Drug seeking or real pain? How do you tell? - page 3

by JudyPRN 143,128 Views | 202 Comments

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... Read More


  1. 1
    Last night we had a woman who rated her pain at 10/10 through about 5 hours of 1-1 nursing, and lots of drugs. She couldn't move (literally couldn't move) without tears in her eyes. The doc had some reservations about her being a drug seeker and we spent 20 minutes on the phone negotiating a treatment plan that would give some relief. Kept the patient up to date on what was going on, and she did a lot of venting about people not believing or treating her pain.Finally was able to give some IV pain med ordered. The patient got up out of bed and walked downstairs and went home with no noticeable limping or weakness.

    Found out later through the grapevine that she had been to at least on other hospital 25 times in the last month for narcs.

    So after advocating with the doc, and takling the " she's in pain if she says she is" I got sucked in like a fool, and have lost credibility with my coworkers to some degree. What happens for the next person who may come in with real pain?
    sharpeimom likes this.
  2. 0
    No one ever said you wouldn't get schnookered every now and then. But ask yourself, "Do I really want to take the chance of sending someone out the door in excruciating pain?"

    Me...I'd rather get taken every now and then than not treat someone in pain. It would be nice if we had a magic wand like Dr. Bones on "Star Trek," but we don't. All we can do is use good assessment, pt input, and hope for the best.

    (And who is to say the woman didn't have legitimate pain, but just didn't have a primary doc? Do you believe everything you hear through the grapevine?)
  3. 0
    Well she lied about previous meds and treatments for pain. She rated her pain 10/10 and inability to move and then walked out once she got her drugs. I'm one of the most ardent pain advocates in this hospital, but this patient sucked us dry for 5 hours, said she would sue if we didn't give her what she wanted, lied to the nurses about the treatment plan she agreed to in the ER, and did I mention that another patient was upset that she had to wait for HER meds because the nurse was in the other room trying to assist the faker?

    I know- this should not affect how I treat my patients and I need to just walk it off. But will I spend time negotiating with the doc like I did in this case? Not without some physical finding, and a little less lip about suits from the patient.
  4. 1
    Well, you didn't exactly mention some of this in your first post (not to be argumentative, but part of the story was left out). Even so, there are people who will exhibit those behaviors because they are afraid they will not be believed (I think McCaffery refers to it as "pseudoaddiction.)

    There is no excuse for abusive behavior, and limits definitely need to be set when that occurs. I'm not sure what physical findings you're talking about though, as VS are not reliable indicators of pain, particularly in a pt with chronic pain.
    RLeeRN likes this.
  5. 3
    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.
    Last edit by Fgr8Out on Feb 1, '04
    TeacupPom, RLeeRN, and sharpeimom like this.
  6. 0
    What a beautiful post!
  7. 0
    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.
  8. 0
    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?
  9. 1
    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.
    danggirl likes this.
  10. 0
    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.


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