chronic pain patients: pain in the behind to care for

SK-222 · Jul 2, 2007

For starters; the side of effect of many of the opioid narcs will have the side of being irritable and some patient's ending up nasty and angry. It does burn me to see many patients who IMHO are over-treated, then others being undertreated. Surely an ORIF of the knee isn't going to feel too good and the meds were very necessary in her case.

EmmaG, RN · Jul 2, 2007

They are a challenge.

At the hospital I'd worked for before starting the travel thing, our pain management doc was superb. All of his patients were under contract; they knew what they were allowed to have, and they knew nothing else would be forthcoming. So they were actually easier to take care of than your typical 'drug-seekers'. They were monitored closely, and if they violated their contract in any way, they were dropped from his care immediately. So they DID toe the line.

But I know of the type of personality you speak of... very difficult to deal with. I have chronic pain issues myself, but I am not seeking treatment for it. I simply do NOT want to go down that road. Sometimes I get aggravated at the frequent flyer/drug seeking types (not those under pain management care) and all their histrionics. Especially the young ones. I'm standing there caring for a person 10 or 15 years younger than I am, in better shape than I'll probably ever be again, wailing and screaming over the least little thing and I have to grit my teeth. But that is my issue, not theirs. I realize that and try to let it roll off my shoulders.

I set limits. I make it known to them that I will provide them the medication that is ordered when it is needed. I find they tend to calm down a bit when they know I will give them what they need, rather than holding back as I've seen others do. It develops a sense of trust (to a point, anyway) and saves my sanity in the meantime.

EmmaG, RN · Jul 2, 2007

For starters; the side of effect of many of the opioid narcs will have the side of being irritable and some patient's ending up nasty and angry.

True. I drove my nurses nuts after my TAH. The doc ordered dilaudid, and for whatever reason it did NOTHING to relieve the pain at all. It made me shaky and crazy, almost to the point of hallucinating. I was on the call light yelling for pain meds literally within minutes of receiving the IV dilaudid. At some level I knew I was acting bizarre, but had no way of stopping myself. The doc d/c'd the dilaudid and ordered darvocet of all things--- and it worked. One would do me for a good 6 hours or so. Pain down to a low rumble, something I could manage, and I stopped acting insane. I was so damned embarrassed. Still am just thinking of the way I behaved.

I've seen patients have this sort of reaction at times. Certain narcs just don't work and/or cause them to act goofy. Switch 'em to morphine or whatever, and they're like a different person.

nursej22, MSN, RN · Jul 2, 2007

Yes, people with chronic pain are some of the hardest ones to care for, for several reasons. It is frustrating to have someone not respond as expected--I have felt indadequate about not being able to help these folks because that's my job, right? And then they are rude on top of it! So, I have learned I can't change their behavior or teach them manners, I am the only person I can change.

I try to establish some trust as well as just trying to get to know them. Sometimes people are hostile as a defense mechanism, in addition to just being irritable because they are in pain, unhappy, sleep-deprived and the effect of meds.

Also, what have they done in the past? Any non-drug techniques? Heat, cold, distraction, relaxation? I am probably not going to reduce their chronic pain during a brief hospital visit, but maybe I help a little with acute issues like post-op pain.

EmmaG, RN · Jul 2, 2007

One of our patients who was frequently admitted for pain issues (and was quite the pain too lol) came to visit our floor one day when she was 'well'.

What we saw was not the shrill, hateful, incredibly rude young woman we'd come to know... she was very soft-spoken, pleasant and gracious. She said she appreciated what we put up with from her and she just wanted us to see her when she was "normal".

It had quite the impact.

Hoozdo, ADN · Jul 2, 2007

I see more of a problem with pts that have high narcotic tolerances to begin with, they get admitted, come to my ICU, and the treating doctors are afraid to order the amount of narcotics that these pts need to control their pain.

I recently had a pt in with a thoracotomy/decortication/x3 chest tubes. Normally a pt with this procedure would have a PCA to control his pain and let the pt be in control. This pt was already taking 160 mg of Methadone at home! They cut his Methadone in half at the hospital and allowed marginal doses of Morphine Q6hrs. No wonder he was mad at the world, he got less pain relief than he did on a normal day of his life!

It sometimes takes a lot of guts to stand up to the Dr and advocate for the pt in these types of situations. They think "He's a narcotic addict, I am not risking my MD license by ordering what he need to relieve pain."

I tell them, at least give the amount of drugs you would a NORMAL patients. Give him a PCA, let him be in control. Geez, stuff like this really upsets me.

ERRNTraveler, RN · Jul 2, 2007

I see a lot of this in the ER, some who are genuinely in pain, others who are obvious drug seekers. If someone is genuinely in pain (it's easy to tell them from the fakers), I understand when they are crabby or needy, but I have NO patience for the obvious drug seekers (allergic to everything EXCEPT Dilaudid, ask you the dose before you give it, and no matter what the dose is, they already know that it won't help, wake up from a dead sleep to tell you their pain is still a 10.....). I have found it's the fakers who tend to be nastier to deal with- they are defensive, and nothing you do is good enough. People who are truly in pain, even if they are sometimes unpleasant, tend to be more appreciative of your efforts to make them more comfortable.

bethin · Jul 2, 2007

Hello,
Another question to throw out there: Why are most chronic pain patients "nasty" to deal with? They always have "attitudes" with the nursing staff. Most are downright rude to everyone who takes care of them. Many do not know the words "thank you" and are very demanding and critical of your care to them.
Sorry if I sound like I am not compassionate. I really am. I just came here because this is a safe place to sound off about these issues. If anyone out there has some answers, please, please post them.
I just want to understand better why these people act the way they do. Thanks.

I am glad you did not generalize all chronic pain sufferers as nasty.

I myself have chronic pain. I have Crohn's or ulcerative colitis (depends on who you speak to, doesn't matter both are painful). I have pain meds and have refused several dr's suggestions that I take something stronger. I HATE that dopey feeling after taking narcotics.

I'm sincerely trying not to be rude, mean, etc. but I have been hospitalized several times for my conditions and each time I don't want to be one of those pts who the nurses speak about. You know, "she's not really in pain" or "look, her eyes are closed so obviously she's ok". Well, when I'm sitting in a hospital bed with nothing to do I can either stare at the wall or close my eyes, listen to my iPod and picture myself on a beach relaxing. Just because my eyes are closed does not mean I'm sleeping. And somehow I always feel like I'm inconviencing them when I do ask for meds.

Because I don't want to be labeled 'nasty' or needy I go longer than I should without meds (just not to be labeled) and that does make me cranky but somehow I always say please and thank you. Yes, there are those out there who are drug seekers and they can test your patience. I am an aide so I see the nurse's reaction when I tell them so and so needs pain meds. Nine times out of ten I get eye rolling and a big sigh and then the messenger (me) gets a big loud rant. I find this very disheartening. Yes, I know that nurse carry a HUGE burden on their shoulders. There's charting, new med orders, computers and watching out for your license among others. And in no way am I am implying that you should hand their meds to them like you are Mary Sunshine, perky and skipping into their room. Just a little respect and I didn't get from your post that you disrespected your pts.

But please, please could we all stop talking about pts behind their backs?

I'm just asking that you look at this from a pts view (who isn't a drug seeker).

ERRNTraveler, RN · Jul 2, 2007

Just because my eyes are closed does not mean I'm sleeping.

True, but when a patient needs a sternal rub to wake them up, I have a hard time believing their pain is still a "10." Yes, they might still have some pain when they wake up, but if a pt is comfortable enough to sleep that soundly, there's no way their pain is still a 10.

bethin · Jul 2, 2007

True, but when a patient needs a sternal rub to wake them up, I have a hard time believing their pain is still a "10." Yes, they might still have some pain when they wake up, but if a pt is comfortable enough to sleep that soundly, there's no way their pain is still a 10.

Oh, I agree. When I wrote that "just because you're eyes are closed doesn't mean you're sleeping" is just what my coworkers think, not necessarily what everyone on this bb believes.

Yeah, if they need a sternal rub to wake up I think they may be doped up a little too much.

rehab nurse · Jul 2, 2007

I am a chronic pain patient, and it hurt to read your post. I know you may not intend to generalize, but it hurt to read the title of this post. I know you are not talking about me personally, but patients like yours ruin for those of us who are legit pain patients.

I am a cancer patient, so that has increased my pain, but let me tell you that I was started on narcotics 3 years ago for intractable back pain. I'm not going into all my problems, but let me tell you that my surgeon referred me to pain management, and he told me nothing will ever help me. So did 3 other surgeons.

I did the PT, the exercises, the heat and the injections, etc. Then I worked my way up the pain med ladder. And, for those of you who freak out, let me tell you I don't practice anymore. I don't want any PM's telling me I'm an impaired nurse like I did last time I responded to a post about chronic pain patients.

CP patients like myself are usually (at least in my area) sent to a pain management specialist, who is usually an anesthesiologist for any type of chronic, intractable pain that doesn't respond to conservative measures. I waited 6 years to go on any meds, and I waited too long. I am young too. I'm just 30 years old. Anyway, I am on these meds because they are the only thing that has proven to give me any quality of life, and therefore, my doctors think they are appropriate. I can barely walk, not without a cane at least. But these meds at least give me a pain level of 4 most of the time and they allow me to care for my children, my home, etc. I can get out of bed and for the most part, do what I want. If I didn't have these meds, I would not be here today, I know that for certain. If you've ever had pain so bad you couldn't walk, take care of your own ADL's, and it lasted for weeks on end, you would feel like I do. Now with my cancer, the pain is worse.

I am sorry for the way your patient treated you. But please know, we are not all like that!!! Some patients are appropriate to be prescribed long term opiates, but those are not every pain patient. It has to be weighed between doctor and patient, and has many factors to consider. In this area, no primary docs prescribe anything more than a short course of C-III narcotics. If a patient doesn't respond, they are sent to pain management, and they start the long road of PT, injections, surgeries, etc. It's not just a "here, you have back pain, so here's your 80 mg Oxycontin. Come back in a month, ok?". I know I can't speak for your area, or even all patients, but I just want you to know that not every pain patient is like that!!! I am not!!! I am a very compliant patient, and my doctors respect me for that. I may be a minority, but I know a lot of people who are in constant pain and they wouldn't be able to function without some type of pain meds.

I know I am rambling here. I hope this is not coming across as condescending, or rude, because that is not my intention, honestly!!! I just wanted to give you a reason that patients are prescribed opiates long-term, and also tell you that I am sorry you were treated horribly by this woman.

I should also say, that pain does horrible things to your mind, especially when it's not adequately treated. You can get very irritable, anxious and depressed. Chronic pain especially depletes the chemicals in the brain and causes depression, that's been proven time and time again. So, a lot of pain patients have psych issues hand in hand with the pain, and that may be why your patient had such a bad attitude towards you?? I'm purely speculating here.

Anyway, I want to thank you for being a compassionate nurse. And again I am sorry for the way you were treated. I just had to reply to you and give you my story.