mechanisms of dependence/addiction

MollyJ · Jan 5, 2002

Your question is complex and cannot be directly answered because there are so many variables in why people fail to experience pain relief. People can have unrelieved pain due to:

personal coping with pain;

complications that need to be evaluated and addressed;

complications that are outcomes of the procedure (ie inadvertent nerve injury that leaves the person with some paresthesia);

previous chemical use that leaves the client with a high tolerance to chemicals--this can be from previous therapeutic use or from "recreational" use;

true history of addiction that may or may not have been disclosed.

There could well be others; these are the ones I can think of.

To me, the model of, "Trust your patients complaint of pain implicitly" simply has limitations and nearly precludes having an index of suspicion for addictions (and, boy, are we poor at that as nurses!) Neither are our patients served if we think of every patient with prolonged pain as an addict.

I know is sounds lame, but patients are best served if we simply listen to them. What are their expectations for pain relief? What other adjuncts have been tried? (Massage, repositioning, ambulation [my body hurts when it doesn't get exercise]). I also think patients need access to other adjuncts like TENS units.

For many of us, pain is a signal to STOP doing something. If I sprain my ankle, I stay off of it. The contradiction lies in, I think, helping clients understand that at some time in a post operative period, you move in spite of pain or discomfort. (I call this pushing through the pain.) Nurses need to provide sufficient pain relief to allow movement but not to preclude it. See how this model "doesn't work" when the patient's thoughts are that pain medicine should entirely relieve my pain so that I can move. You and your patient may never resolve your difference in "pain philosophy" but it will be best if you can at least lay them out on the table.

Nurses must be respectful of their position as "holder of the narcotic keys." This puts us in a very powerful spot, to administer or not to administer. At all times, nurses must think about how it would feel to be in pain and have a BIG SOMEONE out there refusing to give us what we want. Look at these boards. No one is more vocal than NURSES when that happens to them.

In a world where nurses are rushed and have little time for adjuncts, I think it is easy to find ourselves in pain arguments with patients that are very circular. In general, a psychologist I know used to say, "Never give up a crutch til you don't need it anymore!" (ouch.) I would say that in pain relief that means institute adjuncts before you dc the pain meds.

Being in the hospital involves lots of losses and anxieties (loss of control, worries about the dx, death anxiety etc) and confers special roles (the sick role, the family focus). People may use pain meds to numb out feeling their anxieties and losses and they may have a hidden (even from them) agenda to prolong their stay in the sick role. Again, in the olden days, nurses had time to hear some of these anxieties (like during that deceased practice, the back rub) and to acknowledge them. SOMETIMES we can just let them know that some of disability they now experience in part of the normal course of getting well (if that is indeed true) and sometimes we just need to acknowledge the anxiety that goes with knowing that your life is changing and not for the better.

In general, current theories of addiction center around alcohol (where most of the studies have been done) and describe experimentation, use (social use), abuse, and addiction. we know that adults may move through these stages slowly and teens may move through them quickly. Abusive users of alcohol or other drugs are those that use them frequently and have friends that use them frequently but don't show the physical dependence and loss of choice and control of the addicted user. Both abusive and addictive users can be surprisingly functional in their world BUT addictive users are usually experiencing some negative change in their coping with the work and family world in terms of dependability, money management, interpersonal and family relationships. I would refer you to some of the excellent sources on addictions nursing that are available out there.

I've probably given you more to think about as opposed to answering your questions, but hopefully it will give you some things to think about.

Agnus · Jan 5, 2002

I cannot agree with you more. If a patient has pain I see to it that he gets appropriate pain med which more often than not is a narcotic. I was taught that one does not become addicted by taking pain meds when you have pain.

Maby what I was talking about doesn't really exist. I'll Try to explain where I was comming from. Example, late 1800's some cowboy or someone has injury or surgery, He takes MS then years later he still "craves" MS and is totally dependent and has a high tollerance. Maby I watched too many westerns when I was a kid. But in these stories the suggestion was the pain would not still exist if he could just get off the drug. At some point he does go "cold turkey" and detoxes and the the pain is gone with it. Premis is when he started on MS the doctors did not know it was addictive.

Am I just goofy and watched too many westerns circ 1950's 1960's?

MollyJ · Jan 6, 2002

I think in the real and present world a considerable amount of prescription drug abuse/addiction occurs and no one really has a good handle on it because there is no good agreement on who needs meds and who does not (and there is not likely ever to be good agreement on it). In the late 1800's early 1900's cocaine was considered relatively harmless and was in many OTC patent medicines. I guess I think in the year 2002 I think there is more habituation to anti-anxiety agents (valium, librium etc) and some of the habituating psychotropics. http://www.nida.nih.gov did a Research Report on this very topic.

I think many people become accustomed to medicating uncomfortable feelings instead of working through them (...with either alcohol or psychotropics). Working through them is not quick, can be uncomfortable and carries no guarantee of success. Like you, I would never want to be construed as saying no one ever needs a psychotropic, but they can short circuit the working through process. I guess I also believe that they can be used effectively in conjunction with talk therapy to allow people to calm down sufficiently to think or talk about the uncomfortable idea and they may help folks cope until such time as they are ready to doing the working through process, but for a certain number of people, they come to substitute for working through. But, like most nurses, I grew tired of fighting constantly with clients who were accustomed to taking horse sized doses of medicines and wanted us to be their "candy man" in the hospital.

In my work in drug prevention in the school I have come to accept that most people are not going to change their substance abuse/addiction patterns in response to the first (or maybe even second, third or fourth) person who voices a concern about their chemical use. But there has to be a first person who gently and lovingly says, "Gee, I am worried about this." To be effective, confrontation has to come from someone they care about and that is why nurse confrontation may or may not be effective. (Some times people respond to a "concerned" authority figure.)

When I confront kids about chemical use, unless they've been caught red handed (smoking pot in school or drunk at a school event), I am very plain with them that I don't "know them well enough" to say that drugs are a problem and I spend a lot of time relationship building with them and trying to find out about their function in as many other domains as possible (academics, attendance, behavior, legal, getting along with family). Many times parents are very enabling of their teens chemical use and getting them to state their concerns can be hard (they may be in considerable denial). Sometimes parents are chemical abusers too and to be concerned about their kid would mean they have to look at their own usage, too. They don't want to. Helping a patient admit to concern about their chemical use will be very difficult unless a family member is willing to get on board and say they are worried, too.

Though I have only been in this field about 3 1/2 years, addictions has kind of grabbed me; it's interesting.

Agnus · Jan 8, 2002

Hmmm. Interesting take on the use of psycotrophics. I used to feel the same way and then in nursing school I began to feel that maby they were necessary due to a chemical imbalance so that the person could work through the problem.

I don't by any means think that everyone with a problem to be worked through needs them but I was taught that some times the chemicals in the brain are so screwed up that it must be addressed before a person can work on a problem.

I agree sometimes we are seen as and easy way to get "candy" and I think sometimes that is true. But like you said we can't change people who won't be. And we are generally not segnificatn enough in thier lives to make a diffrence. BUT sometimes we can plant just a little seed that might someday sprout. DYou never know just what influence you might have on someone. I think about the people who influenced me by just some little thing and they are very surprised to learn hear the influence they had on me.