Do you ever feel like we are contributing to the creation of addicts

[Nola009]

... By scheduling opiate / opioid analgesics Q 4 hrs post-operatively for weeks, and weeks, which turn into months during their Skilled Nursing / Rehab stay... only to send them home with a script for one month's worth?? And who knows how long they will remain on until the prescribing physician cuts them off?!

I have heard about countless otherwise unlikely heroin addicts who went from taking Percocets or Norcos post-op, and got addicted, so they bought the same pills on the street, and when that became too expensive to keep up with, they started using heroin.

In school we were taught to medicate at the first signs of break-through pain so that the patient would end up using less pain medication overall.

Do you think we should be educating patients more about the possibility of addiction to these prescribed pain pills as well?

http://www.oprah.com/health/Lisa-Ling-Investigates-Americas-Heroin-Epidemic

[OhioCCRN, MSN, NP]

Why is a lap chole even in the hospital overnight? Here we discharge them home on ibuprofen within 2 hours. I'd never prescribe a post op lap chole a narcotic analgesic.

In response to the OP, yes I believe we as prescribers are definitely responsible and for myself, I'm doing my best to stem the tide. I cut off far more scripts than I provide. I almost never renew opioids or benzodiazepines when patients transfer to me from someone/somewhere else. I never initiate benzos, ever. I avoid narcotic pain relievers and I don't prescribe sedative/hypnotic sleeping pills. My staff are amazed when they see me give someone 10 T#2 tablets. I use ultram on occasion, but I don't typically write for more than a dozen tablets. I don't even rx any codeine cough syrups. Nor do I rx amphetamines for weight loss, and I don't treat adult ADHD at all. Nor do I prescribe those drugs for kids unless there has been a complete neuropsych eval and the patient was initiated and stabilized by behavioral health first.

The overdose on the 6:00 news isn't going to have my name on the bottle next to the body.

Consequently, all the drug seeking patients go elsewhere. I can usually predict which patients I will never see again after the first visit, lol.

YOU ARE MY HERO!!!

[lmccrn62, MSN, RN]

Blue devil it would not want to ever be your patient. I don't think your views on prescribing are in the best interest of your patient. If you assess,monitor and have frequent follow up there shouldn't be a problem.

[BuckyBadgerRN, ASN, RN]

OMG, yes!! I work in rehab, I swear I have half a hall who do nothing but watch the clock for when they can have their next pain pill. To cut down on so many PRN's, they started scheduling narcs at regular intervals, with PRN's for break through pain. Want to guess how many utilize that PRN back up? I know, we cannot be the judge of someone else's pain, it's completely subjective. But, we've got one woman who now is racking up the falls, personally, I think it's b/c she's high as a flipping kite!!

[lmccrn62, MSN, RN]

Then she isn't being managed correctly. A good practitioner does the right thing and doesn't just feed opioids. I use adjuvants because opioids are not necessarily good for every type of pain. Having a psych eval is helpful as many patients have a underlying anxiety and depression.

[BuckyBadgerRN, ASN, RN]

I don't disagree. She's refused a psych eval, we all agree she needs one.

[toomuchbaloney]

Are we likely contributing to addicts?

Perhaps in some cases.

Is the alternative to avoid giving pain medications that may be abused?

Is it okay for patients to have chronic health conditions which make them dependent upon a pharmaceutical as long as that medication is not an opiate?

[Nola009]

Are we likely contributing to addicts?

Perhaps in some cases.

Is the alternative to avoid giving pain medications that may be abused?

Is it okay for patients to have chronic health conditions which make them dependent upon a pharmaceutical as long as that medication is not an opiate?

I give my scheduled narcs as close to on time as I possibly can, prns asap per request. Im not refering to ltc pts here, more post-op pts who take so many while in the hosp and maybe even more during their snf stay. In class, we were taught to keep ahead of intense pain so that less is needed overall. I see stories of people who became addicted to opioids following a surgery, then ended up buying them on the street when their scripts dried up all the time. Some even go on to use heroin. Do drs or anyone else educate pts regarding the risk of addiction?

[SubSippi]

I don't think narcs should be withheld from people who actually need them. I do, however, think they should be prescribed with a plan in mind, as a short term solution while a long term goal is trying to be met. This doesn't include those with a painful, terminal illness. If someone only has a short time to live and wants to be comfortable, they should be.

The problem I see with pain med seekers is that they still always seem to be in pain. Maybe increasing dosages will help for a very short time, but for those looking for a long term solution narcotics are ineffective.

People seem to want a short term fix for everything. They don't want to spend time going to pain clinics, exercising, getting steroid shots, and everything else it takes to work with doctors to find something they can actually live with.

[toomuchbaloney]

I don't think narcs should be withheld from people who actually need them. I do, however, think they should be prescribed with a plan in mind, as a short term solution while a long term goal is trying to be met. This doesn't include those with a painful, terminal illness. If someone only has a short time to live and wants to be comfortable, they should be.

The problem I see with pain med seekers is that they still always seem to be in pain. Maybe increasing dosages will help for a very short time, but for those looking for a long term solution narcotics are ineffective.

People seem to want a short term fix for everything. They don't want to spend time going to pain clinics, exercising, getting steroid shots, and everything else it takes to work with doctors to find something they can actually live with.

Are you assuming that people are not actually in pain?

Do we assume that our medical efforts to eliminate, reduce, or eliminate pain are always acceptably effective? Do all prescribing providers have the same level of knowledge and expertise in pain management?

[BuckyBadgerRN, ASN, RN]

I can relate two incidents that I've experienced in the past few days:

Resident A asked for PRN vicodin, as nurse went to retrieve med, therapy came to escort resident to session. They passed by the nurse desk and resident was giddy, laughing and joking with therapists so nurse asked resident if she'd still like the pain pill. INSTANT light switch, resident began to grimace, hold her head and proclaim how much PAIN she was in, she "could hardly stand it".

Resident B's spouse came to nurses desk wanting to know why her husband didn't get his 5pm pain pill. It was explained that it isn't a SCHEDULED pain pill, if he feels like he needs one, he can have one, etc. The wife poked her grinning husband repeatedly and said "tell them you need a pain pill!" He asked why? The nurse asked the happy, smiling resident to rate his pain, he looked at his wife and said "Oh, I guess maybe an 8". So he got his pain pill and the wife's parting words were, you can have another one at midnight, be sure to ask for it! And to us "because you won't wake him up for it, I'll bet!". She's right about that!

So while I DO believe people have very real pain, I also think that clock watchers are being bred every minute of every day.

[suanna]

LOOK OUT- LONG RANT!

Addiction, tolerance, and dependence are all facits of narcotic use that can and will happen with prolonged use. They are different from ABUSE. Narcotics are the most effective, best tolerated type of analgesic for many patients- both those with acute and those with chronic pain. If you use a narcotic for any prolonged period of time you are going to find you are going to require dose increases to accomplish the same pain relief the longer you are needing pain ,management= tolerance. Addiction can happen fairly earily in the use of narcotics- but that doesn't mean the patient not still in pain and needs to have that managed. Craving for the medication in absence of pain, physical withdrawl-tremors, sweating, aggitation, HTN, tachycardia= withdrawl. and are a good indication that a physical addiction has developed. It dosen't mean the patient doesn't need thier pain managed as well. The symptoms of withdrawl are painful and may themselves require NARCOTIC intervention in to resolve the pain. My real question is if the drugs are interfering with the patients participation in a normal lifestyle to lesser extent than the pain was/would be- aren't the drugs the better answer.

Beta blockers are great for controling HTN, but if a patient is on them long term, they are going to require higher and higher doses to accomplish the same effect, and if you hold them suddenly they are going to go into "withdrawl" beta blocker rebound, with dangerous tachycardia and HTN. I don't see nurses holding Beta blockers for this reason.

PLEASE- just because a patient has a prolonged use of narcotics- don't turn it into a moral issue. Our job is - Are they in pain? Is what I have ordered effective for controling that pain? And, if you see indications of drug seeking behavior, withdrawl, and excessive tolerance- What alternatives can I offer my patient to manage thier pain that is less likely to have negative side effects. It isn't right for the nurse to decide independant of the patient that narcotics are "bad drugs" and refuse to give them or to try to "wean" the patient off narcotics just because the nurse has set that priority.

[rheath222]

What about people with low pain tolerance? I have a very low pain threshold. I have had appendicitis, and cholecystis in the ER. They did a Ultrasound in the ER and couldn't find any stones. They still gave me pain meds, Hida scan showed gallbladder was at 24%.

Also, I have CPRS in my R arm. I got it from a injury I sustained from a resident two years ago. My hand DR and his PA thought I was faking it and refused to acknowledge my pain and swelling. It was excruciating. I though about chopping it off myself. Yes, I am young, have had quite a few surgeries for my age, and quite a bit of pain meds. Pain is subjective. You can't tell me how much I'm hurting, I would be very upset if all I had was a tramadol for my arm pain (when it gets really really bad I get ketamine infusions ). I have gone to the ER crying in pain because of my gall bladder and arm. You can't deny someone's right to pain relief just because you THINK they could become a addict or dependent. That's not right!!