Drug seeking or real pain? How do you tell?

teeituptom, BSN, RN · Apr 13, 2006

thats ok give them some dilaudid and they are even happier

lisalau · Apr 28, 2006

I 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.

z's playa · Apr 28, 2006

Thank 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... :lol2: )...

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....

Z :biggringi

lisalau · Apr 28, 2006

thankyou 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

MattyMoe · Jan 19, 2007

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.

WOW! What a wonderful post!

Templedoll · Sep 24, 2007

If a patient is seeking drugs but has no pain physically, mentally he has a lot of it. A nurse is never in the profession to play judge and jury. The best thing you can do is have belief in your patient and not judge. You ask how can you tell. I don't really think you can.

teeituptom, BSN, RN · Sep 24, 2007

If a patient is seeking drugs but has no pain physically, mentally he has a lot of it. A nurse is never in the profession to play judge and jury. The best thing you can do is have belief in your patient and not judge. You ask how can you tell. I don't really think you can.

Sounds like you are making an excuse for drug seeking behaviour

cmo421 · Sep 26, 2007

Sounds like you are making an excuse for drug seeking behaviour

Pain is subjective!!!!!!!!! Should I say that again, SUBJECTIVE. Unless the DOCTOR has documented proven evidence that a pt is purely drug seeking, then they have pain.Even with that evidence, they still have pain. Now what is also subjective is pain tolerance, your 10 might be my 5.We need another scale of some sort. Sorry this angers me so. Until you have been at the oposite end of someone questioning your pain, or maybe your loved ones, you will have no idea. We are not the judge and jury. The one time you withold something or pass someone over instead of acknowledging their pain, could be the time that something acute is being missed.

teeituptom, BSN, RN · Sep 27, 2007

Pain is subjective!!!!!!!!! Should I say that again, SUBJECTIVE. Unless the DOCTOR has documented proven evidence that a pt is purely drug seeking, then they have pain.Even with that evidence, they still have pain. Now what is also subjective is pain tolerance, your 10 might be my 5.We need another scale of some sort. Sorry this angers me so. Until you have been at the oposite end of someone questioning your pain, or maybe your loved ones, you will have no idea. We are not the judge and jury. The one time you withold something or pass someone over instead of acknowledging their pain, could be the time that something acute is being missed.

And as long as you rely completely on subjective that will not change. Like the cute little brunette last night, flapping her eyelids, smiling sweetly, in no distress, "My pain is a 10" We as nurses are held against our will to a subjective pain scale by patients who have learned to manipulate it, to get drugs. I realize this, I accept this, I never get angry about this.

Our triage sheet has stated pain scale, and face pain scale to document on if you like. I have charted pt stated 10 with quotation marks on stated , and written zero on the face scale.

cmo421 · Sep 27, 2007

And as long as you rely completely on subjective that will not change. Like the cute little brunette last night, flapping her eyelids, smiling sweetly, in no distress, "My pain is a 10" We as nurses are held against our will to a subjective pain scale by patients who have learned to manipulate it, to get drugs. I realize this, I accept this, I never get angry about this.
Our triage sheet has stated pain scale, and face pain scale to document on if you like. I have charted pt stated 10 with quotation marks on stated , and written zero on the face scale.

Ok ,I can relate to this,but what happens when u get someone who has never had pain? Some people say a hang nail is a 10.and others who could have an open fx and they are saying its a 5. Everyone's backround with pain is different. It always has to be subjective,sorry. What helps correlate pain level is with physiological reaction to pain. Even if the pain is "just" withdrawal. Vital signs will always show some reaction to pain.

If things do not add up and they r still c/o severe pain, I ask a few questions and also state we will be doing a urine for tox to help us keep them safe. When approached in a non judgemental manner, most will own up to what they are on,and why they r there. I tell them we can not care for them safely unless we know what's really going on. Now granted u will get some who could con a nun out of her habit, but many will own up. Sometimes u hear bstories that change own's attitude . It's not a perfect bsystem and ER nurses see so much abuse, but I still say u have to believe untill u could say in a court of law u nknow otherwise. Then there'sletting the doc handle it,,,lol

teeituptom, BSN, RN · Sep 27, 2007

Ok ,I can relate to this,but what happens when u get someone who has never had pain? Some people say a hang nail is a 10.and others who could have an open fx and they are saying its a 5. Everyone's backround with pain is different. It always has to be subjective,sorry. What helps correlate pain level is with physiological reaction to pain. Even if the pain is "just" withdrawal. Vital signs will always show some reaction to pain.
If things do not add up and they r still c/o severe pain, I ask a few questions and also state we will be doing a urine for tox to help us keep them safe. When approached in a non judgemental manner, most will own up to what they are on,and why they r there. I tell them we can not care for them safely unless we know what's really going on. Now granted u will get some who could con a nun out of her habit, but many will own up. Sometimes u hear bstories that change own's attitude . It's not a perfect bsystem and ER nurses see so much abuse, but I still say u have to believe untill u could say in a court of law u nknow otherwise. Then there'sletting the doc handle it,,,lol

Passing the buck to the MD ehh

loricatus · Sep 27, 2007

There is a certain manipulative behavior, very similar to that seen in some mental illness, that a drug seeker will demonstrate.

While in the ER, they know they don't have time to play the game slowly, so in the course of a couple of hours you may see: try to befriend you while complaining about everyone else's insensitivity; whine, cry, scream in pain at eardrum shattering levels; report you; play helpless and needy; play the misunderstood one; educate you; become verbally abusive & occasionally physically abusive; have a tantrum or two; apologize and state that they really didn't mean to be [whatever]; try a few attention getting stunts [accidently pull out the IV, wet the bed, get tangled in the sheet, fall, etc]; try to turn staff against you; enlist the help of a codependent friend or family member; set the days record for the amount of time the word 'nnnuuuurrrrrse' was yelled out ...

I do have to admit that sometimes I find the inept manipulator amusing and have fun with it. It's probably a survival thing.

For instance: I have an allergy to dilaudid IV and PO, demerol and po morphine. The only thing I can take is IV Morphine and anything less than 6 mg doesn't help my 15/10 back pain.

What happens to you when you have morphine pills?

I get hives and my throat swells up.

Well, the doctor has ordered the Morphine injected into your muscle.

I can tell you now that it's not going to work, I'm just going to be allergic to it.

How do you know for sure?

I just know

Post IM injection, pt seen rubbing the site and hitting it under the sheets

NNNNUUUURRRRSSSSE

What is it?

See, I'm having an allergic reaction?

Are you sure?

Yes I'm sure!

Do you want me to document it as an allergic reaction?

Yes. Now can I get the Morphine IV?

Don't think so because you are probably allergic to all opiods and I don't think the doctor's going to order something going into your vein that you are now saying caused you an allergic reaction. I'll go tell the doctor.

Nurse, wait, you know what, I don't think I'm allergic to what you gave me, I was lying down on it and I think it just fell asleep, see, see how better it is looking.

Sorry, we can't take a chance that you'll have an bad reaction-I'm going to get the doctor and let him decide.

Talk to doc & he comes to bedside: I see here on the chart that you said to the nurse to report the redness where you got the injection of morphine as an allergic reaction, is that the way it was?

No, the nurse must have misunderstood me.

Pt on other side of curtain yells out : everyone here heard her yell at the nurse to report it as an allergic reaction, she hasn't shut up for over a half hour now.

Doc: Sorry, but we can't give you anything that you might have an allergic reaction to.

I'm leaving, nobody listens to me, nobody cares about all the pain I'm in and how I can't walk (while standing up, putting clothes on over the gown and trying to storm out)

THIS IS A TRUE STORY (I left out some things and changed /deleted medications that might be too specific to the patient).