Drug seeking or real pain? How do you tell? - page 9
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
Dec 27, '07 by teeituptomQuote from scarletEven if they c/o pain of 10 out of 10 on abd pain while smiling and eating potatoe chips. It is whatever they say.tx = treat. Reminder: Pain is what the Patient says it is.
Dec 28, '07 by lalaladydeleted because accidentally posted 2xLast edit by lalalady on Dec 28, '07 : Reason: deleted
Dec 28, '07 by lalaladyHere's a fun (not funny) story appropriate for the subject, but not really in response to the origional question...
I was a patient in an ER in 2003. I was 23 then, mother of two and living with roomates whom I didn't know very well while I was going through a divorce and trying to get established in a new city and new job. I had an abscessed tooth. I had one or two before (once it was the same tooth) while I was pregnant, so I knew that if I kept it clean and I self-medicated, the pain might subside for a year or so. If I'd land in the ER, they would give me vicodin, antibiotics and novicaine to hold me over till I got an emergency appointment with a dentist (which I didn't keep before because the pain went away - I know, not smart). This particular time, I had been dealing with it for several days by combining tylenol and 3 or 4 ibuprofen and eventually (in the middle of my work-week) I was having to combine dayquil with 4 or 5 ibuprofen just to take one or two of the several "edges off." I called a dentist that would accept my lousy insurance and was prescribed vicodin over the phone to hold me over for a week till I could get seen. So I was crying and could barely think at all when my roomate drove me to the ER one night when the pain woke me from a vicodin/ibuprofen sleep. I knew one thing for sure: I could get some novicaine. The problem was my doctor treated me like I was "seeking" or whatever you call it. He treated me like I was a fool, less than human, like I was a pest or a parasite to humanity. I felt disgusting. He left me in the room in severe pain to call the dentist who prescribed the vicodin. Now I have had children. In my experience, I know that an abscessed tooth can be worse than the pain of child-birth if left untreated. The funny thing is, in retrospect, my dentist failed to get me an antibiotic, which is the only thing that can really make the pain subside...Anyways, this ER doctor came back to tell me he and my dentist are not sure, but they think I might be going through my vicodin too fast...??? I didn't ask for vicodin! I told him it made me nothing but nauseous and it wasn't working! I NEEDED Novicaine! Now I have NEVER felt sedated or drunk or "fun" from novicaine in my entire life. I felt like he was getting a kick out of stalling while I had tears comming out the corners of my eyes! Like he enjoyed it! I felt like he was torturing me. So after an hour or so of him making "phone calls" and "judgement calls" he finally gave up and gave me one shot of novicaine. Not enough to make a dent in the pain. NOT A DENT. I told him I needed more, so guess what he did? He told me that there was no possible way I could still be in pain. He accused me of lying. Horrified, I said I most certainly did NOT feel like the novicaine was working AT ALL. So guess what he did next? He told me to open my mouth and close my eyes. I felt his fingers pushing on my gums and he asked me if I could feel "that" and "that," which I could. Obviously frustrated with my ability to guess when he was touching me, he used a Q-tip instead and tried to "trick" me by not actually pressing on me sometimes...no, I did not feel "that..." What a jerk! And after all that nonsense, he says he can't give me more anyway, he gave me the max allowed by law or some crappy excuse. I told him I have had novicaine before in an ER when I was pregnant and have been administered up to 4 or 5 shots for an abscessed tooth. Then he actually ACTED like he was ACTING (totally and completely insulting my intellegence) when he opened his eyes real big and said he could not believe that I would have ever been administered THAT much novicaine at an ER. He proceeded to give me one more injection, "TWICE the maximum limit," which barely, you guessed it, took the edge off. I hadn't gotten real sleep for days and that night was no exception. The next day I went to a clinic and got a surprise! A nice healthy dose of sumthin' shot into my butt cheek by a no-nonsense nurse who made my roomate all but carry me out of the building. I vomited before we got in the car and I felt like eating for the first time in days. I slept like a baby when I got home and was better able to manage my pain after a solid meal and good sleep until I got to the dentist. Woo hoo! Had I not been going through so much as it was I would have sued the pants off that doctor. I'd love to see the look on his face if he saw me all dressed up for court without the bags under my eyes and smeared make-up...ah, well...my tooth is gone now and that's all that matters.
After all that, before you think that my doc was smart to try his Q-tip method, how do you think you would look in court when you describe the tactic in which you decided you COULD 'tell' the pain was not 'real', as my doctor would have surely been embarrassed by his Q-tip antics. Especially after it proved the pain was 'real' after all. lol
Dec 31, '07 by maelstrom143, ASN, RNQuote from Kanani_Ikike~~~~~~~~~~~~~And I am saying that if more people trusted in God, (Jehovah) or whomever they claim as their deity, life isn't so hard to handle. Man, and his coping mechanisms, shouldn't be the answer. People put too much faith in worldly things.
In my limited experience, some patients tend to ask for less pain meds when their pain is validated and met with belief, with the nurse offering not just pharmaceuticals, but also elevation, hot or cold compresses, validation of their pain, acknowledgements of what they have that is good...both for those patients who believe in God and those who don't. Religion does not offer a rose garden without the thorns; it just offers paradise after the fact.
Some of our patients' life styles often contribute to their pain and suffering; it does not make it any less real nor can we judge what they are going through, lest we be judged likewise...some people are not as strong as others in dealing with life and its myriad hills and valleys...
Dec 31, '07 by nanacarolYou are right, religionand or faith do not negate the reality of pain. It is unfortunate that some encourage others to feel it is the lack of faith and trust in God that hinders pain relief or healing. Pain is real and should be treated, faith is an adjunct to treatment and has a place in refocusingaway from self, but Pain is very, very real. nanacarol
Jan 17, '08 by luvyluvyMy specialty has been in subtance abuse for 8yrs and whether they are seekers or not they are in pain, withdraw does cause a patient to go into immediate pain as soon as the pain med wears off so yes now they are seeking, intentionnally or not, the patient may not be aware that they have developed a problem or that they are developing a problem, I have to say that it is up to the M.D. to determine what the patient needs are all we can do is continue to educate ourselves in the field we specialize in, so that we can educate our patients, and pray for the patients we work for, there are alot of excellent sites you can look up in regards to addictions and recognizing withdraw Sx, in order to differentiate the seeker from a new patient, who can be taught other ways of pain management, because once addicted to pills, I have learned that it is a long road to freedom. Some withdraw symptoms are chills, dialated pupils, muscle aches, their back and leg hurt the most, sweats, yawning, teary eyes, runny nose and difficulty sleeping, but most commonly you will find the patient over medicating or switching doctors alot, some patient frequent the E.R. so they can get an immediate script for pain medication these are definite tell tail signs. But they are still patients none the less and they still have a sickness that needs to be treated.
Feb 18, '08 by KarenGeorgeBSRNGood Morning!
I have run a network for almost 10 years for those in NIP (nonmalignant intractable pain), and the true victory was the definition of PAIN as a disorder; not just a symptom. As another nurse mentioned FM and CFS are still not scientifically diagnosed but by subjective statements and objective criteria, but the pain experienced by such clients is extreme.
We have found (statistics) that when QOL (quality of life) is addressed, and clients are treated for NIP there are benefits to society as a whole. Less time lost from work, less family dysfunction and divorce, less psychiatric outcomes although most who suffer NIP do have "depression" as an outcome of nontreated pain, and some pain disorders which affect the SNS and ultimately destroy REMs sleep or what we can simply term restorative sleep; where healing can occur in "normals."
There are legal and ethical considerations. As an Adminstrative nurse it is imperative to me when I take on a position that my staff understands pain as a disorder and a symptom of a disease process. Just as years ago the extremes in developmental stage (infant and elderly) were thought "to not have pain perception" and we would operate on premature infants who would "collapse" on the table due to the pain perception (go into shock). Can even one of us imagine not being able to verbalize, move away from, scream out something to stop the scalpel from cutting our wee chest?
The elderly suffer deterioration of normal function not just "pain disorders" and to keep mobility, ROM, and ambulation (so that further deterioration does not occur) their pain should be treated. I have worked with many seniors who live a very good existence on a LA (long acting) medication such as Oxycontin, MS Contin, or Duragesic without negative (but positive) outcomes.
The DEA however is practicing medicine. With all research in place we see DEA busting good physicians and even clients of the same. I personally have helped thousands around the country with referrals, follow up, case management and support, and right now pain is a political statement for many practicing medicine, and those of us who care for their clients.
Opiods are the safest method overall of treating NIP. I always in teaching about pain give the example to nurses "if you have a heroin addict come in with a bad appendicts do you administer his or her morphine?" Many will balk, and the look of disgust is evident (think of what that poor individual feels when they see our experession), but the answer is "yes" and along with that we better make sure that order is high enough to meet the needs of tolerance for their daily habit. Yes we do treat their pain, and if they are lucky perhaps get some help for them (a referral) for some therapy, and addiction interventions.
Another example in practice which bends more to DNR mandates is "If Mrs. Jones (terminal end stage pancreatic cancer) who is a DNR is eating lunch, having a good day with her pain chokes do we intervene?" Many not few have answered "no she is a DNR!" and the truth is "yes we do; she is in house for her uncontrolled pain in OP hospice and stabilization--her choking episode is and has nothing to do with her end stage disease."
For the new nurse good topic! I wish more nurses coming into practice would ask and not remain confused. It takes a lot of courage to say "I do not know" about important parts of practice, rather than the energy wasted on ignorance. There is in some cases no right or wrong answer, but as you gain time in working you will see many nurses, many environements, and gain what we call a good instinct. We must also remember though that "our instinct in isolation from our peers" leaves us sadly uneducated.
What is wonderful about our profession is the constant change and learning; each day!
Have a great week!
Feb 19, '08 by KarenGeorgeBSRNDear Temple,
Thank you for reading; this is one of the most difficult parts of modern medicine today and when they state "pain kills" it is truth.
Quote from TempledollThankyou Karen for your great post.
Feb 19, '08 by KarenGeorgeBSRNGood Morning!
One of the most difficult concepts for a nursing professional who is brainwashed into thinking of "drug seeking" as a medical term is the differentiation between "tolerance" and "addiction." The physical symptoms are the same for either person; yes they are both viable clients with overtly different diagnoses and outcomes!!
Over and over I read posts on this topic in the year 2008 where modern research has shown that "tolerance" and "addiction" appear the same physically, when indeed the only similarity is the symptoms physically that occur between a person who is legally prescribed medication for pain, and someone with a serious disorder which is entirely different; this disorder is termed "addiction."
Physical withdrawal can occur between the "pain patient" and "the addict" with the same result; an uneducated physician or nurse can infer by value system (not by the subjective verbal report of the client) that a person is in fact "drug seeking" and one of the top pain specialists in the United States told me "at some point a patient not treated for his or her pain will be RIGHTFULLY drug-seeking at some point if not treated, for he or she cannot tolerate the suicidal level of pain they experience."
Nursing professionals are in the role of advocate by the nature of our profession; with or without a value system in place; putting ourselves as "God" does nothing for the client in need, makes us look like idiots, and furthermore negates the value of our very comprehensive education. I do not care whether you are a LVN, two year or diploma RN, or four year RN--you know through clinical experience if not through text book knowledge the truth.
Reply after reply show nurses who have years "in the trenches" learning from their own misconceptions about the term "drug seeking." When I tell you that stating such in an ER with a client in true need is malpractive for a physician and the nurse involved I mean this. If any of you who use this term freely or believe somehow that you know better than the client experiencing pain "his experience" then you are wrong. Lack of objectivity will keep you miserable in your role as a potential advocate, and then when someone you know and love, even yourself falls through the cracks, and is attacked or mistreated in thousands of ER's (in particular) throughout the United States you might change.
We have an obligation to continue the learning process throughout our lifetime. I know of no other profession where it is encouraged, applauded, and complimented. Our profession can make a difference in the lives of many; this particular concept of "drug seeking" needs to be trashed along with foul language, abuse, and a thousand other crimes of a medical nature that occur with frequency today.
I ask all of you in disbelief to further educate yourself; get your nurse managers or DON's (such as myself) to arrange inservices, really make yourself an open book when you approach any new client, and "stop the violence." One day it might be you so labeled and suffering, please do this for your client's and for yourself.
There is no "seeker" this is a disgusting judgement. An addict is also suffering a serious disease process; one that is incurable, but a psychiatrist is in the role to truly determine if a person fits into that diagnostic criteria; not a one shot five minute analysis rendered by a value statement.
Quote from luvyluvyMy specialty has been in subtance abuse for 8yrs and whether they are seekers or not they are in pain, withdraw does cause a patient to go into immediate pain as soon as the pain med wears off so yes now they are seeking, intentionnally or not, the patient may not be aware that they have developed a problem or that they are developing a problem, I have to say that it is up to the M.D. to determine what the patient needs are all we can do is continue to educate ourselves in the field we specialize in, so that we can educate our patients, and pray for the patients we work for, there are alot of excellent sites you can look up in regards to addictions and recognizing withdraw Sx, in order to differentiate the seeker from a new patient, who can be taught other ways of pain management, because once addicted to pills, I have learned that it is a long road to freedom. Some withdraw symptoms are chills, dialated pupils, muscle aches, their back and leg hurt the most, sweats, yawning, teary eyes, runny nose and difficulty sleeping, but most commonly you will find the patient over medicating or switching doctors alot, some patient frequent the E.R. so they can get an immediate script for pain medication these are definite tell tail signs. But they are still patients none the less and they still have a sickness that needs to be treated.Last edit by KarenGeorgeBSRN on Feb 19, '08
Feb 20, '08 by vamedic4, EMT-PKaren you really should post more!! Those two posts were some of the best I've read on pain management. It is truly appalling the ignorance that pervades the medical and nursing professions on the topic of pain management. Too afraid of making their patients addicted, I suppose. Perhaps they don't realize the negative quality of life that those who suffer from chronic pain endure on a day to day basis.
What's sad is that so many people know just how to work the system. Like teeituptom says - they could be sitting there eating potato chips (or, in the case of my facility- fries and a coke), and tell us their pain is a 5/5. Do the fries make it better? These are the people who make providers jaded, the ones who make us doubt their claim because we can't feel what's going on inside their bodies. Because they "look" fine, they "sound" fine. It's a shame people just can't be honest...but that would be too much to ask.
Feb 20, '08 by twotrees2Quote from Dragonnurse1living with chronic pain i disagree with you on the "if you have to shake em to wak em or thier snoring" etc comments- - when my body gets in the best position i can zonk out quite soundly - not really sleeping but my body wore out type sleep - but when i awake i am in so much pain it isnt even funny - i snore even when i am not sound asleep with sleep apnea - dont assume i am sleeping just cause i am snoring. also during a acute pain episode i was given demerol - it took care of the edge of the pain allowing me to sleep between spasms of pain- teh spasms of pain would wake me right up screaming - -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).
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.
Feb 20, '08 by twotrees2Quote from stevieraepeople who have chronic pain can have acute pain also - i dont see any reason they should NOT go to the er if they end up with other pain - one because with our chronic pain we know whats causing it and what fixes it - i sure am not gonna have severe abd pain and just medicate myself with my pain meds and perhaps have a ruptured appendix opr whatever -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 www.placebojournal.com
There is an amusing animated picture called "Narcotic Mystery--just click on it.
oh and i have seen somone who ran out of the pills ( not thinking to refill them as they werent scheduled )- and he tried hard to not take em - and he let it go so far he went toget some and had only a few pills left - not enough to get through the weekend to get to doc on mon. it happens.