Drug seeking or real pain? How do you tell? - page 5
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... Read More
Jul 17, '05[B]...Seanymph et al, I truly feel what you are going thru, and you shouldn't get slammed. It is difficult for me as a nurse to be judgmental...is it real pain or just helping a high? When my pt. comes back on the floor (or while visitors are there) I can't help but wonder if he/she is supplementing his PCA or IVP meds. Other than drug screening every day, is there something we can do for pt. safety and safety of staff?
As an aside, when I was a young teen, my monthlies were unbearable. I was told, after you have a baby it will be better. After my first baby there was no change. After my 2nd baby my cramps were worse!! BCP's helped the bleeding but cut the pain to barely managable. When I went to military and civilian ERs I was told it was all in my head, I said no, in my abdomen!! So after an ultrasound reading of a small "mass", I had a laparoscopy that showed endometriosis all over the place, ovaries, tubes, clinging to my bladder, ureters, perfect textbook case and then some. So danocrin (sp) (that didn't help) for 9 months and then a total hysterectomy. No more back pains or horrible cramps, just the joys of hormone replacement therapy...at age 31. So I know about chronic pain...and because I do, I don't want to deny relief to anyone.
Jan 7, '06Hi all,
I've read the posts and am at a loss. I agree that we need to treat all patients (whether they are drug abusers or not) with dignity and respect. But we are so ethically challenged in this situation. A doctor in Florida was sent to prison for 30 years for prescribing drugs to those "drug seekers" as we have referred to them. I work in an ER and see these patients day in and day out...almost a revolving door. Some are post GSW's who now have total paralysis or semi-paralysis and they come in with EMS knowing them all by name and every nurse and doctor on staff on a first name basis. Some of them are constant abusers that hospital hop and doctor shop...they don't think we know this because they come to a different hospital but many nurses in the area work at several hospitals and can identify them. So how do we deal with this fast growing epidemic? Can we legally and ethically deny them pain medication when pain is so subjective? Can we legally and ethically give them pain medication when we know they are abusers? Is there an answer?
Jan 7, '06I hear ya...mine was diagnosed (after the 3rd child) after years of unbearable pain as adenomyosis. The doctor that finally figured out what was wrong with me ordered an immediate hysterectomy and I've been pain free ever since.
Jan 7, '06Quote from JudyPRNThere 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.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.
Jan 10, '06I think that to really understand and not have bias where pain is concerned you need to have some personal experience with it- or close. Works2Xs told a very sad but all too common occuring story of how people are treated. Yes, there are those that are manipulative and true addicts, but people in pain in need of better med mgt or other options do present as drug seeking patients. Working in home health has really showed me how much people suffer and most are too afraid to really address it. By then it becomes much harder to treat. Giving placebos is unethical and illegal- completely. It is hcp's playing judge jury and executioner. I feel very passionate about this. The older I get myself and the longer I have been a nurse the more I feel this way. It helps since I have been through some chronic pain issues myself and see both sides. The bottom line is that we listen to the patient. Depending upon what area of hc you're in dicatates what you do. If you work in the er you'd give them the meds and tehn do some followup planning. Make an appt with them for a specialist, social worker, etc. Do they come back into the ER with no follow through from before- okay, you have an idea that there's something fishy going on. In home health when I have pt's who state they are suffereing, I try to see if things like PT helps. I also encourage them to keep a pain diary to take to their doctor to see and make it as detailed as possible. I help them with some of the descriptive word choices, etc. Instead of judging our pts, we need to give them tools to try to remedy their situaiton (be it a lt narcotic program, PT, or rehab) and then sit back and see what you think. Do not pass judgment when they walk in the door- it could be you or a family member of yours being judged. And never ever agree to placebo for pain. That is cruel. This is a subject near and dear to my heart- can you tell?
Apr 13, '06I agree that it should be that if a pt. says they have pain that then they have pain. But, where I work we use the 0-10 pain scale, & we have several patients that when asked to rate there pain they will say "it's a 10" but the next minute they are laughing with there friend or talking on there. How can I believe that they are in so much pain if they do not look like they are in pain? No guarding, no open wounds or fractures, & they are giggling like a school girl, how can I believe that they are in any pain, other than maybe emotional pain??
Apr 28, '06I have read through this thread and like others, have felt humbled by the enlightened attitude of some of our finest...and recognised others.
It is a thin line, and a difficult one to walk. Like others here, i never felt it was my call to judge, just to deliver.
having said that, i have felt the frustration of patients claiming they rate their pain 10 and then feasting on McDonalds while giggling on the phone while their syringe is being drawn...
I, too, have been on the other side of the bed (or in it as the case is) and have a story.
I presented with acute pancreatitis...17 times in 4 months! Not the worst numbers i have ever seen but i have never claimed to have a high pain threshhold. Eventually they tired of me and gave me morphine to subcut/IM prn. This was deemed appropriate by both disciplines, immunology and infectous diseases that were in charge.
(I wont get into the continual judgement that i was an alcolholic, even though i am and have always been a teetotoller)
Within a few months I was having difficulty with prn usage and started agitating for a change in plan...i was sicker with withdrawal than i was medicated during pancreatic attack. In the meantime I had genetic testing and my flares were found to be FMF (familial medeteranean fever) and pancreatitis is one of the more unusual but documented manifestations.
i was hospitalised for pain management and met with a wonderful, enlightened pain team who appreciated my concerns with the injectables but still thought i would need some meds. We agreed on detoxing from the morphine and asessing my pain once it was out of my system.
The detoxing was uncomfortable but i had been through it a few times already so i knew what to expect. on the third day, my nurse came in, sat on my bed and asked how i was feeling. I responded that i was fine. She touched my arm and said...we expect this to be your roughest day so please tell me everything you are feeling and i will help you in any way i can.
So i told her i was experiencing some hot/cold flashes and slight nausea. i explained to her that the urethral spasms i was experiencing before the narcotic therapy were returning and that was driving me a little loco but overall, i was ok, considering.
She said she was very sorry for my discomfort but that i couldnt have any morphine. I was surprised by her words and i responded that i didnt want any, that i was admitted because I wanted to discontinue the morphine. She said, I know but you still cant have any. I said, I didnt ask for any. She said, You see how agitated you become when i deny you morphine? I said, you cant deny me what i havn't requested. She said, You are behaving very aggressively now, did you hear your voice rise? I said, this sounds like a comic strip to me, I do not want any morphine. She wrote in her notes "Aggressive when denied morphine"
When i saw the pain team, i relayed the entire conversation to them and they changed the notes. Although i appreciate this nurse must have some personality issues, it remains both a comic strip and a warning in my mind.
I am not even sure why i felt the need to share this experience...possibly because it has coloured every experience since.
The spasms i reffered to earlier were dismissed at that intake as a side effect of withdrawal (even though i had been experiencing them for months prior to opiate therapy) and dismissed for a year longer as they are impossible due to only inflammation which was their finding. Finally amylase was discovere and urodynamics proved the muscles are in continual spasm (i read with interest an earlier post relating that we treat animals with more sensitivity...my condition is a primitive one, found only in animals and they are put down because it is too cruel to allow them to live with such pain, apparently it is not too cruel for me to live with it and be told i am imagining it for years)
I guess the moral to my story is this...because what someone says seems impossible, it doesnt mean it is. Because doctors cant find why something is happening, doesnt mean it isnt. And sometimes, as once again, others have mentioned, sometimes patients seek drugs because without them, their life is unbearable. It took me 2 years to accept a pain regime and i almost lost my family, my house and my life...that nurse took away all my esteem and made me fear if i took opiates, noone would ever hear/see me again...i would remain...aggressive when denied opiates whether i asked for them or not.
thanks for reading, sorry for the whine
I have to add that in my care were also extremely diligent, caring sensitive nurses to whom i owe everlasting gratitude...why my personality is such that one represented such a lasting impression, even though at the time, i was able to laugh about it, I dont know and it speaks poorly of the many i should have allowed touch me. I suppose this was a lesson for me.
Apr 28, '06Thank you so much for taking the time to enlighten us with your story. It is soooo refreshing to read something real..if you know what I mean...I relly felt your frustration as you relayed that nurses' word game...wow....I would have "freeeeeeeked" !!!!! :uhoh21: She sounded like she was picking on you.....what a freak..and a very unprofessional one at that !
As you may have read alooong time ago..I used to come here often to gripe about my migraines and all the pain I went though at the ER ...... but since I started nursug school I havent had time....(how people go to school and accumulate over 30000 posts eludes and amazes me LOL )..anyways.....I used to come often but it grew old on this thread....same comment stuff........frequent flyer this......drugseeker that......"special of the night" stuff......and well....your post came along and brought me back.....(I feel a song coming on... )...
Thank you for your post is all I have to say....I am glad you had an entire team on your side...more often than not its the entire team againt the pt and only one HCP advocating......sometimes strength comes in numbers...thank god for you !
Talk to you later....
Apr 28, '06thankyou for your post...its great to know someone enjoyed it...the story remains too funny and tragic at the same time for me...but i do enjoy telling it...opiphobia reigns in some people, i hope some day that will change. I would rather give 10 people their hit than refuse 1 patient their pain relief. Who am i to judge?
Someone earlier said an interesting thing, isnt an addict, without their DOC, in pain?
and personality plays a great part in how people behave? personally, unless the pain level is a 8+, i can still manage to smile, be polite
I once met a nurse who was going to teach me intermittant catheterisation (this is a different thread, but do you all tell docs/nurses who are treating you, your qualifications? i will start a thread on this in general)
When she met me, i smiled and thanked for her time (she had stayed back to teach me) she made the judgment from that exchange that i was not in pain and didnt need this...when inserting the cath, i started to shake and tears rolled down my eyes with the agony of my urethra being stimulated and she looked at me, full of compassion and said, darling why dont you tell us how much pain you are in? I guess I just dont think every exchange needs me to be crying or frowning or whining...if i chose to live like that, i would not be choosing to live. I spend a great deal of emotional energy using cognitive therapy and trying to diminish my pain as much as possible. That doesnt mean the pain is not there, simply that i dont choose to BE my pain. I think that is something we all need to recognise, as patients become more willing to take responsibility for their conditions and become more learned in the discipline of PAIN, we will see more and more people who are not willing to allow their pain rule their lives, that doesnt mean the alternative methods are enough to help them lead a full life, it just means they are willing to put the effort in to learn the available modalities to lessen their need for pain relief and sometimes that will mask the signs we are accustomed to seeing.
enough, thanks for reading
Jan 19, '07Quote from Fgr8OutWOW! What a wonderful post!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.