Questionable Pain

JJFROG · Sep 16, 2002

I have seen this a couple of times with diabetics, sorry I cannot remember the name of the problem. One is a 25 year old frequent flyer of my old ER. Let me rack my brain to remember his diagnosis, but sounds similar to your patient....nothing helped his pain.

sunnygirl272 · Sep 16, 2002

J Assoc Physicians India 1999 Dec;47(12):1176-80 (ISSN: 0004-5772)

Tripathi BK

Gastroenterology Unit, Dept. of Medicine, Safdarjung Hosp., New Delhi, India.

Our understanding of gastric motility disorder--diabetic gastroparesis has advanced in the last ten to fifteen years, but the published data regarding pathogenesis are confusing and show conflicting results. The pathogenesis is sometimes linked with hyperglycemia, autonomic neuropathy, gastrointestinal hormone or myogenic mechanism. Antral hypomotility is often associated with hyperglycemia which is often accompanied by reduction in duodenal waves. Varying level of motilin, a gastrokinetic hormone has been reported. However none of the mechanism could explain the exact pathogenesis. The relationship of this mortality disorder with clinical symptoms is not always established, however nausea and vomiting lasting for days or weeks are the prominent symptoms. Other symptoms are post-prandial fullness, early satiety, bloating, belching, and vague abdominal discomfort. In a few cases, it may be the cause of poor nutrition, uncontrolled diabetes and recurrent ketoacidosis. Last one or two decades have seen some advancement in the investigational procedures like scintigraphy, radio-opaque markers, breath test, electrogastrography and MRI. Which can lead to a proper diagnosis. Such objective assessment is all the more important as nearly half of the patients do not have any symptom. Symptomatic improvement of gastroparetic patients should be the aim and in asymptomatic patients, treatment is often not recommended. Some dietary advice and prokinetic agents like metoclopramide, cisapride etc. are often prescribed but much needs to be further known as management is not always uniformly rewarding.

shannonRN, BSN, RN · Sep 16, 2002

sunnygirl, thanks for the article. way interesting! a while back, i learned about diabetics getting neuropathies in the gut...had one with frequent obstructions.

i once diluted phenergan for a patient and they yelled at me saying that i was trying to avoid giving their meds....didn't care to listen that i was actually trying to prevent a new pain from starting... :rolleyes:

precious, there is a whole thread about drug seeking patients...here is the link https://allnurses.com/forums/showthread.php?s=&threadid=7225&highlight=drug+seeking+patients

JJFROG · Sep 17, 2002

Thanks Sunny, it was right on the tip of my tongue and was driving me nuts!!

2rntish · Sep 25, 2002

I remember a pt that was turned away from ER several times. CC:Back pain. Nothing on xray-CT. For some reason the Ed finally admitted him with modest pain control orders. Prior to admission the only way he got relief was sitting in a hot tube. had pressure sores on both cheeks. Every evening during report the comments usually centered around this OBVIOUS DRUG SEEKING behavior. All the usual stuff; clock watcher, just wants the rush...Comments about maybe an occasional NSS bolus instead of the MSO4 that was ordered. Transfered after 4 days on the ward to larger facility. Tumor in spinal column finally big enough to see on CT. Pt died within a year.

If it comes down to a judgement call...I'm giving the pt what I can. Would you rather deny a TRUE DRUG SEEKER his/her thrill or deny the above pt pain control. I have worked in ED and in-patient and I know that there are folks that have and will continue to abuse the system but it is a fine line that we walk when WE decide who is hurting and who is not.

finallyRN · Sep 25, 2002

we are having the same problems right now with a patient. I work on L/D so much of the pain we deal with we know is real. However we also care for antepartum patients. We recently got a patient who currently lives in a drug rehab facility for pregnant women. She came in screaming bloody murder. saying she had excruciating back pain. We ruled out labor then looked at everything else. Nothing on a renal ultrasound, MRI showed two bulging disks. Evidently this is the source of the pain. A neuro surgeon came and saw her and said her type of injury would not cause the amount of pain this patients claims.

Now with her past history of drug abuse (she had been clean for about 100 days at her admission), it is hard to believe her when she is mainly demanding pain meds. Her actions also don't always correlate with the amount of pain she claims she is in. We are all having a hard time with her because I think she is in some degree of pain but definatly not as much as she claims.

Last night we alternated her demerol with NS (per MD orders). She lasted about 5 hours post NS without pain meds. I guess her pain isn't as bad as she says.

2rntish · Sep 26, 2002

I have heard that NSS boluses do work for some pts. Are they really not in pain or is it the distraction? Mind over matter? With the OB pts past history I would be hesitant as well. But, lots of old drug addicts out there with special problems and real pain. Time and time again you hear docs and nurses state that "that can't be causing that much pain".

I remeber an OB pt that was dilated to a 3. Asked to rate pain on 10 scale. She stated 10. Several hours later dilated to a 5, asked to rate pain, still 10. Dilated to 9, pain was obviously worse, still rated 10. Pts perception change.

We should explore our own perceptions of how we feel pain, how we listen to pts, how we treat pts with different reports of pain that don't match ours.

I DO NOT want us to become the corner crack house but as I get older and closer to total hips, total knees, chronic back pain, spastic colons...I would like to think that when I report pain to a doc or nurse they believe me and I don't need to figure out how they think I should act to rate my pain at 8 on a 10 scale. If NSS boluses work, so be it. But don't let my pain go uncontrolled because I don't act the way someone else does.

LydiaGreen · Nov 6, 2003

Really wish I had a reference at hand for this but, I was told by a doctor that people with a history of drug abuse have incredibly low pain tolerance. A stubbed toe feels like a fracture - constipation feels like an obstruction - so on and so forth. Even if a person has been clean for several years, it still takes much more pain medication to resolve their 10/10 then it would for a patient without a history of drug abuse.

allnurses Guide · Nov 6, 2003

Is giving NS between Demerol ethical? Are placebos really effective? I found the following article quite interesting:

"Against Depression, a Sugar Pill Is Hard to Beat Placebos Improve Mood, Change Brain Chemistry in Majority of Trials of Antidepressants" by Shankar Vedantam Washington Post

The placebo effect:

The placebo effect is the measurable, observable, or felt improvement in health not attributable to treatment. This effect is believed by many people to be due to the placebo itself in some mysterious way. A placebo (Latin for "I shall please") is a medication or treatment believed by the administrator of the treatment to be inert or innocuous. Placebos may be sugar pills or starch pills. Even "fake" surgery and "fake" psychotherapy are considered placebos.

Researchers and medical doctors sometimes give placebos to patients. Anecdotal evidence for the placebo effect is garnered in this way. Those who believe there is scientific evidence for the placebo effect point to clinical studies, many of which use a control group treated with a placebo. Why an inert substance, or a fake surgery or therapy, would be effective is not known.

the psychological theory: it's all in your mind

Some believe the placebo effect is psychological, due to a belief in the treatment or to a subjective feeling of improvement. Irving Kirsch, a psychologist at the University of Connecticut, believes that the effectiveness of Prozac and similar drugs may be attributed almost entirely to the placebo effect. He and Guy Sapirstein analyzed 19 clinical trials of antidepressants and concluded that the expectation of improvement, not adjustments in brain chemistry, accounted for 75 percent of the drugs' effectiveness (Kirsch 1998). "The critical factor," says Kirsch, "is our beliefs about what's going to happen to us. You don't have to rely on drugs to see profound transformation." In an earlier study, Sapirstein analyzed 39 studies, done between 1974 and 1995, of depressed patients treated with drugs, psychotherapy, or a combination of both. He found that 50 percent of the drug effect is due to the placebo response.

A person's beliefs and hopes about a treatment, combined with their suggestibility, may have a significant biochemical effect. Sensory experience and thoughts can affect neurochemistry. The body's neurochemical system affects and is affected by other biochemical systems, including the hormonal and immune systems. Thus, it is consistent with current knowledge that a person's hopeful attitude and beliefs may be very important to their physical well-being and recovery from injury or illness.

However, it may be that much of the placebo effect is not a matter of mind over molecules, but of mind over behavior. A part of the behavior of a "sick" person is learned. So is part of the behavior of a person in pain. In short, there is a certain amount of role-playing by ill or hurt people. Role-playing is not the same as faking or malingering. The behavior of sick or injured persons is socially and culturally based to some extent. The placebo effect may be a measurement of changed behavior affected by a belief in the treatment. The changed behavior includes a change in attitude, in what one says about how one feels, and how one acts. It may also affect one's body chemistry.

The psychological explanation seems to be the one most commonly believed. Perhaps this is why many people are dismayed when they are told that the effective drug they are taking is a placebo. This makes them think that their problem is "all in their mind" and that there is really nothing wrong with them. Yet, there are too many studies which have found objective improvements in health from placebos to support the notion that the placebo effect is entirely psychological.

Doctors in one study successfully eliminated warts by painting them with a brightly colored, inert dye and promising patients the warts would be gone when the color wore off. In a study of asthmatics, researchers found that they could produce dilation of the airways by simply telling people they were inhaling a bronchiodilator, even when they weren't. Patients suffering pain after wisdom-tooth extraction got just as much relief from a fake application of ultrasound as from a real one, so long as both patient and therapist thought the machine was on. Fifty-two percent of the colitis patients treated with placebo in 11 different trials reported feeling better -- and 50 percent of the inflamed intestines actually looked better when assessed with a sigmoidoscope ("The Placebo Prescription" by Margaret Talbot, New York Times Magazine, January 9, 2000).*

It is unlikely that such effects are purely psychological. But it is not necessarily the case that the placebo is actually effective in such cases.

the nature-taking-its-course theory

Some believe that at least part of the placebo effect is due to an illness or injury taking its natural course. We often heal spontaneously if we do nothing at all to treat an illness or injury. Furthermore, many disorders, pains and illnesses, wax and wane. What is measured as the placebo effect could be, in many cases, the measurement of natural regression. In short, the placebo may be given credit that is due to Nature.

However, spontaneous healing and spontaneous remission of disease cannot explain all the healing or improvement that takes place because of placebos. People who are given no treatment at all often do not do as well as those given placebos or real medicine and treatment.

the process-of-treatment theory

Another theory gaining popularity is that a process of treatment that involves showing attention, care, affection, etc., to the patient/subject, a process that is encouraging and hopeful, may itself trigger physical reactions in the body which promote healing. According to Dr. Walter A. Brown, a psychiatrist at Brown University,

there is certainly data that suggest that just being in the healing situation accomplishes something. Depressed patients who are merely put on a waiting list for treatment do not do as well as those given placebos. And -- this is very telling, I think -- when placebos are given for pain management, the course of pain relief follows what you would get with an active drug. The peak relief comes about an hour after it's administered, as it does with the real drug, and so on. If placebo analgesia was the equivalent of giving nothing, you'd expect a more random pattern ("The Placebo Prescription" by Margaret Talbot, New York Times Magazine, January 9, 2000).*

Dr. Brown and others believe that the placebo effect is mainly or purely physical and due to physical changes which promote healing or feeling better. It is assumed that the physical changes are not caused by the placebo itself. So, what is the explanatory mechanism for the placebo effect? Some think it is the process of administering it. It is thought that the touching, the caring, the attention, and other interpersonal communication that is part of the controlled study process (or the therapeutic setting), along with the hopefulness and encouragement provided by the experimenter/healer, affect the mood of the subject, which in turn triggers physical changes such as release of endorphins. The process reduces stress by providing hope or reducing uncertainty about what treatment to take or what the outcome will be. The reduction in stress prevents or slows down further harmful physical changes from occurring.

The process-of-treatment hypothesis would explain how inert homeopathic remedies and the questionable therapies of many "alternative" health practitioners are often effective or thought to be effective. It would also explain why pills or procedures used by conventional medicine work until they are shown to be worthless.

Forty years ago, a young Seattle cardiologist named Leonard Cobb conducted a unique trial of a procedure then commonly used for angina, in which doctors made small incisions in the chest and tied knots in two arteries to try to increase blood flow to the heart. It was a popular technique -- 90 percent of patients reported that it helped -- but when Cobb compared it with placebo surgery in which he made incisions but did not tie off the arteries, the sham operations proved just as successful. The procedure, known as internal mammary ligation, was soon abandoned ("The Placebo Prescription" by Margaret Talbot, New York Times Magazine, January 9, 2000).*

Of course, spontaneous healing or regression can also adequately explain why homeopathic remedies might appear to be effective. Whether the placebo effect is mainly psychological, misunderstood spontaneous healing, due to showing care and attention, or due to some combination of all three may not be known with complete confidence.

the powerful placebo challenged

The powerful effect of the placebo is not in doubt. It should be, however, according to Danish researchers Asbjørn Hróbjartsson and Peter C. Götzsche. Their meta-study of 114 studies involving placebos found "little evidence in general that placebos had powerful clinical effects...[and]...compared with no treatment, placebo had no significant effect on binary outcomes, regardless of whether these outcomes were subjective or objective. For the trials with continuous outcomes, placebo had a beneficial effect, but the effect decreased with increasing sample size, indicating a possible bias related to the effects of small trials ("Is the Placebo Powerless? An Analysis of Clinical Trials Comparing Placebo with No Treatment," The New England Journal of Medicine, May 24, 2001 (Vol. 344, No. 21)."

According to Dr. Hróbjartsson, professor of medical philosophy and research methodology at University of Copenhagen, "The high levels of placebo effect which have been repeatedly reported in many articles, in our mind are the result of flawed research methodology."* This claim flies in the face of more than fifty years of research. At the very least, we can expect to see more rigorously designed research projects trying to disprove Hróbjartsson and Götzsche.

the origin of the idea

The idea of the powerful placebo in modern times originated with H. K. Beecher. He evaluated over two dozen studies and calculated that about one-third of those in the studies improved due to the placebo effect ("The Powerful Placebo," 1955). Other studies calculate the placebo effect as being even greater than Beecher claimed. For example, studies have shown that placebos are effective in 50 or 60 percent of subjects with certain conditions, e.g., "pain, depression, some heart ailments, gastric ulcers and other stomach complaints."* And, as effective as the new psychotropic drugs seem to be in the treatment of various brain disorders, some researchers maintain that there is not adequate evidence from studies to prove that the new drugs are more effective than placebos.

Placebos have even been shown to cause unpleasant side-effects. Dermatitis medicamentosa and angioneurotic edema have resulted from placebo therapy, according to Dodes. There are even reports of people becoming addicted to placebos.

the ethical dilemma

The power of the placebo effect has led to an ethical dilemma. One should not deceive other people, but one should relieve the pain and suffering of one's patients. Should one use deception to benefit one's patients? Is it unethical for a doctor to knowingly prescribe a placebo without informing the patient? If informing the patient reduces the effectiveness of the placebo, is some sort of deception warranted in order to benefit the patient? Some doctors think it is justified to use a placebo in those types of cases where a strong placebo effect has been shown and where distress is an aggravating factor.* Others think it is always wrong to deceive the patient and that informed consent requires that the patient be told that a treatment is a placebo treatment. Others, especially "alternative" medicine practitioners, don't even want to know whether a treatment is a placebo or not. Their attitude is that as long as the treatment is effective, who cares if it a placebo? Of course, if the placebo effect is an illusion, then another ethical dilemma arises: should placebos be given if it is known that deception does not really reduce pain or aid in the cure of anything?

are placebos dangerous?

While skeptics may reject faith, prayer and "alternative" medical practices such as bioharmonics, chiropractic and homeopathy, such practices may not be without their salutary effects. Clearly, they can't cure cancer or repair a punctured lung, and they might not even prolong life by giving hope and relieving distress as is sometimes thought. But administering useless therapies does involve interacting with the patient in a caring, attentive way, and this can provide some measure of comfort. However, to those who say "what difference does it make why something works, as long as it seems to work" I reply that it is likely that there is something which works even better, something for the other two-thirds or one-half of humanity who, for whatever reason, cannot be cured or helped by placebos or spontaneous healing or natural regression of their pain. Furthermore, placebos may not always be beneficial or harmless. In addition to adverse side-effects, mentioned above, John Dodes notes that

Patients can become dependent on nonscientific practitioners who employ placebo therapies. Such patients may be led to believe they're suffering from imagined "reactive" hypoglycemia, nonexistent allergies and yeast infections, dental filling amalgam "toxicity," or that they're under the power of Qi or extraterrestrials. And patients can be led to believe that diseases are only amenable to a specific type of treatment from a specific practitioner (The Mysterious Placebo by John E. Dodes, Skeptical Inquirer, Jan/Feb 1997).

In other words, the placebo can be an open door to quackery.

LydiaGreen · Nov 6, 2003

From what I have been told, the use of placebos in Ontario is not allowed.

Fgr8Out · Nov 6, 2003

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.

As for the use of placebos, who does this benefit? Certainly not the patient, who should have every right to expect that they are being cared for in a professional manner. Placebos are deceptive at best and can be considered malpractice. Physician's should be discouraged from ordering placebos and Nursing should never substitute NSS for a narcotic to verify if a patient does indeed have pain. To do so is completely presumptuous.

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.

Lastly, the use of adjuvants such as vistaril and phenergan should be discouraged. These products DO NOT enhance the analgesic effects of opioids and may actually contribute to over sedation and other side effects. Because the opposite has been reported for so long, (that phenergan and vistaril potentiate the effects of opioids) destroying this myth is ongoing.

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.

http://www.aspmn.org/index.htm