Isn't pain whatever the patient says it is???

[momcats3]

Hi,

I'm pretty P.O.'d too.... Am a Hospice nurse with a patient who's had a lifelong hx of neurological pain. Each time I see her she c/o pain "all over", is grimacing, moaning, cries out when moved, etc. when I ask if she needs pain meds she says yes...Requested her order for be increased to 30 gm oxycodone TID (now on 20 gm TID) w/breakthru pain meds PRN. The facility and the NP in charge claim that "she's always been like this - it's just what she says. We don't even ask her about her pain, and she doesn't bring it up so she's fine" Urgggghh!!!! So they never give her any PRN pain meds.:angryfire I've been gradually titrating her up, and it hasn't touched per pain, hence the request for the increase. What on earth happened to "Pain is whatever the patient says it is?" Is that only for patients under a certain age, or does it exclude dementia patients, or what?

This small battle may be lost for now, however, the war is not close to being over!

[Angela Mac]

That is a tough one.

HOSPICE patients- we all know have terminal pain- and should be titrated as needed.

Different conditions require different pain management, and of course, each patient needs to be assessed differently.

Take for example- the mother who delivered a child by c-section- on day one she has a MS drip and day two is asking for Darvocet

Then look at the patient who is treated for back pain with oxycontin and wants a dosage increase- when the MRI, and Xrays are negative

I do believe alot of patients are over medicated

We had a rigid inservice on assessing pain and providing pain management in conjunction with being able to evaluate those with "drug seeking personalities"

it is afer all- a double edged sword.

So I must disagree----pain is not always what the patient says it is------

[Dixiedi]

That is a tough one.

HOSPICE patients- we all know have terminal pain- and should be titrated as needed.

Different conditions require different pain management, and of course, each patient needs to be assessed differently.

Take for example- the mother who delivered a child by c-section- on day one she has a MS drip and day two is asking for Darvocet

Then look at the patient who is treated for back pain with oxycontin and wants a dosage increase- when the MRI, and Xrays are negative

I do believe alot of patients are over medicated

We had a rigid inservice on assessing pain and providing pain management in conjunction with being able to evaluate those with "drug seeking personalities"

it is afer all- a double edged sword.

So I must disagree----pain is not always what the patient says it is------

You can not always "go" by the results of Xrays and MRIs. One major problem with both of these diagnostics is the pt is positioned in the correct anatomical position. Being positioned for optimal viewing by the tech/Doc does not always lend optimal viewing of the problem.

I am sure a lot of people are overmedicated, but until you can prove they do not need the med, it is best to medicate. Every one has differing levels of tolerance, what I may call a 3 or 4 you might call a 5 or 6. Can you prove what another person is feeling, or are you just going by your own personal perception?

Toss me a bit more than this darn Vicodan I am on now for my knee and I reallyl don't care what anyone else is taking for a similar injury. I am only concerned aobut my own pain and referred pain.

[teeituptom, BSN, RN]

Just give everyone a menu

let them order what the want

life is simple

life is happy

lets go golfing

[fab4fan]

pain is not always what the patient says it is

This is dead wrong...I'm sorry. That statement flies in the face of tons of research out there proving just that pain is what the pt says.

Even if the pt is a seeker, the only person qualified to dx someone as an addict would be an addictions specialist. Not the ED doc, not the nurse.

Chronic pain is nothing to wave off; it is life-changing and devastating. There are plenty of reasons why someone with chronic pain may need a dose change and NOT be doing it because of an "addiction."

Someone comes to the hospital with chest pain. Can anyone imagine saying, "No, I don't think your chest really hurts that bad." Why is it OK, then, to treat other pts that way?

[Blackcat99]

Yes I agree pain is what the patient says it is. I have been an LPN for many years. Some nurses have critized me and said " Why are you doing it? I just give her regular TYlenol and tell her it is her narcotic pill. You shouldn't give her the narcotic ones because they are addictive." :angryfire

[teeituptom, BSN, RN]

Even if the pt is a seeker, the only person qualified to dx someone as an addict would be an addictions specialist. Not the ED doc, not the nurse.

I have only met 3 so called addiction specialists, and all three were previous addicts and the only way they could work in medicine at all was as an addiction specialist, that tells me something there.

To say that ER MDs arent qualified to dx Addictions is wrong, they deal with addicts on a daily basis, or nightly. They mostly seem to come out at night for some reason.

I have no problem treating those in pain, I have no problem giving pain meds to anyone. But when an ED MD cuts them off I also have no problem showing them the door out.

Its the doctors call to make

[dhudzinski]

Very interesting dialogue. I am always amazed at the variety of opinions there are about pain, and its treatment. This is very stimulating material for me. Pain is my passion. I want to know more about it. How does it do what it does? Why is it different in each person? Why can't we see it and measure it more objectively? (acutally there is research out there that shows that when a painful stimulus is administered in the lab that there are changes on the PET scan. So I think that is a breakthrough and a beginning.) How do we customize pain treatment? How do we know the pain is real?

Pain is as unique as your thumb print. Even IF you were to administer the same measured pain stimulus to 100 individuals they would all have a unique experience, interpretation and coping skill to deal with it. The differences are in part related to their unique life experiences.

Pain treatment needs to be unique also. No cookie cutter approach. What works for one person may not work for the next person. and that DOES NOT mean that the second person's pain is not real...IT IS JUST DIFFERENT.

Let me tell you 2 stories...to illustrate something...

At the age of 11 years old DMH had surgery to remove a "sebaceous cyst " from the top of her head. Within weeks after the surgery she began getting severe headaches. They were nauseating and she would vomit. her eyes hurt and her vision began to change. DIAGNOSIS: Malingering and wanting attention. After all she is 11 yrs old and is the second in a string of 12 children.

each year the headaches continue. Until at age 20 she can no longer stand them and seeks medical help again (you see she thought she was going crazy since no one believed her) Well this physician did one thing he listened and examined very thoroughly. And made a referral to his buddy the neurosurgeon. Within 2 weeks DMH was in surgery to remove a meningeocele and an AV malformation from the very spot that the previous "surgeon" had removed the supposed "sebaceous cyst".

RESULT: DMH still has migraines on a regular basis but thanks to Imitrex these are not as dibilitating as they used to be. and she no longer doubts her perception of what her body is saying.

*************************************

A participant at the Academy of the Healing Arts was attending a weekend intensive training session. The topic was healing the traumas of the past. learning new techniques to cleanse the mind of the debris of these traumas and experiences. While on a break, this participant suddenly felt a sharp almost nauseating pain in her right shoulder. It was as if her shoulder had somehow been dislocated but it was not. The pain was excruciating a 10/10 pain. She went to the instructors and told them she would not be able to continue the session and would need to go home and possibly to the ER. After talking for a few minutes it was decided that this individual would stay and continue with the session and that whatever it was would be dealt with in the next 24 hours. She trusted the instructors and stayed. the pain continued and she was unable to take notes as it was too painful to move her right arm at all.

the next day the pain was still there as intense as the day before. The session started and a new therapy was introduced to the participants and they all paired off to Practice the technique with each other. When the practice time was over and the group was brought back together they were each asked to share their experience with the technique. The individual with the shoulder pain volunteered enthusiastically, waving her right arm in the air. The pain was gone and she does not recall what moment it left she just knows that it was there and now it gone completely.

*********************

These stories are my story.

The first story illustrates true pathological cause for pain. (we did not have Cat scans or MRI's back then) The saddest part of this is that I know too many more stories like this one. I hear it from my hospice patients and others that I do consults on. People are dying out there because they are not believed and NO ONE IS ASSESSING the pain. Ruling out an organic cause with all the technology we have. LISTENING with every fiber of your being.

The second story illustrates the power of the mind-body connection. I knew that I would have to deal with some tough stuff in this session and my mind did not want to go there so it manifested in a very painful shoulder. I wanted to disconnect (dislocate) from the painful emotional experiences of the past. I carry my stress across my shoulders and in my neck so it is not surprising that it manifested itself there.

I am now convinced that psychological pain is just as real and hurts just as bad as physical pain. the problem is that not everyone has the coping skills to deal with the deeper issues. and there are not that many practitioners out there that can teach them the techniques that I learned at the Academy of the Healing Arts.

We are on the brink of new discoveries. Keep your minds open to the possibilities and stop judging or placing blame on the individual before you know the facts.

Addiction is a disease and needs to be attended to. I do not want to ignore that possibility but I do know that even addicts get migraines and have traumatic injuries and disease states that generate painful sensations. It is a difficult balancing act and we need to fine tune our skills and knowledge base. Pain management is a specialty with its own skills and knowledge base.

The research is out there folks! start reading!

OK I will get off my soap box for another day!

[dhudzinski]

How do you feel about people using Methadone or duragesic patches and driving cars and operating heavy machinery or even working as a nurse

I think that is a difficult question to answer. It is not clearly black and white. there are too many variables.

My advise to my patients is:

1. Do not drive if you have just started on a new medication

2. Do not drive if you have just increased a dose even if you have been on it for months to years.

3. Do not drive if you are having a flare of pain and using increasing numbers of rescue doses for breakthrough pain.

4. Do not drive if you Feel the effects of the medications ie you feel spacey, tired etc.

This advise also is true for those operating machinery or having to make critical decisions.

Now the short answer is I think that individuals can drive, operate machinery and make critical decisions safely if they use common sense. But there is monitoring and teaching that needs to occur up front for that to occur.

Most chronic pain patients I know that are on Opioids of any sort for pain do not feel spacey or tired when they have been on a steady dose for several weeks to months. I take it on a case by case basis and try to facilitate the patient through a process of decision making that will help them to make the most responsible decision.

[fab4fan]

tom, I respect your right to a different opinion, but my comment about addiction needing to be dx by an addictions specialist is not my idea...that's what the curent info. in pain mgmt. says. Following your line of logic, a pt with a cardiology problem could be treated by a gynecologist.

Sorry you had the misfortune of not working with a good substance abuse specialist, but just because you had a bad exp. does not mean that all of them are incompetent.

[lawrencenightingale]

Angela Mac,

I agree. Assessment is basic to nursing. Pain assessment included. Absolutist statements such as," ______ is whatever ______ says it is" seem simplistic,formulaic, and emotional(as opposed to compassionate). Don't they? Formulas are useful tools,but I wouldn't my nurse to rely solely on them. I would want him/her to use his/her judgement.

[dhudzinski]

The problem with that is... what are you basing your judgement on? Pain is so subjective and the only one who can judge how much pain and when it is there is the patient. Pain assessment is absolutely important BUT it must be a thorough systematic assessment if it is to be of any value.

Judgement is a value statement. Assessing and then using Critical thinking to come up with a plan as to how you might best intervene...I know it is symantics and a bit picky BUT....

[teeituptom, BSN, RN]

I think that is a difficult question to answer. It is not clearly black and white. there are too many variables.

My advise to my patients is:

1. Do not drive if you have just started on a new medication

2. Do not drive if you have just increased a dose even if you have been on it for months to years.

3. Do not drive if you are having a flare of pain and using increasing numbers of rescue doses for breakthrough pain.

4. Do not drive if you Feel the effects of the medications ie you feel spacey, tired etc.

This advise also is true for those operating machinery or having to make critical decisions.

Now the short answer is I think that individuals can drive, operate machinery and make critical decisions safely if they use common sense. But there is monitoring and teaching that needs to occur up front for that to occur.

Most chronic pain patients I know that are on Opioids of any sort for pain do not feel spacey or tired when they have been on a steady dose for several weeks to months. I take it on a case by case basis and try to facilitate the patient through a process of decision making that will help them to make the most responsible decision.

If you are under the influence of narcotics you dont drive or operate heavy machinery etc, pure plain and simple.