Drug seeking or real pain? How do you tell?

Brian, ASN, RN · Jan 6, 2004

Hi Judy,

I made your reply a new topic (thread), so hopefully you will get more responses to your question.

Rapheal · Jan 6, 2004

I always have my suspicions about some patients. But to keep things simple- and to perform my duties without value judgements I just accept the concept that pain is what the patient states it is and treat it according to what medications are ordered.

It is sad however when I see people come in for bowel obstructions and need surgery and the main suspect of the bowel obstruction is constipation related to narcotic use. That is a sad consequence of narcotic use in some patients as well as other consequences. The best I am able to do is to perform teaching that people d/c'd with narcotics add fiber and extra water to their diets.

bellehill, RN · Jan 6, 2004

As a nurse if a pt says they are in pain then they are in pain. Unfortunately there is no way to determine if their pain level is true. I question the people who want Phenergan for nausea but have a full dinner tray or fast food brought in while I am pushing the med. I question people who are allergic to Toradol, Percocet...the "lesser" or non-narcotic pain meds. You will pick up on your own clues the longer you are a nurse.

Many people live with pain everyday, we have to believe them and try to make them as comfortable as possible. Unfortunately it is the drug seekers who make believeing patients so difficult but we have to try!

Dave ARNP · Jan 6, 2004

Pain managment is a good part of my job. I see atleast ten patients every day who's cheif complaint is pain. Are they all in pain? I'd like to think they wouldn't say they are, if they're not.

Now, as far as being able to tell if someone is in pain, or seeking. It is almost impossible. Have I medicated a seeker? I'm sure. I think anyone who has been a nurse, or MD/NP more than an hour has. It is very hard to make that call. Even if you DO decide they are seeking. Do you really KNOW? I don't think so. I've had my doubts about a few patients in my time, but when I begin to venture down that road, I remember how long my mother suffered before finding someone who would adquately treat her pain. Several docs she saw, just labled her as a seeker. Would I want to chance labling somone just like her? Nope. Every patient that I see is treated to the best of my ability. If nothing we can do will get their pain under control, then I will find someone who I think can.

Now, to the issue of being able to tell when someone is in pain.

I have a *few* and I mean very few patients who I can really tell when they are in pain. Facial expressions, tone of voice, the way their skin feels. It makes it very obvious. I can tell you almost to the number (Pain scale rating) what my mothers pain is. I think the biggest difference in being able to see when someone is in pain, is seeing them when they are NOT in pain. On a good day, persay. The majority of my patients, I do not KNOW what their pain is. Many, I do not know if they are in pain or not. Again, I treat them to the best of my ability. But there are a few, a select few (most ones I knew BEFORE their pain started) that I can tell instantly they are in pain, not seeking, and to a very high degree-what their pain is.

Just like alot of this job, this one is a gut feeling. You just gotta remember what that you still have to do the best to ease their suffering, even if your gut is saying seeker.

Dave

Fgr8Out · Jan 7, 2004

Someday, Nursing will accept that pain is whatever the individual experiencing pain says it is. Why do we persist in this need to control an issue that is out of our hands, namely a patient's report of pain? There is no way to measure pain through biomechanical means, no magic machine that pinpoints the exact site or severity of pain. Pain is completely subjective, yet there are those in Nursing who simply can't or won't accept the fact that we don't have the ability to say "Yes, here is proof you have or haven't pain" with any reliability.

Patient's with a history of drug use/abuse can certainly develop a tolerance to opioid narcotics which require that they receive a dose higher than that of an opioid naive patient. This does not mean that individual is making their pain up and even if they are, again, Nursing cannot accurately assess this. The best we can do is administer pain medication as ordered once we've assessed our patient to determine there is no respiratory depression, and continue to monitor and intervene if it becomes apparent that an individual is overmedicated. Patient's who are awake do not code from respiratory depression, especially not with the dosage of opioid generally ordered. This is not to say Nursing should be cavalier in administering narcotics. We need to realistically look at our patient's level of sedation in relationship to the amount of narcotics they've been receiving and, with our critical thinking skills, assess the effectiveness of their pain management and treat them accordingly.

People in pain may or may not display behaviors that we consider indicative of "being in pain." Coping mechanisms such as distraction or avoidance, may often mask a person's true pain level. I believe that if health care professionals expect someone in pain to act a certain way, some patient's learn to adopt those very behaviors. They become concerned that if they don't "look" as if they are having pain, their report of pain won't be believed and they won't receive the proper pain management. What exactly does that say about our practice?

So long as a patient has appropriate respirations and arouses easily, their report of pain should be believed and appropriate measures taken to alleviate it. Pain assessment, including sedation and respiration, should be ongoing to determine efficacy of the medications and ensure no undesirable effects are occurring.

The American Society of Pain Management Nurses has a website with research based information for Nurses to better care for their patient's in pain.

Dave ARNP · Jan 7, 2004

Very good post, FGR8OUT.

I've said it before, but it bares repeating.

Medicine is not an exact science. If it were, we wouldn't just be PRACTICING it. Till then, patients pain is what they say it is. No if's, and's or butts about it. (unless they're suffering from a rectal injury... :) )

Dave:rolleyes:

live4today, RN · Jan 7, 2004

If a patient says they are having pain...they are having pain. It doesn't matter if they are 'drug seeking' or not. My belief is they are in pain because if they weren't they would not be seeking drugs to "numb the pain" they feel whether that pain be physical or emotional pain. Pain is more than physical. It's emotional, mental...unseen physical findings....so treat the person and leave the judgement to God. :nurse:

mags-rn · Jan 7, 2004

Ok, I have to weigh in here. You are walking a fine line when you start to label pts as "drug seekers" Granted, they are out there. Because a person asks what medication they will be receiving does not imply they are a drug seeker. Some pts know what works for their pain. Moreover, some people are allergic to NSAIDs or they are intolerant of these meds. They may be allergic to sulfa nad were told to avoid NSAIDs because of possible cross allergy.

Chronic pain is significantly different than acute pain. Persons with exacerbation of chronic do not usually present with the typical S/S of pain i.e., VS changes, writhing/restlessness and agitation etc. I also have to comment on the fact that there may be an inter-relation between MH issues and pain. One must ask "what came first, the pain or the MH issues" So MH patients may have pain issues.

There are so many causes of pain and so many reasons people take pain medication to begin with and some people seeking pain meds are so manipulative. I do think significant ethical issues exist when pts are labeled as "drug seeker", or their pain is not adequately treated.

chris_at_lucas_RN, RN · Jan 11, 2004

Well, like so many have already written here, we are certainly taught that if the patient says they are in pain, they are in pain. Personally, I like that idea for a number of reasons. If they are, and I "guess" wrong, I will have been instrumental in continuing someone's discomfort. I don't like that. Also, the onus must be on the patient. If we think they are dependent, we can certainly teach about alternatives that can render their pain med more effective, and we can refer them for counseling, etc., to learn some of those techniques.

Isn't it true that someone who is dependent is in fact in physical pain when their blood levels drop enough?

In my previous life as a psychotherapist, I had a client whose cc was intractible pain. She reported a hx of a work injury, and so favored her back and neck in my office and anytime I saw her that I would almost wince. I felt so bad for her! And then our secretary (we lived in a very small town) saw the client *skipping* to the drug store to get the scrip filled! Boy, did I have a hard time not confronting her.

Same town, same MHC, I had another client who just seemed to have all kinds of vague complaints, and went from doc to doc, and no one could ever find a cause. She was also depressed, had some other mild MH problems, and I really didn't have a lot of patience for her aches and complaints. I didn't confront her, I didn't treat her any differently I (I don't think), but I didn't have the empathy for her that I might have, had I really believed her. Later, much too late, she was dx'd with multiple myeloma. Had she been in "real" pain? Uh, yeah.

Interestingly, the second lady is very much responsible for my finally going into nursing, and for my interest in pain management and hospice type work. The day I was moving from that small town, I went to see her at the nursing home she was then living in. She was bedridden, in constant pain, and only "with it" some of the time. She knew I was there, though. She had a BM (incontinent, of course) while I was there and the NH staff was short, so I helped clean her up, not wanting her to suffer the indignity (and more, I know now) of lying in her own poop.

This was a first for me--the belief that I could not stomach taking care of someone that way had kept me out of nursing school (along with a couple of other minor things). So today, when I think of Sylvia, I am grateful for several things, not the least of which is the lesson of believing when someone says they hurt.

BTW, she died about four hours later. And what a gift she had given to me in those last hours.

Okay, enough rambling--thanks for your "ear." Gotta love this BB!!

angelbear · Jan 12, 2004

I have chronic pain (FM etc...) when I am in a lot of pain I am either very very quite or angry. I dont know why but that is how I react unfortunately because I am known to have chronic pain I am terrified of ER due to judgementalness. I think just as all nurses should have to work as an aid at leaste for a short time It would probably be benificial (not being mean here) for all nurses to have pain that is not treated promptly and effectively at leaste once in their lives. Not that I want anyone to hurt it is just that it is very hard for people to understand something they have not experienced. Jumping down off of soap box.

sbic56, BSN, RN · Jan 12, 2004

Originally posted by JudyPRN
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.

While you certainly want to consider your patients compalints of pain seriously, I think what you were looking for was how you might be able to spot a patient with a drug problem. That is a very legitimate concern and a huge problem we are faced with as nurses.

This link has some good information and in particular points out behaviors of drug seeking individuals.

http://nsweb.nursingspectrum.com/ce/ce210.htm