or "clock watchers" or who "really like their pain medicine" is as follows: "Good morning Mrs. Smith, I'm Lori and I'll be your nurse today." In the course of my assessment, (if not sooner, as determined by the patient) I turn the topic to the subject of their pain level, where the pain is, etc. "I understand you've had some difficulty managing your pain while hospitalized. Would you care to tell me what seems to have helped your pain, what times your pain seems to be more intense and perhaps your history in the past with pain control?" After reviewing the information shared with me by my patient, I review with them their ordered medications, the frequency it can be administered and how shifts prior to mine were managing the patient's pain. In essence, I let the patient know I believe their report of pain and gain their trust. Almost invariably, I find that the patient has had at least one experience (generally far more) with nursing staff who under medicated this patient, were less than punctual when providing medications and had even spoken condescendingly towards the patient in regards to their pain and requirements for relief. In other cases, it wasn't so much this particular hospitalization, but previous ones that set the tone for how the patient perceived their treatment of pain now.

My point is this... Nursing (physicians too, for that matter) are very often to blame for how our patients behave when it comes to pain and pain relieving measures. At some point in their care, someone made them feel as if they didn't deserve appropriate pain relief, in some way downplayed the patient's report of pain or were only interested in treating a patient's pain when the patient behaved (ACTED) in such a manner as to EARN sympathy of their caregiver and THEN receive appropriate management of their pain.

I myself have had the humbling experience of being told to "suck it up" when I had a horrific case of strep throat a few years back. Antibiotics had yet to effect any relief and the pain was excruciating, in spite of judiciously dosing myself with tylenol and/or ibuprofen. I've never ever been prescribed any sort of narcotic or other prescribed pain relief previously... so there was certainly no reason to suspect I was inappropriately seeking alternative pain relief. All I was asking for was "something" to get me through the 24 hours I knew I would be in pain, while awaiting my antibiotics to work their magic. But because of unfounded prejudices (a nurse, asking for something "stronger" for pain) I was forced to endure an agonizing 36 hours.

How likely then is it for those thousands with pain, to have their pleas for relief cast aside... expected to also "suck it up" because health care professionals don't want the responsibility of prescribing/administering appropriate pain relief out of an unfounded fear of creating (or aiding and abetting) an "addict"? How many of our "problem patient's" are of our own creation because we've failed to intervene appropriately early on... instead foisting our prejudices on our patients... only to see them later with even bigger pain related issues, because we've taught them that, in order to receive validation they have to "act" the part? How many of us in the Profession of "healing" have cared enough about a person with pain related issues to find out when their problems in achieving pain relief or abatement first occurred... and have the presence of mind to reassure a patient that yes, they ARE entitled to receive unbiased assessment of their pain and receive the most appropriate (not necessarily narcotic) treatment to assist them with their pain... and then to go that extra mile and really WORK with a patient to help them find out what really DOES work? I would venture to say if people were appropriately managed early on in their pain again, not necessarily with narcotics, but with all the management tools (diversion, stretching, heat/cold application, posture, imagery) we have at our disposal we'd see many less "seekers" because we would have given our patients the tools they need to appropriately treat themselves.

In my experiences, I've found that when patients receive appropriate pain intervention during their hospitalization, they are far less likely to require a narcotic pain reliever upon discharge. During the time I'm caring for them, I ensure they receive enough medication to allow them to fully participate in their recovery... to ambulate frequently, to cough and deep breathe. We do a disservice to our patients when we give them only the miniumum medication they require early on... because their pain is never truly at a managable level. Research shows that the vast majority of people hospitalized who initially require medication to aid in the alleviation of their pain DO NOT become addicted and quite easily are able to cease the use of narcotics or other pain medications, once the initial reason for their pain (incisions or trauma, for example) has had time to resolve. However, if we fail to treat their pain appropriately early on... they most certainly do not fare as well and may indeed develop a chronic condition.

Food for thought: how many diabetics, anxious about their blood glucose ... have you heard described as a patient who is "just seeking their insulin"... how many hypertensive patients have you reported to the next shift as just "wanting their labetalol" (or other HTN medication)? You don't. Why? Because we don't cast judgement on these medical conditions. So why then, do we make these assumptions when our patients require treatment for pain?

Maybe... just maybe, if people were appropriately treated early on...(physically, pharmaceutically, emotionally, etc) we'd have fewer "problem patients" to deal with in our future.

My post in no way is meant to include those manipulative persons who do, in fact, permeate our Universe. But let's be certain we make every attempt to treat all patient's appropriately from the get go.

Naysayers need not reply.

fab4fan · Feb 2, 2004

What a beautiful post!

jude11142 · Feb 3, 2004

You can be my nurse anytime!!!

Excellent post and more important you sound like someone who is very educated regarding chronic pain. I have to agree that if a pt is given adequate pain control then they are less likely to require more meds. Studies have shown that with the PCA, pts did use less med than if they were getting pain meds from their nurse. I also think that because of the way pts with chronic pain are made to feel like a criminal, they get upset or afraid that they are not going to get their pain meds and then maybe they start getting agitated or start crying etc.....I have been in that situation before I got a permanent doctor and it's no fun. Esp. if what you take are narcotics. Look out, because the minute they ask you what you take for your pain and you tell them percocet or vicodin etc.......their whole demeaner changes. Now, you are told quite coldly, "I will not or I do not write out scripts for any narcotics. One such walk-in clinic has a big sign that states, "This office does not prescribe narcotics, so don't ask"...........This really is bad esp for those who use these clinics for all of their medical needs. You don't always see the same doctor, so each time you have to go over your whole situation. Plus, these docs don't really stay too long at these clinics, so the turnover is amazing. It seems like when you finally get a doctor who knows your history, ran the tests, sent you to the specialist etc....and prescribes you medication that works that he/she leaves the practice. Then you have to start over with another doctor. One time, I was at a local clinic and was seeing this one doc for over a yr. During that time, he prescribed all of my meds. Well, one day I go in for my monthly visit and for my refill(new script)and found that my doctor has left and gone to another state. So, I had no choice but to wait and see one of the other docs. She comes in, introduces herself and asks me what can she do for me. So, I try to tell her how my pain has been, and I have a journal that the other doctor suggested I write in. Well, she is not interested....After not even 2 minutes of scanning my chart, she tells me, "you can forget about getting such and such med, I do not prescribe it".........I am not ashamed to say that I started to cry and aks her what am I supposed to do etc......She was a very cold doc........told me to go home and take Alleve if I have pain. It was a terrible experience, one that left me in the ER later that night.

Something needs to be done for those in chronic pain. They need to stop treating us like junkies.....

I could go on and on, so I am going to end this now, lol

Thanks for letting me vent,

JUDE

Originally posted by Fgr8Out
I've been doing a good deal of thinking recently, in light of the numerous patient's I've cared for who were having difficulty attaining control of their pain. In many cases, their behavior pointed towards some sort of reliance on narcotics to alleviate their pain and the nursing staff had become very judgemental towards them.

My general routine with patient's, who are described as "seeking" or "clock watchers" or who "really like their pain medicine" is as follows: "Good morning Mrs. Smith, I'm Lori and I'll be your nurse today." In the course of my assessment, (if not sooner, as determined by the patient) I turn the topic to the subject of their pain level, where the pain is, etc. "I understand you've had some difficulty managing your pain while hospitalized. Would you care to tell me what seems to have helped your pain, what times your pain seems to be more intense and perhaps your history in the past with pain control?" After reviewing the information shared with me by my patient, I review with them their ordered medications, the frequency it can be administered and how shifts prior to mine were managing the patient's pain. In essence, I let the patient know I believe their report of pain and gain their trust. Almost invariably, I find that the patient has had at least one experience (generally far more) with nursing staff who under medicated this patient, were less than punctual when providing medications and had even spoken condescendingly towards the patient in regards to their pain and requirements for relief. In other cases, it wasn't so much this particular hospitalization, but previous ones that set the tone for how the patient perceived their treatment of pain now.

My point is this... Nursing (physicians too, for that matter) are very often to blame for how our patients behave when it comes to pain and pain relieving measures. At some point in their care, someone made them feel as if they didn't deserve appropriate pain relief, in some way downplayed the patient's report of pain or were only interested in treating a patient's pain when the patient behaved (ACTED) in such a manner as to EARN sympathy of their caregiver and THEN receive appropriate management of their pain.

I myself have had the humbling experience of being told to "suck it up" when I had a horrific case of strep throat a few years back. Antibiotics had yet to effect any relief and the pain was excruciating, in spite of judiciously dosing myself with tylenol and/or ibuprofen. I've never ever been prescribed any sort of narcotic or other prescribed pain relief previously... so there was certainly no reason to suspect I was inappropriately seeking alternative pain relief. All I was asking for was "something" to get me through the 24 hours I knew I would be in pain, while awaiting my antibiotics to work their magic. But because of unfounded prejudices (a nurse, asking for something "stronger" for pain) I was forced to endure an agonizing 36 hours.

How likely then is it for those thousands with pain, to have their pleas for relief cast aside... expected to also "suck it up" because health care professionals don't want the responsibility of prescribing/administering appropriate pain relief out of an unfounded fear of creating (or aiding and abetting) an "addict"? How many of our "problem patient's" are of our own creation because we've failed to intervene appropriately early on... instead foisting our prejudices on our patients... only to see them later with even bigger pain related issues, because we've taught them that, in order to receive validation they have to "act" the part? How many of us in the Profession of "healing" have cared enough about a person with pain related issues to find out when their problems in achieving pain relief or abatement first occurred... and have the presence of mind to reassure a patient that yes, they ARE entitled to receive unbiased assessment of their pain and receive the most appropriate (not necessarily narcotic) treatment to assist them with their pain... and then to go that extra mile and really WORK with a patient to help them find out what really DOES work? I would venture to say if people were appropriately managed early on in their pain again, not necessarily with narcotics, but with all the management tools (diversion, stretching, heat/cold application, posture, imagery) we have at our disposal we'd see many less "seekers" because we would have given our patients the tools they need to appropriately treat themselves.

In my experiences, I've found that when patients receive appropriate pain intervention during their hospitalization, they are far less likely to require a narcotic pain reliever upon discharge. During the time I'm caring for them, I ensure they receive enough medication to allow them to fully participate in their recovery... to ambulate frequently, to cough and deep breathe. We do a disservice to our patients when we give them only the miniumum medication they require early on... because their pain is never truly at a managable level. Research shows that the vast majority of people hospitalized who initially require medication to aid in the alleviation of their pain DO NOT become addicted and quite easily are able to cease the use of narcotics or other pain medications, once the initial reason for their pain (incisions or trauma, for example) has had time to resolve. However, if we fail to treat their pain appropriately early on... they most certainly do not fare as well and may indeed develop a chronic condition.

Food for thought: how many diabetics, anxious about their blood glucose ... have you heard described as a patient who is "just seeking their insulin"... how many hypertensive patients have you reported to the next shift as just "wanting their labetalol" (or other HTN medication)? You don't. Why? Because we don't cast judgement on these medical conditions. So why then, do we make these assumptions when our patients require treatment for pain?

Maybe... just maybe, if people were appropriately treated early on...(physically, pharmaceutically, emotionally, etc) we'd have fewer "problem patients" to deal with in our future.

My post in no way is meant to include those manipulative persons who do, in fact, permeate our Universe. But let's be certain we make every attempt to treat all patient's appropriately from the get go.

Naysayers need not reply.

laurakc · Feb 10, 2004

I agee.

Now here is my two cents worth.

I think that "drug seeking" is a bad term, judgemental, and no one should have the authority to use it. However, we do get many patients that try to manipulate us and that is when managing their pain starts to become a problem.

I find it difficult whenever I go in with a pain medication, and instead of even trying it, the patient will get very anxious (which only makes the pain worse) and says "I am leaving if I can't get Demerol...dilaudid...morphine instead of _____..Or I really like you, you are the nice nurse that gave me ____ the last time I was here. Or the ones that have such severe pain they moan and cry the whole time you are in the room, and then start reading a magazine the second you leave. I do believe that they are in pain and would like to help them, but am limited in what the physician will order because it is not like I am able to prescribe the medications. But I am constantly being told "you will be hearing from my attorney" if I am not offering them the drug they are requesting. I, of course have notified the doctor of the drug requested and it has been refused, so legally am I responsible for their pain management? (if anyone knows) by the way, most of the ones that do this are of course, unknown cause of pain, like headache with neg ct, mri, which makes the physicians less likely to prescribe heavy duty narcotics in the emergency room.

Sometimes, it just feels like you are so in the middle. And it is so bad when someone who takes these large doses of medications for chronic pain comes in with something acute, because some very large doses are not even beginning to help.

Any advise anyone?

laurakc · Feb 10, 2004

and, by the way, we are nicer to animals than to humans. If an animal is suffering as much as some of the patients I have had, the vet would have to put them to sleep. So, why are we so hesitant to treat humans with dignity and respect?

Although, I am sure it would not be easy to do such a thing to a human being, it has not been easy to do it to an animal either.

Dragonnurse1, ASN, RN · Feb 10, 2004

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.

teeituptom, BSN, RN · Feb 10, 2004

Well Laura"put them to sleep" thats novel

I am not going to defend those in legitimate pain, thats not what is behind this thread, I am not going to defend drug seekers, yes I used that bad and judgemental term.

All a pt has to do is tell me they are hurting, then if the doctor chooses to medicate them, then I will. I no longer question their motives or needs for pain control. I am not going to fight with them or argue with them in the least, I just say discuss that with your doctor. He is the one paid to make those decisions and I will abide by whatever he decides. I used to argue about it in the old days when I was younger, but now Ive chosen the path of least resistance. No more stab wounds in the back for arguing with patients, those that abuse it will pay in their own way.

They end up loosing their families, their jobs, their respect from others. Who am I to judge. Judge Not Lest thou Shall be Judged. Or something like that anyway.

I feel for people who hurt, My back has been killing me for over 12 years now. I take my ASA and thats it. I have decided that if I ever wake up pain free, then I must have died. Meantime I keep working, I keep Golfing, what else is there. I certainly dont need anymore grey hair from battling. And trust me, I have seen how drug seekers end up by loosing everything worthwhile in their lives. Why should I fight it.

Dave ARNP · Feb 10, 2004

Tom,

You are truely a wonderful nurse! I would be privilaged to work with you.

Dave, humbled by Tom's awareness of Pain Mgmt.

P_RN, ADN, RN · Feb 11, 2004

Chris what a powerful post! Thank you.

unite911 · Mar 16, 2005

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.

hi, a really great site I came upon is PAIN.com,Great stuff about addiction vs. chronic pain sufferers who use oploids, a lot of great articles,studies on differentiating and identifying drug abusers(even those with chronic pain issues who need proper pain management).today's view on pain management,I could go on and on,just check the site out, you won't be dissappointed.Our society;Law makers, the medical establishment,we all need to educate ourselves.....people in pain should not have to suffer needlessly,we can not hide behind the door's of ignorance any longer! you can also just type in pain management, and a lot of useful sites will come up,it can be overwhelming,but our education has to start somewhere right! good luck and God Bless, mar

barefootlady, ADN, RN · May 21, 2005

I too understand and feel your post, Tom.

Keep on the green, Tom. :balloons:

stevierae · May 31, 2005

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.