Administering pain meds to narcotic seekers

RNTutor, BSN, RN · May 12, 2010

This is an interesting discussion because I think a lot of nurses have a hesitancy to about giving narcotics and pain meds, even when the pt is not a known user.

After I gave birth to my son (normal lady partsl, with episiotomy), I was one of those pts that knew exactly when it was time to get my prn pain meds, because I am a firm believer that the best way to control pain is to prevent it. So I asked for my meds everytime they were due. Of course, the RNs always asked my pain rating. There was this one RN who asked, and I honestly told her it was a 2. She said, "well, I can't give you percocet for that pain rating, so I'll just say it's a 6."

I was dumbfounded. She was more comfortable falsifying her documentation then just giving me an ordered prn pain med within 48hrs of delivery. But I think there are many nurses (heck, many people in general) who are nervous about being accused of enabling drug users.

whichone'spink, BSN, RN · May 12, 2010

My primary RN would probably not agree to pull out a Percocet if the patient said his or her pain level was 2. I wish pain medication was ordered round-the-clock rather than just PRN. That way it covers the nurse's ass with regard to giving narcs.

~Mi Vida Loca~RN, ASN, RN · May 12, 2010

This is an interesting discussion because I think a lot of nurses have a hesitancy to about giving narcotics and pain meds, even when the pt is not a known user.
After I gave birth to my son (normal lady partsl, with episiotomy), I was one of those pts that knew exactly when it was time to get my prn pain meds, because I am a firm believer that the best way to control pain is to prevent it. So I asked for my meds everytime they were due. Of course, the RNs always asked my pain rating. There was this one RN who asked, and I honestly told her it was a 2. She said, "well, I can't give you percocet for that pain rating, so I'll just say it's a 6."
I was dumbfounded. She was more comfortable falsifying her documentation then just giving me an ordered prn pain med within 48hrs of delivery. But I think there are many nurses (heck, many people in general) who are nervous about being accused of enabling drug users.

What the heck, she can't give for that pain rating?? I have never heard of such a thing.

I am someone that has a high tolerance to pain meds myself. I have dealt with chronic back issues for YEARS. That said I don't take oppoids daily. I do agree with you that it's best to tackle pain before it gets bad in acute situations like you described.

In my situation that isn't feasible because it's a daily thing. So I would take my narcs when I had a really bad flareup. I could take 3 10mg norco and feel nothing. I would be prescribed 45 and it would last 2 months.

I have tried to tell them the Norco is not effective and I was treated like a drug seeker. I finally got a Doctor that is great and being proactive in my care. She has prescribed a topical NSAID gel for the inflammation are of my back instead of the TID 800 mg Motrin the other Dr prescribed for long term use :| I took it BID instead because once a day wouldn't keep the inflammation down but TID scared me. She also prescribed Percocet, 10 MG helps the pain, not fully but it at least takes the edge off enough to be functional when I have a flare up. I have been trying to work out a lot so I have been having a lot of flare ups.

She is also a specialized ortho doc and can do manipulations and since she is a "medical" doctor Ins. will cover the adjustments. In our first appointment she felt down my spine and said something about being able to tell I have some big rotations (whatever that means) and Xrays have confirmed I have some bone spurs.

One day I will be able to get a breast reduction and I think that will solve 80% of the problem right there.

Usually though unless someone has experienced it, they just don't understand and are so quick to label. I think people with chronic pain get it even worse (the stereotypes) because they learn how to deal with it so well that they might not "look" in pain and it doesn't effect their vitals like in acute situations.

rn/writer, RN · May 12, 2010

Newer guidelines (from JCAHO, I believe) instruct docs to write more specific parameters for prn meds.

For example for a vag delivery:

600 mg ibuprofen PO every 6 hours for pain prn.

1-2 Percocets PO every 4-6 hours for pain prn if ibuprofen ineffective after 30 minutes.

We are seeing this "stepping stone" kind of prescribing for other meds as well.

Our Duramorph patients get IV Benadryl as the first line of defense with itching. If there is inadequate relief after thirty minutes, the patient can have Narcan. If that hasn't worked in a half hour, they get Nubain.

A graduated response like this would address the issue of multiple prn opioid analgesics and how to give them without overwhelming the patient's respiratory system. This is going to be the gold standard in the future, but I imagine some facilities and some docs will drag their heels and have to be pressured into prescribing this way. I know it takes a bit longer to write out each step, but doing so really does offer greater protection for both the patients and the practitioners.

I agree with what the others have said about it not being your job to try to deal with the patient's addiction or dependence.

Withholding properly ordered medication is not going to help the addicted folks quit using. That takes a desire and a willingness on their part along with the help of specially trained rehab folks.

Those who are dependent have real pain and require the medication to manage it. The fact that you don't see them sweating and writhing in misery probably has to do with the fact that they are taking the meds on a regular basis.

Some people who are addicted--hooked on drugs, not because they have pain, but because they like the altered experience--look "normal." And some who are legitimately dependent--needing medication to deal with pain that can be chronic and severe--look pretty rough. How do you as a floor nurse decide the difference? You don't. You leave it to those accustomed to sorting out that mess and medicate as prescribed.

Now, if you are worried because the patient has prn orders for ibuprofen, Darvocet, Percocet, and morphine, tell the doc about your concerns (that the patient wants overlapping meds at the same time) and ask for the kind of parameters I mentioned above. This will cover YOU if the patient tries to bully you into giving everything at once, and it will cover you and the doc if Joint Commission wants to throw a hissy fit because the patient didn't get to knock out her respiratory drive because she wanted an Easter basket full of pills and you said no.

Thank you for being concerned about keeping your patients alive. Breathing is a good thing. But don't try to sort out addiction/dependence issues while they're in your care. They'll end up mad and you'll end up crazy, and no one will leave the dance happy.

RNTutor, BSN, RN · May 12, 2010

Agreed...I definitely think people with chronic pain have it worse, and are looked at more suspiciously. But it really bugs me when people can't use common sense to see "hey, this woman just had a baby and an episiotomy less than 2 days ago. I bet she might start having some pain if she doesn't get her pain meds, so let's be proactive about this. After all, the MD DID give a prn order (that did not say "prn for pain ratings greater than...")." It's not like I walked in the door and asked for a percocet 2 months after giving birth. Sheesh.

And back pain is rough...it's not like you can just 'rest' your back, you kind of need to use it for everything you do. Chronic pain is such a difficult condition to manage in our culture today, because it is almost impossible for MDs to tell the difference between true pain and drug seekers. And they are hesitant to try because everybody is so 'sue-happy' :uhoh3:

RNTutor, BSN, RN · May 12, 2010

Newer guidelines (from JCAHO, I believe) instruct docs to write more specific parameters for prn meds.
For example for a vag delivery:
600 mg ibuprofen PO every 6 hours for pain prn.
1-2 Percocets PO every 4-6 hours for pain prn if ibuprofen ineffective after 30 minutes.
We are seeing this "stepping stone" kind of prescribing for other meds as well.

Yes, I think that is a great way to do it! Hopefully my hospital will have the protocols in place whenever child #2 comes along...

~Mi Vida Loca~RN, ASN, RN · May 12, 2010

Newer guidelines (from JCAHO, I believe) instruct docs to write more specific parameters for prn meds.
For example for a vag delivery:
600 mg ibuprofen PO every 6 hours for pain prn.
1-2 Percocets PO every 4-6 hours for pain prn if ibuprofen ineffective after 30 minutes.
We are seeing this "stepping stone" kind of prescribing for other meds as well.
Our Duramorph patients get IV Benadryl as the first line of defense with itching. If there is inadequate relief after thirty minutes, the patient can have Narcan. If that hasn't worked in a half hour, they get Nubain.
A graduated response like this would address the issue of multiple prn opioid analgesics and how to give them without overwhelming the patient's respiratory system. This is going to be the gold standard in the future, but I imagine some facilities and some docs will drag their heels and have to be pressured into prescribing this way. I know it takes a bit longer to write out each step, but doing so really does offer greater protection for both the patients and the practitioners.

That is great that they are doing this. Especially if the lesser one can end up being effective and the pt wouldn't have known!

~Mi Vida Loca~RN, ASN, RN · May 12, 2010

Yes, I think that is a great way to do it! Hopefully my hospital will have the protocols in place whenever child #2 comes along...

I noticed with each kid the overall pain got less, ESPECIALLY "down there", but man those after birth pains with nursing, by kid 4 I needed some heavy stuff to nurse. (just meaning more than motrin) it was worse then labor :|

~Mi Vida Loca~RN, ASN, RN · May 12, 2010

Agreed...I definitely think people with chronic pain have it worse, and are looked at more suspiciously. But it really bugs me when people can't use common sense to see "hey, this woman just had a baby and an episiotomy less than 2 days ago. I bet she might start having some pain if she doesn't get her pain meds, so let's be proactive about this. After all, the MD DID give a prn order (that did not say "prn for pain ratings greater than...")." It's not like I walked in the door and asked for a percocet 2 months after giving birth. Sheesh.
And back pain is rough...it's not like you can just 'rest' your back, you kind of need to use it for everything you do. Chronic pain is such a difficult condition to manage in our culture today, because it is almost impossible for MDs to tell the difference between true pain and drug seekers. And they are hesitant to try because everybody is so 'sue-happy'

Very much agree.

I had a patient that had PE, he was in a lot of pain but was trying to be strong. I tried to explain the importance of keeping his pain under control and how much harder it is to chase the pain rather then address it when it first starts up. It was his first time with any of this and he had toradol in the ER and said it helped but it was wearing off.

it was hardest for him in a laying position and he was going to have an EKG or EEG done (can't remember which) and any position other then straight up and down was increasingly painful. But he was afraid of becoming addicted and wouldn't take anything.

Well finally when he couldn't breath (effectively) he was willing to take something and he ended up having that vagal (crap it's late and I can't remember the name) response and went down. His HR dropped to 26 and they called RRT.

As soon as they got the pain under control he was better. He listened to me after that and it was nice as a student to be able to educate on something so important.

~Mi Vida Loca~RN, ASN, RN · May 12, 2010

My primary RN would probably not agree to pull out a Percocet if the patient said his or her pain level was 2. I wish pain medication was ordered round-the-clock rather than just PRN. That way it covers the nurse's ass with regard to giving narcs.

If pain was a 2 and Motrin was effectively controlling it than the nurses I have worked with would probably just try that again too, (if it was in the 6 hr frame). But I have never seen one of the nurses deny an opioid at our hospital for a low pain rating if everything was in parameters and it was asked for.

Usually the Motrin and the opioid are at different time frames and when the pain for the pt. is starting to come back it's to early for the Motrin so they will go with the opioid. At least that is what I mainly saw on the womans care unit where pretty much the 2 Rx on every ones chart was Motrin, perc and a stool softener.

crusec · Feb 27, 2017

I have the same concerns as you do. I have seen people taking more medication for pain than is safe for years. What it comes down to is that we as nurses are not allowed to judge such things even when it is obvious. I have come to the conclusion that I am just a stoke in the wheel. It is sad to say but that is the only way that I can look at it. As long as they do not code on me then I am force my law to give them what they want.