Drug seeking or real pain? How do you tell?

psalm, RN · Jul 12, 2005

...we have pts. on PCA for pancreatitis or sickle cell crisis who want to go out to smoke. Some come back looking "higher" than when they left the floor. One pt. messes with his IV so it infiltrates, then goes down for a "smoke". I left early and saw this pt. walking in the parking lot like he was waiting for someone...can't do that with an IV pole attached to you! So, aside from documenting and assessing pt upon return, any suggestions? And these are the pts. who won't work with the meds, ie, quiet environment, low lights...no, the tv is blaring, lights are on, talking loud on the phone. When I suggest pain clinics I hear "I tried that it doesn't work for me".

seanymph · Jul 17, 2005

I didn't read through all these threads and I'm sure i will get slammed on some aspect of this, but I want to share what happened to me and a patient's point of view. Let me start it by saying I am a migraine sufferer since the age of 18 and when they get bad enough that I have to go to the ED I have had them for days and my home meds aren't working and I am either nauseated and/or vomitting.

Well, I had one this week, brought on by the all wonderful monthly visitor. Unfortunately my home meds did not clear this up after 3 days along with trying ice packs, relaxation and massage. My S.O. takes me to urgent care. I tell the Physician all my history, what I take daily to prevent my migraines and what I have tried the last 3 days to get rid of this one (alternating Tylenol and Ibuprofen, ice pack, dark room, relaxation, massage and then my Tylenol #3). He asked me three times, very rudely, if I had taken my Topamax and Elavil that day to prevent my migraine. I assured him that I take my meds everyday and that the Topamaz is BID. Then he asked me what I usually get for my migraines when I come to the ED and I said, "Demerol with Phenergan IM and I can go home and sleep and it is usually gone." He then asked me, "how many times have you been to this hospital for your migraines?" and I told him "none". He asked me this 3 times and got nastier each time he asked it. I couldn't figure out why he was being such an a**, but as is the case when I have had to go get a shot for my migraines he was making me feel like a "drug seeker". He then asked me how often I "went and got shots", "Is it like 5 or 6 times a year?" I told him, "no, actually it is like 2 or 3. The last one was in November when my Dad died." All he said was, "Oh. Well, we don't have Demerol here we'll give you Stadol."

They gave me the shot and he came in to ask if I had any relieve and I didn't, but I was afraid to tell him different because of the way he had treated me.

Later today I got to thinking about why he kept asking if I had been to "this hospital for migraines" and didn't believe me when I had told him "none". I had been seen in the same urgent care by their PA for a URI. If he had just come out and asked me I would have told him and of course, they couldn't "pull it up" because they aren't computerized charting here

I guess the point I want to try to make after this long spiel is don't just assume things...ask. And some of us after 23yrs of our condition do have an insight into what works and what doesn't and would like to be treated with a little respect. I wish my head hadn't been hurting so bad yesterday and I could've been thinking a little straighter...there is no reason to be rude and make assumptions......

Works2xs · Jul 17, 2005

I gotta say that while I understand the desire not to be duped by someone seeking to feed their fix, as a patient, it really bites to have to wade through somebody's informal protocols for determining if it's "real". Where am I coming from? Well, I guess a little background is required.

I seem to have a propensity for producing kidney stones. Since 1980, I seem to kick out another stone on a 1.5-3 year schedule. Frankly, I've lost count of how many have come and gone in total. Even today, I'm toting around a 9mm passenger in one kidney and several smaller ones in the other (found during scans for recent appendix/gallbladder surgery). Yes, I'm seeing a urologist and yes, they've run a bevy of tests, and yes, I push fluids. In the past, urologists have NOT wanted to use such treatments as lithotripsy because of coumadin therapy and assoc. risk of bleeding (hist. of DVTs, the first of which happened after kidney stone surgery!) and they don't want to pick up the responsibility of taking me off anticoagulants for any stretch of time to do a procedure. I'll save the "gutless Dr." discussion for another thread...

So here's my dilema. I know that there are attitudes in the ER regarding pain seeking behaviors. I also understand stones are a ploy used to get a shot by some seekers. Knowing that, I can at least wrap my brain around the concept that my complaint will linger in doubt until someone gets a "film" to confirm - even though I'm thrashing around and sweat is pouring off my face, etc. I even understand that the condition isn't an immediate threat to life (after AAA has been ruled out...) which means I'll drop to the lower end of the priority list for attention from ER staff. But what kills me is, why does it take so danged long for the doc's to manage the pain AFTER they have film in hand? Over 8 freaking hours last time (~3 years ago). Now, I also seem to be cursed by not getting relief from the demerols and morphines of the world.

So, as I sit here on this little ticking bomb, the anxiety level gets pumped everytime I think about a) the interminable wait and b) the looks I'm going to get when I say, "no, this drug doesn't work and that drug doesn't work; this is what worked the last time."

I guess what I'm asking is, are there any protocols for how pain is such cases is managed? I'm not looking for time tables (I can just hear the comments in the ER about "clock watching"). I don't want to rob the truely emergent patients from needed attention. And most of all, I dred the thought of becomming a burden to the staff, esp. the nurses, by pestering them with "it's not working, can you check on what to do next?" On the other hand, I don't want to live through that degree of suffering again. Ever.

So is there something I can do or say to facilitate this process? Is it "normal" to wait 2 hours before someone decides the previous shot didn't work? How do I help myself so that I'm not deemed the pain-in-the-orifice guy behind curtain #2? Is there some secret handshake?! Or is this one of those deals where "it's just pain - suck it up, you aint gonna die"?

/rant off. Sorry for the long post.

PS: noticed z's link below didn't work. Try this one...

http://www2.nursingspectrum.com/CE/Self-Study_modules/test.html?CCID=3151

z's playa · Jul 17, 2005

The stuff one can find when googling :chuckle

http://www2.nursingspectrum.com/CE/Self-Stdy_modules/test.html?CCID=3151

z

psalm, RN · Jul 17, 2005

...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.

krystaldragon721 · Jan 8, 2006

Hi 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?

krystaldragon721 · Jan 8, 2006

I 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.

DutchgirlRN, ASN, RN · Jan 8, 2006

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.

There 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.

Traveler · Jan 10, 2006

I 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?

krystaldragon721 · Jan 10, 2006

Thank you for your post. It was enlightening.

teeituptom, BSN, RN · Jan 11, 2006

The easiest way to treat them is just give them a menu

Tonights special is.........

happyfeet · Apr 13, 2006

I 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 cell phone. 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??