Pain control ethics

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    I work between our hospital's medical and surgical floors. The other night, I was assigned to work on the surgical floor. As I took on my usual patient load, I was awaiting the arrival of my last patient who was in surgery. He had an appendectomy and was recovering fine. When I asked if he was in pain he hesitantly said yes. Once I offered pain medication, he informed me that he was a recovering "drug addict" and he didn't think it was a good idea to receive a narcotic such as his prescribed morphine. I did some educating as far as explaining the difference between recreational usage and actually needing the medication for what it was intended for. But, I started to think that maybe I might be responsible if he was to slip into a relapse upon discharge. He proudly told me he had his 13 year anniversary coming up of being "drug-free", and of course I commended him on that accomplishment.
    I am just wondering what others think about this situation? Withholding pain medication definitely falls under the patient neglect catagory. But, on the other hand, the patient verbalized a concern about becoming addicted very easily.
    I did give the morphine, times three doses through the night. I personally felt that pain control was in the patient's best interest at the time, but on my way home from work I was heavily thinking about this patient's near future upon discharge.
    Should I actually feel guilty about doing the "right thing" for my patient?
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  4. 10 Comments so far...

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    MrRNman-
    You should feel relieved to know that current pain management experts assert that even addicts may need opiods during recovery or when in severe pain. True, they might have a higher risk of becoming dependent, or of requiring higher doses for *actual* pain (due to higher tolerance). You did the right thing. To withhold pain medicine or to medicate with something inappropriate like vicodin immediately post op would be cruel.

    The American Pain Society http://www.ampainsoc.org/ and other groups will stand behind you. Many nurses and even doctors are biased and ignorant and therefore withhold pain medicine from patients with drug abuse histories (which is really unethical, when you think about it). I can't tell you how many judegemental and pious medical professionals I have come across. You can sign up for some CEUs on pain control if you want to learn more about why what you did was the right thing to do. You are right- giving someone medicine for pain is different than giving meds for recreational use.

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    While I agree with the above information and read this before I have seen clean abusers relaspe after surgery which is very sad. KInda like being between a rock and a hard place as far as the patient perspective looks to them. I always gave it and hoped for a good outcome for the client.

    Good thread,

    renerian
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    I've always given it. I've also had patients who flat out refused it because they're just afraid they'll relapse. If they're that nervous about it I just get a toradol order or something, usually helps. But I think you did the right thing!!
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    I'm surprised that this patient did not address the issue of his addiction with his surgeon and the anesthesiologist prior to surgery. Does your hospital have an alcohol/drug treatment center? I bet the physicians heading that department could suggest alternatives. I agree with renarian, it would be sad to see this gentleman relapse with 13 years even if recovery is a day at a time.

    Paula
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    I think this is a very difficult area to deal with. My dad is a recovering alcoholic and I suffer from Fibro so take narcs fairly reg. I am often concerned that I will become addicted. I know that my tolerance to pain meds has gone up. Meaning it takes more to control my pain. It is a tough call but if you dont treat the pain adequetly they will not heal as well and will be more apt to self medicate with alcohol or other things. I know I would. Good thread good topic to debate.
  10. 0
    Hey, thanks for all the input!
    chartleypj:
    Yes, our hospital does have treatment available for those in need, but this guy is already active in various programs and denied further help. You had a good point, addressing his situation to the surgeon & anesthesiologist. Actually, I told him to bring it to the doctor's attention when he made his rounds the next morning. I also passed the info on to the day shift in report. I just had a funny feeling when he approached me with this information--it was like his eyes were begging me not to give him the morphine. I don't know...it's just one of those instinct things. I just hope to God he is strong enough to follow through with his "drug-free" environment at home and that he keeps the support system that has proven to be effective all these years.
    Thanks again for everyone's input and support.
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    Remember, while the patient has the right to receive pain meds, they also have the right to refuse!

    Alternate comfort measures, like calling for non-narcotic pain med orders should be tried first. IMHO.
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    I am a recovering addict. The day after I celebrated 1 year clean in the program, I was scheduled for surgery.
    When I was first diagnosed with breast cancer, I told the surgeon I was working with that I was an opiod addict.
    She promptly told me she would to a mastectomy with only IV ibuprofen and aspirin. She said I would be "uncomfortable" but the pain would not last forever. She told me my year was "nothing" and that I WOULD be drug seeking if I had even a small amount of opiates. She also told me that if I could not take the pain, I should not do the reconstruction.

    I talked to my sponsor and my psychologist, and after much discussion and input, I decided to consult another doctor.

    Because I thought what the first surgeon prescribed was barbaric, I was frightened to confide in my second set of surgeons. In the past, since I was a young girl, I had always had problems with post operative pain. There was no way I was going to do a mastectomy without narcotic pain meds.

    So I didn't tell the second set of doctors about being in recovery.

    Things turned out fine. My pain was wonderfully controlled in the hospital, where I stayed four nights. I was pretty much out of pain by the time I went home, but I did continue on pain meds for four days after returning home. I then got rid of the pills.

    I have another surgery scheduled in a few months. I plan to follow the same protocol.

    I stuck close to my sponsor, my meetings and my professional support.....a psychologist and my meds prescriber, an RN who is an addiction specialist.

    I think the first doctor I spoke to had no understanding of addiction. I probably will never tell another doctor I am in recovery. I think there is a great deal of medical ignorance on the subject of addiction.
  13. 0
    Quote from MrRNman
    I am just wondering what others think about this situation? Withholding pain medication definitely falls under the patient neglect catagory. But, on the other hand, the patient verbalized a concern about becoming addicted very easily.
    I did give the morphine, times three doses through the night. I personally felt that pain control was in the patient's best interest at the time, but on my way home from work I was heavily thinking about this patient's near future upon discharge.
    Should I actually feel guilty about doing the "right thing" for my patient?
    I personally, don't see where the confusion lies. You don't have the legal right to withhold a medication that has been ordered, the patient is pain, just because they say they have a "concern" with regards to receiving an opiate re-triggering addictive behavior. That isn't a nursing decision.

    If the patient is awake, alert and oriented, your job is to tell the patient what is ordered, what they can have, educate the patient, but THEY GET to make the decision whether to accept it or not. There is nothing that says a patient cannot stay in pain if they choose to be and I have SEEN patients choose to not have pain meds after surgery because they refuse...that is their right as a patient.

    The patient had a valid concern. You were incorrect in saying, "There is a difference between opiate use as recreation versus pain control". The patient was concerned about re-triggering his addiction.

    I have a friend who had a horrible time recovering from alcoholism....it took him two years to stop drinking...we went to a fondue restaurant and he took one bite of the cheese fondue and immediately asked for water (as in a panic) and I watched him down an entire glass in seconds. When I asked what had happened, he said, "The fondue had wine in it...I could taste it. I can't take a chance on it." It was because the taste triggered an instant desire for another drink. He said he had not thought about drinking in a long time before that evening...but then was obsessed with it for several days after.

    I would have told the patient that the body processes opiates differently when there are real pain receptors vs none, but would have also told them, "I understand your concern, it's a valid concern. However, the decision is up to you...I have the morphine if you feel like you need it or I can see if the doctor can prescribe you an alternative medication."

    I wouldn't have given my personal opinion or advice and would have told them to make the decision.

    Addiction and dependency are very different...addiction is a drug seeking behavior. A couple of doses of morphine are not enough to re-trigger dependency...but addiction, is very different.


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