Drug seeking patients?

kids · Jun 9, 2002

I'd much rather get it for a migraine than Demerol!

Nubaine has always stopped the pain where as Demerol makes me feel stupid and cranky...and in pain.

caroladybelle, BSN, RN · Jun 9, 2002

I have a history of ulcerative colitis - full bowel involvement, per biopsy result - for 13 years. I have very well controlled GI disease w/asacol and holistic treatment. Unfortunately, I do have the erythema nodusem/autoimmune mediated febrile arthralgias at times. As this is an inflammatory problem, the only drugs that will ease the pain are Anti-inflammatory drugs. Unfortunately, virtually all anti-inflammatory pain meds cause GI bleeding and are generally contraindicated in UC.

I have had several MDs order narcs for me (doesn't relieve the pain well but makes me too stoned to care) and wonder why that don't work. There are times that I would kill for some Toradol, but they won't prescribe it for me. Anaphylactically allergic to Tylenol - respiratory arrest. So most of the time, I just stay at home, and take Ibuprofen on my own.

With Demerol, you really have to worry about normeperidine (metabolite) intoxication/overdose? - it can happen after a few doses or after many - it is very insidious and unpredictable. Demerol is not a good drug for pain at all, but I have had plenty-o-docs order for me and other patients.

pappyRN · Jun 19, 2002

Hello,

This is very long, I'm sorry but it's necessary.

I am new to this BB and this topic really caught my attention because I am a chronic pain patient.

Over the course of the last seven years of chronic, unrelenting, burning neuropathic pain I have been on the butt end of health professional's attitudes regarding treating pain pt's pain.

A little bit about me to understand from where I come.

I was working in a busy NICU/SCN in a local pediatric hospital when I got "pulled" to the transitional care unit(PICU step down). I had been a nurse for 23 yrs when I was injured lifting a patient on the vent- he was only 35 lbs but for whatever reason it caused me to have a neck and rt shoulder injury. The house supervisor told me she would write up the incident but never did. By the time I found out that she hadn't my opportunity to file for WC had expired-30 days in my state.

My doc treated me conservatively with Rx and ice then heat. Eventually, he finally agreed to PT at my insistence because I was getting worse. He gave me Skelaxin and told me to take Ibuprofen for the pain. PT just made me worse by the day and especially when one of them got the bright idea of doing cervical tx. My doc refused to let me off work during this time.

About 3 months after the injury, I began to have color and temp changes in my rt arm and hand(dominant side). The nature of the pain began to change to burning and if anything or anyone touched my arm it would hurt and that sensation wouldn't go away for several hrs only to let up and come back. I was diagnosed with Reflex Sympathetic Dystrophy also now known as Chronic Regional Pain Syndrome.

Several months later as trophic and sudomotor changes continued to worsen I had an EMG/NCV. The temp of my fingertips was 69 degrees and my shoulder was 81 degrees. During this time I was accused of malingering and making it up. The neuro said it was because the room was cold. Doc finally prescribed Darvocet. Didn't help. Was referred to NUMEROUS specialists and given NUMEROUS dx and didn't know whom to believe.In between, I had numerous nerve blocks, epidurals, stellate ganglion, lumbar sympathetic etc. that did not give relief for more than a few HOURS. Finally, saw an OS who was a cervical spine specialist. Had ACDF at C4-5, C5-6 for spondylosis and nerve compression. He sent me to the National Institute for Neurological Disorders and Stroke. I underwent diagnostic testing which basically along with clinical symptoms confirmed my dx. Next had surgery for shoulder decompression and acromioplasty. Was told I had neurogenic thoracic outlet syndrome and would need extensive PT and surgery along with another shoulder decompression. Doc also did a sympathectomy which proved to be a disaster because the pain returned with a vengeance.

I was at the lowest point of my life in excrutiating pain. I suffered nerve damage to my brachial plexus and also phrenic nerve damage so even breathing was difficult.

I also had tachycardia and chest pain during this time. After a cardiac cath I developed a pseudoaneurysm which to this day I believe would have been prevented or discovered sooner if I had not had a nurse who was "pulled"! I was hemorrhaging and underwent a vascular repair 2 days after the cath. During the repair I also had a huge whole in the saphenous vein repaired. Then the doc LIGATED my FEMORAL NERVE. When I woke up I was screaming in unbelievable pain. Guess what??? They BLAMED IT ON ME because "you know, you pain patients feel things worse than most pts."!

Again, 2 days later at my insistence a groin exploration was performed where it was discovered that he had made a bad mistake. He even had the decency to CHARGE ME for the surgery to free up the nerve.

The RSD spread from my abdomen to my toes- internally a Pap and pelvic causes horrible pain- my leg and foot turn blue and are swollen and freezing at times. I have lightening jolts of electrical sensations stabbing me without warning. My clothes are almost intolerable to wear. I've been back to NINDS to participate again in diagnostics and the researcher was also able to make some suggestions regarding meds for the tachycardia and the profuse sweating that is present in episodes numerous times per day. A good day is when I only have to change my clothes 4 times.

I also have Fibromyalgia/CFIDS ( 16 out of 18 positive tender points), Myofascial Pain Syndrome, Postural Orthostatic Tachycardia syndrome, and suspected lupus.

Did I engage in "clock watching?" You damned right I did. It's called pain behavior and it happens when a pain patient is undermedicated! It also happens because most short acting narcotics begin to wear off in 3 hours and most patients realize that it will be a while from the time they ring their call bell until the actual time a nurse comes to their room with their pain medicine and that's IF the nurse is given the message by the person answering the lights/intercom.

Now about Oxycontin and MS Contin. Thank God for those meds. I am now on MS Contin. It allows me to take the Rx on a regular schedule only 2-3 times/day instead of every 3-4 hours. It's easy on the liver. It helps to keep the pain as manageable as possible. Addicts are responsible for their own behavior and will do almost anything to get their drug of choice for the high it causes. Pain patients just want relief from pain.

Do I fear my pain? Yes, I sure as hell do and you would also if you felt like you were on fire- it's now in 3 quadrants of my body. Thank God it is transient in my left arm.

Please don't judge me for my pain. It has come at a HUGE SACRIFICE. I am unable to work at what I loved and dreamed of all my life. I no longer have the income and I do not have Rx insurance because my husband lost his job and I am on Medicare with no Rx benefits. My medicine costs almost $600.00/month OUT OF POCKET. I am unable to do things such as camping, tubing, and all the fun things I used to do. My husband has to cut my meat- yes, even in restaurants.

Our families have had to suffer right along with us and watch us become someone they don't recognize from the toll pain takes on a person. They are immensely relieved when meds such as Oxycontin and MS Contin allows us to go out once in a blue moon.

What have I learned and what do I suggest? Definitely, that Palliative and Hospice care should be taught in nursing and medical schools. Nurses should be taught that if they are going to say something about pain patients or people using pain Rx's- KNOW the difference between PHYSICAL DEPENDENCE, TOLERANCE, and ADDICTION!

Don't try to guess if I'm in pain or if I FEAR it. It is inappropriate for you to guess unless you know for sure or strongly suspect misuse. If you see behavior that causes you to be suspicious then document it and confide in the doc. You demean patients when you automatically suspect them of abuse without reason or evidence. TRUST ME, WE ALREADY FEEL TERRIBLE ABOUT OURSELVES BECAUSE WE HAVE TO TAKE THIS MUCH MEDICINE TO FUNCTION.I would bet that sometimes when nurses think the doc isn't listening to them- that the doc really is ignoring you if you are using the wrong terminology. ADDICTION is absolutely different than PHYSICAL DEPENDENCE.

Clock watching is something all pain patients do until they are on adequate pain management if ever they are. A lot of us are on very large doses of morphine or codeine, methadone, etc. Doses that probably scare you but they make us functional so we can sometimes get out of bed and experience some joy in our lives.

Since pain is now the "5th vital sign" you owe it to your patients to educate yourself as much as possible about pain management and the terms that are used. Schedule an inservice with a pain management physician.

Until I have personally gone through this horrendous experience I was guilty of all the same behavior as some. I think back a long time ago when a doc may have ordered Demerol 50-100mg for a postop patient and that I probably chose the lowest dose because I was opiophobic and terrified of "overdosing" the patient. But, the patient suffered because of my ignorance and naivete.

Most of us are really frightened of what is happening to our bodies. I certainly never thought that I would be in this shape at age 49. Pain meds allow me to hold my grandson for a few minutes.

I'll trade places with anyone who wants to volunteer.

I am not looking for a fight nor do I need one. My purpose in replying is to try to help you see the other side from a fellow RN.

Please do a search on Reflex Sympathetic Dystrophy or Chronic Regional Pain Syndrome if you are unfamiliar with it. You might be the person who someday sees the symptoms in a patient when the doc hasn't been able to.I'm at the point in my life when I will no longer feel that I have to apologize for my pain.

Most of the time you can't see a patient's pain unless you look very closely at things like facial expression, guarding, body language.Just remember if you judge a person harshly about their pain and need for medicine that someday what goes around comes around. I hope you don't ever have to find out the hard way what it feels like to be left in terrible pain without hope for relief because someone doesn't believe you or accuses you of being a drug seeker. Even pain management physicians have a hard time telling with some and they have way more education in the matter than nurses get.

Thank you for allowing me to express my opinion. Again, I apologize for the length.

Warm regards,

PappyRN

Fgr8Out · Jun 19, 2002

OK, I'm not even going to finish reading all of these posts. I am simply going to (yet again) remark on the primary complaints/concerns nursing seems to have with medicating patients who they feel are "drug seeking" and try to dispel myths and provide education so that those of you who still have this negative mindset can put your little minds at ease.

First, I want to squash the part of this thread in which certain nurse(s) feel Nursing is responsible for deaths attributed to drug overdose, in particular, oxycontin abuse. Drug abuse and death have occurred for centuries, even before Nursing existed. If not oxycontin, then another drug will be utilized. Yes, oxycontin prescriptions have increased but not all of this is due to drug abusers. It's a great drug for it's purpose. Period. Misused, it most certainly can be lethal, as can any narcotic. But again, to imply that Nursing is to be held accountable for any deaths attributed to the "abuse" of this (or any) drug is complete BS.

"Drug Seeking Behavior" - "No healthcare professional has the right to deprive a patient of appropriate assessment and treament simply because he/she believes the patient is lying...When the care giver conveys to the patient that the report of pain is not accepted, this amounts to accusing the patient of lying" (M. McCaffery, Fall 2001). The term "drug-seeking" is a label and a nonmedical, derogatory term. A "myth" and one that Nursing itself perpetuates. We (the collective "we") expect our patients to "act" in a certain way to demonstrate they are having pain. Could this not be the very reason our patients begin to develop behaviors such as clock watching, grimacing when we are in their presence, moaning and the like???? If Nursing notes a patient happily engaged in conversation with family or friends, there is an automatic assumption that the patient must not be in pain. Let's remember that talking, laughing, joking, CAN be coping mechanisms for someone in pain. Thank GOD because, can you IMAGINE how stressful it would be for everyone if those in pain spent their days writhing in pain, audibly moaning and crying out loud???? "Lack of pain expression does not necessarily mean lack of pain!" (M. McCaffery Fall 2000). I don't know about the rest of you, but when I have a headache, backache, toothache or other condition that causes pain, I head straight for the Ibuprofen (tylenol, aleve and the like) to hopefully reduce or alleviate the pain. Guess that makes me drug-seeking, huh?

Remember, too, that sleep or sedation is not an indicator of pain relief either. Many of the medications we give our patients (phenergan, droperidol, benedryl) produce sedative effects which can lead Nursing into the false sense that a patient isn't in pain when, in fact, they are very much in pain and simply unable to awaken enough to be eligible to receive further narcotics. "Sleep or sedation may be mistakenly equated with pain relief, but patients in severe pain can fall asleep; sedation isn't the same as analgesia. In fact, patients may use sleep to help control pain" (AJN).

With regard to sedation/respiratory depression... Nursing needs to understand how to assess sedation and properly use sedation scales. Watching an individual's response, particularly with the first dose of an opioid, is the safest, most effective way to administer an opioid (M. McCaffery Fall 2001) adjusting the dose of the medication as warranted. "No patient has succumbed to respiratory depression while awake" (APS, 1999, p.23).

Nursing is known also to use the label of "addiction." Opioid addiction is a disease and the official DSM-IV term is substance dependence. The definition is: "Psychological dependence. Pattern of compulsive drug use characterized by continual craving fo an opioid and the need to use the opioid for effects OTHER than pain relief (or for non-medical reasons) (M. McCaffery, Fall 2001). Additionally, there is Physical Dependence and Tolerance. The latter two can occur in patients who receive long term narcotic treatment for pain, but this does not negate the fact that these individuals may continue to experience pain. In the case of someone who has developed Tolerance, "tolerance to analgesia may be treated with increase in dose." So long as a patient is able to tolerate an opioid without significant respiratory depression, they may be safely medicated. Again, refer to the earlier reference on assessment of sedation/respiratory depression.

Another misconception is the idea that there is no known physical cause of pain, or when pain is chronic rather than acute. The cause of pain can't always be determined. Deal with it and treat the patient's report of pain. You don't have some magical, infallible assessment tool so accept what data you do have... the patient's report.

Personal Bias - Whether we want to believe it or not, our own personal biases do exist and they do have an impact on the care of a patient in pain, sometimes with a negative effect. Physical appearance, gender, age, race/culture and our own personal experiences all help to develop our own definition and attitude regarding the presence of pain. People whose lifestyle conflicts with our own morals/ethics may trigger a bias and affect the way in which we care for them or accept/deny their report of pain. Is this a basis for good Nursing? Absolutely not.

As Nurses, we are in a position to provide the very best care for our patients in pain, assuming we have the proper tools in place. Let's not allow misconceptions, biases and myths to cloud our minds. Accept and act on the patient's report of pain; proceed with appropriate assessment and treatment.

"Although I was probably fooled by some patients, I never failed to help someone who did have pain" (M. McCaffery, Fall 2001). Good motto to follow.

fab4fan · Jul 4, 2002

1. Vital signs are not accurate indicators of pain.

2. Behavior is also not an accurate way to measure pain; pts. will do things to distract themselves from pain.

3. Sleep/sedation does not equal pain.

4. Misleading a pt by giving NSS IV push and letting them think it is a pain med is ILLEGAL; placebos MUST be given with pt consent. You will have no leg to stand on if a pt finds out and tries to sue.

5. Calling someone a "drug-seeker" is an inflammatory a judgemental statement, and is considered inappropriate in any of the reputable pain mgmt. materials.

6. Everyone, including addicts, has a right to appropriate pain control; there may even be times when giving an addict a narcotic for a limited time may be appropriate and even necessary; again this is in reputable pain mgmt literature, e.g. AHCPR guidelines, ASPMN literature, etc.

7. Pain is whatever the pt says it is, and exists whenever the pt says it does--M.McCaffery MSN, RN

8. In line w/ #7, the pt self report of pain is the most reliable indicator of pain.

fab4fan · Jul 4, 2002

Whoops, I meant to say the sleep/sedation does not equal pain RELIEF.

Sorry!

nursegoodguy · Jul 6, 2002

As a nurse if they have an order for pain meds then I will give it as long as I don't think they are in jeopardy, but... There are drug seeking patients PERIOD!

pappyRN · Jul 8, 2002

In my never ending quest to search for possible new treatments for my diseases and conditions I frequently search the net as do a lot of patients. In fact, the internet is somewhat responsible for my being able to finally get diagnosed. Now mind you, I have seen over 40 physicians in the last seven years and as I replied in the above post I have run the gamut from accusations of faking, malingering, making it up because I'm a nurse, making it up because I found it on the internet, etc., to finally being believed. I'm sure you get the point.

You know, I think it is really sad that I cried with JOY when I finally got all my diagnoses: Chronic Regional Pain Syndrome types I and II (aka reflex sympathetic dystrophy), Fibromyalgia/CFIDS, Myofascial Pain syndrome, POTS, Dysautonomia, Aortic Insufficiency, Neuritis/Neuralgia, Brachial Plexus Neuritis, Long Thoracic Nerve injury, Thoracic Outlet syndrome, Phrenic nerve injury, Bilateral Trochanteric Bursitis, Impingement syndrome rt shoulder, Cubital Ulnar Nerve Entrapment, Carpal Tunnel syndrome, Degenerative Joint disease and Degenerative Disc disease, Facet Joint Disease, Uncovertebral Joint Spurring, Cervical Spondylosis, Herniated Thoracic and Lumbar Discs, Bulging Cervical Discs, Sciatica, Meralgia Paresthetica, SI Joint Dysfunction, Plantar Fascitis, Occipital Headaches, Femoral Neuritis, Insomnia, GERD, Vestibular Neuronitis and possible Lupus. Oh, I forgot- and Depression.

Why would the above cause me to feel even a shred of hope or joy??? Because I thought the suspicion and accusations would stop!!! I could finally get treatment without being judged. Wrong!!! For the most part my disabilities are invisible as I don't flash my extremities with the swelling and discoloration. Yes, I have a handicap placard and I only use it when I absolutely have to. The only reason that I can even go anywhere or do the little driving that I do is because I am on MS Contin and MSIR. Because I don't "look" sick I get stares and sometimes even cruel comments and arguments from people who don't think I have the placard legally. They get told to blow it out their a$$. I'm not shy.

I am unable to tolerate any of the anticonvulsants such as Neurontin and Tegretol etc. because they render me incoherent which defeats the purpose of taking them. I can completely attest to the fact that at least the TCA antidepressants such as Nortriptylin and Elavil DO have an impact on the pain, not a lot but I'll take whatever I can get. I was really a skeptic at first but I'm a believer now.

I can assure you that even though they are not supposed to help at all with neuropathic type pain the opioids are the only things in the way of pain meds that have helped. In a more perfect world my dose would be raised at my next office visit with the PM doc because I have been on my present dose for almost 1.5 yrs.

Behaviour such as clock watching is a sign that a pain pt. is undermedicated. As a matter of fact, UNDERMEDICATION is a huge problem for most pain pts. We try our best to avoid ER's -at least most of us do, to avoid the judgement, the looks, the suspicion. When I call the Pain Service the doc on call usually ok's an additional rescue dose and says see your doc at your regular visit. In the last 4 years I have only called twice and that's because my husband said he would call if I didn't. I've sobbed in excrutiating pain, begged for God's mercy, and prayed for SLEEP rather than having my husband take me to the ER. Yes, SLEEP. I have learned to live with the pain while I sleep, when I sleep and IF I can sleep and STAY asleep. It doesn't mean I'm not hurting but more than likely I've passed out from exhaustion. Actually, sleep is a legitimate coping mechanism.

I am reminded of it every time I roll to either side and even when I am on my back. My rt shoulder blade is so winged that it protrudes from my back onto the mattress and caues pain and pressure. I am unable to sleep on my abd because of adhesive capsulitis and limited cervical ROM.

So, if you see a pain pt sleeping don't be suspicious and think that all is well- be happy that the pt was able to get some merciful peace from the agony but they are very likely to still be in pain. It takes a LOT of energy to try to employ cognitive behavioural techniques and distraction to avoid letting yourself FEEL how much you hurt.

I will go to great lengths to NOT let you know that I am hurting as badly as I do. I won't scream, grimace, or attempt to PROVE to you that I hurt. Why? Because it is degrading and demeaning and I'd like to retain my pride- integrity also prevents me from having to put on a show. I am an honest person and I'd much rather be in pain at home in miserable pain than having to report and repeat my extremely lengthy history ad nauseum for the gazillionth time only to be met with the "look". I have exhausted every possible intervention, modality, and cognitive behavioural technique before I give in and ask for additional help because I've been burned. At this point my trust has been severely tested. You know, I can't even stand to repeat my own history and have to listen to it myself!

This experience has motivated me to do all I can to let docs and nurses see it from the patient's point of view from "one of their own". Sometimes I am appalled at the resistance but that won't stop me from trying to advocate for myself and patients in pain. Those jerks that have abused these very necessary meds have set pain management back so far- but it really wasn't that far ahead to begin with! LOL!!! It's so aggravating that their irresponsible behaviour makes it so hard on people like me.

What has really hurt has been the disbelief from my fellow colleagues. I spent 23 yrs. caring for others but when I needed it the most I was horrified. Please be compassionate and try to think of the impression you will leave on your pain pt. I know there are patients who take advantage of you. I am asking you to open your minds and your hearts to those of us who are legitimately in need. Remember, you might not be able to see our pain but at least give us a chance to tell you why we are there without judging us before you've even talked to us for a while.

If I can help even ONE pain patient avoid the doubt and suspicion of their complaint, then I guess I will have succedeed. My heart is just broken that I am too ill to practice nursing ever again. You are so lucky that you still can even though many times it is tiring and exasperating. At least you can still go there and experience what nursing is all about.

While searching the net I came across some info on one of my favorite pain sites.

http://www.pain.com

There are several excellent articles about pain and pain management.

Dr. David Marley on "Opioid Addiction and Abuse"

The CME/CE section entitled " Care of the Patient with Pain"

and I encourage you to read the "Ask the Doctor" section. Check out the "Ask the Doctor" archives.

AND I would be remiss if I didn't ask you to read about Reflex Sympathetic Dystrophy now known as Complex Regional Pain Syndrome typesI and II and also Central or Thalamic Pain (aka Shoulder Hand Syndrome- sometimes happens after CVA's or MI's - it's a form of RSD). It is extremely difficult to diagnose and is far more common than one realizes.

One more thing- check out the articles on preemptive treatment of pain where it is discussed doing incisional blocks and epidurals before a pt's surgery to avoid being bombarded with pain signals. There's even an interesting article about treating pain in premies.

So if I can do my part to get the word out- so be it!

I thank you for your patience or impatience if that's the case for reading my lengthy replies. I am so happy to have found this site to be able to converse with other nurses even though I can no longer practice. I am amazed at the number of injured/disabled nurses.

Warm personal regards,

PappyRN

MollyJ · Jul 8, 2002

Originally posted by fab4fan
1. Vital signs are not accurate indicators of pain.

2. Behavior is also not an accurate way to measure pain; pts. will do things to distract themselves from pain.

3. Sleep/sedation does not equal pain.

4. Misleading a pt by giving NSS IV push and letting them think it is a pain med is ILLEGAL; placebos MUST be given with pt consent. You will have no leg to stand on if a pt finds out and tries to sue.

5. Calling someone a "drug-seeker" is an inflammatory a judgemental statement, and is considered inappropriate in any of the reputable pain mgmt. materials.

6. Everyone, including addicts, has a right to appropriate pain control; there may even be times when giving an addict a narcotic for a limited time may be appropriate and even necessary; again this is in reputable pain mgmt literature, e.g. AHCPR guidelines, ASPMN literature, etc.

7. Pain is whatever the pt says it is, and exists whenever the pt says it does--M.McCaffery MSN, RN

8. In line w/ #7, the pt self report of pain is the most reliable indicator of pain.

Margo McCaffery has done so much for the problem of pain eval and management and I am really glad she is practicing and researching, but to me there is a problem. Her mindset creates a framework where no patient can be regarded with an index of suspicion for addiction, no evaluation can be contemplated, no referral can be made. Addiction is a legimate and common health care problem. Public Health officials tell us it is all too common. For nurses to fail to address addiction IS AS EGREGIOUS as neglected pain management. Addiction is very destructive to lives, families, and communities.

The problems of patients are hardly ever black and white and so we _cannot_ say there are no legitimate patients that fail to receive adequate pain relief. We also cannot say their are no addicted patients requesting narcotic pain relief. Life sure would be simpler if we could say either one of those things. Just as false reporters of child abuse, rape, and almost anything else complicate pictures, so do addicts who do manipulate the system for pain medicines.

Now lest some of you object to the phrase "index of suspicicion" above. This term is a fine and not prejudicial term. It describes the ability to think broadly about a subtly presenting but often devastating health care problem. ER nurses must always have an index of suspicion for ectopic pregnancy in females of child bearing age with lower abdominal pain. If they don't, they will miss this subtle presenting problem. So they must suspect it in the "mayor's" teenage daughter and the respectable married woman who's hubby had a vasectomy and the widowed peri-menopausal woman. Let me tell you those can be uncomfortable situations, but if the nurse and ED doc don't do it, someone can die. We work to increase our index of suspicion all of the time on subtle but devastating health care problems like the woman's unique presentation of acute MI, acute aortic aneurysm and child sexual abuse.

However, here we have a framework that practically forbids us to have an index of suspicion for addiction, an all too common and devastating problem. I find that disturbing.

Now my ideal world IS NOT one where nurses run around acting on hunches about addiction and confronting their hapless patients right and left. Being the person who has possession of the narcotic keys (and power over them) requires compassion and thoughtfulness. However, patients with chronic pain need pain management by a single doctor or group of docs and they need to understand their obligation to not doctor shop and to stay within the rules of their pain contract, which should include a plan for breathrough pain. Nurses who interact with patients that tick their "index of suspicion" for addiction should document, document, document and communicate with the primary care giver. If they can have a positive relationship with the family, they may come to understand the dysfunction or lack of dysfunction that addictive vs functional behavior can create in a family, though I would guess that families that deal constantly with a member's chronic pain experience some of the problems related to families coping with chronic illnesses (a no-brainer, right?)

Gee, i wish we could make a sweeping pronouncement about addiction and say that it does or does not ever occur, but it really is more complex than that.

pappyRN · Jul 8, 2002

Hello Molly J

I agree with you about the "index of suspicion" and to fail to address the issue of addiction would be egregious. Pain and the failure to treat it and it's udermanagement is also destructive to lives, families, and communities. I guess where I feel the most sensitivity regarding this issue is when judgemnetal behaviour is projected on the patient right from the start without even having any information except a personal bias. I did not mean to imply that addiction should never be suspected.

Fortunately, there are nurses such as yourself that would hold your index of suspicion to yourself until you have made your assessment. There are also nurses who wear their suspicion on their sleeves before you have even had a chance as a patient to open your mouth. They look at why you are there, see "pain" and out comes the attitude.

By the time that pain patients get to the point where they have finally been diagnosed as accurately as possible they have been to several different doctors- this has been documented in many studies. In my own case, what looks like "doctor shopping " is NOT the case.

Yes, I have seen over 40 different docs over the last seven years. In all but 3-6 occurences right at the start of my " diagnosis seeking " with a cyanotic, cold very painful arm I have been REFERRED to almost every one of the docs I have seen. The exceptions are at the onset of the RSD symptoms when my primary , neurologist, and neurosurgeon had NO answers and accused me of making it up. How in the world can you make up fingertip temps of 69 degrees and shoulder temp of 81 degrees measured while having an NCV/EMG? ( the neurologist accused his assistant of turning the a/c too low and reprimanded her right in front of me!) I knew something was VERY wrong with me but I kept being told that I was making it up or faking it. The other changes in docs came with insurance provider changes.

I can see where this might appear to be "doctor shopping" to some but if time is taken to elicit a fair and complete history there are also the circumstances when insurance changes necessitates changing pcp's and specialists who are managing (now that's a relative term!) care. For the most part I went in the direction the docs pointed me- kind of like being a hot potato getting passed around. By the way, each one had a different diagnosis to add to the confusion- mine included.

Your analogies are great and make perfect sense. I would hope that more staff would develop this mindset. You have obviously been provided the knowledge to understand that each entity is a separate problem. You either took the time to educate yourself or it was provided to you by another source or both and more. Nurses who are faced with these issues in their areas of practice have a responsibility to seek clarification through education.

I wholeheartedly agree that there are addicts and people who would go to any lengths to obtain their drug(s) of choice. Personal experience with family members and when I was working in NICU provided the opportunities for me to witness it firsthand sometimes. The hospital where I practiced was a large, pediatric, tertiary refferal hospital locatecd in the city. Our patients ran the entire economic spectrum and proved for any doubters that problems with drugs was not an entity confined to a lower economic bracket.

There is so much room for education regarding both the issues of pain management and addiction. Let's hope that as time goes on more nurses will be amenable to learning and understanding the difference. It is a very frustrating issue for all involved. After my experiences I just wanted to explain from my point of view what it feels like to be labeled unfairly and incorrectly. It felt wrong and I felt the need to speak up regarding a patient's perspective.

If by some miracle I was ever able to return to practice I would hope that my experiences would help me bring to the table some greater perspective on the matter to make an assessment based on all of the ways an accurate assessment should be made.

It is apparent in my zeal to attempt to provide further depth and understanding that it seems like I feel that most nurses don't take the time to get the info from the pt or that I am naive about the possibility of addiction. However, I think it is just a reflection of what happens when a nurse doesn't take the time to educate himself/herself about all of the issues. There can be a significant amount of emotional damage that may inhibit a patient from seeking the necessary treatment because they are afraid of repeating a very negative experience. It is exactly why I will not go to an ER when my pain has flared despite all interventions that I have employed to get it under control. I've had many hours of mind numbing pain that could have been helped but wasn't because of my own hesitation to avoid all the hassles it involves to seek emergency treatment for pain.

I hope that none of you would have to experience some of what I have. But if you do for your sake I hope your nurse will be educated and informed regarding pain management vs. addiction and will not inflict personal biases on you.

Hopefully, the pain patients bill of rights and sincere efforts on the part of hospital's etc. to provide the education needed for nurses to make good decisions will shed some necessary light on this problem and will spare some patients a lot of misunderstanding. I think Margo McCaffery's intentions are to basically tell nurses and doctors to hold back the index of suspicion until the facts have been explored but not to indiscriminately provide treatment. She seems to be saying to give the patient the benefit of the doubt. By looking at me you would never guess that I am a pain patient. I make every effort to wear nice clothes and makeup in an attempt to feel halfway normal. The only way one would know would be to look at my arm and to interview me or to touch me- now that would definitely get a strong reaction.

Thank you Molly J for taking the time to reply. I appreciate your views. You are obviously very educated regarding addiction and have provided some excellent analogies.

Warm personal regards,

PappyRN

MollyJ · Jul 9, 2002

Pappy,

To me "doctor shopping" is when a patient is getting narcs from 2 or more doctors and those doctors DO NOT know that another doctor is prescribing narcs for that patient. This is how addicts keep a ready and complete supply of narcs on hand: multiple sources. Complex care patients often have multiple specialties involved and ideally they all know about each other and interact and, for the outpatient, only one of the those docs does the pain management.

fab4fan · Jul 9, 2002

There was nothing in my post that stated that addicts don't exist; what I was saying was that many of the things nurses use to label someone a "seeker" are not accurate measurements.

For that matter, to call someone an "addict" is to make a medical diagnosis...nurses do not make medical diagnoses. Usually, the term is used arbitrarily and in a derogatory manner.

Pts. with chronic non-malignant pain usually try very hard to look "normal". This winds up being a double edged sword: Look too good, and no one believes your pain is that severe...look bad and you're overdramatizing your symptoms.

Even "doctor shopping" may not be a hallmark of an addict. People with chronic pain have usually tried multiple doctors and multiple meds...I prefer to think of them as being "pain relief seeking", something that I don't believe is a crime.

I work in the ED, and yes, there are people that are looking for their fix. But I don't believe it's my job to determine if someone is an addict or not...there's not enough time to do the kind of evaluation that's needed, and again, this is a medical determination.

I live with a chronic pain condition, too; unless you have had these labels tossed at you, you will never be able to understand how truly devastating it is. I am so very thankful that after 15 years of suffering (in silence, a good deal of the time, since no one wants to hear about your pain) I was able to find a doctor who had the intelligence and compassion to realize that I needed relief.

If you have any doubts about someone requesting pain meds, ask yourself this question: Will providing pain medication improve this person's quality of life. It won't, in an addict. In someone with chronic pain, it usually does...it lets them get out of the house, go back to work, socialize, etc.

Pts. with chronic pain don't usually experience a "high" like an addict does...pain pts. will usually have no idea what you're talking about when you refer to it. That's because the drug is relieving their pain...there's nothing left over to give a "buzz."

True addiction rarely occurs in pts with chronic pain. Tolerance does occur, over time, but tolerance is a physiologial reaction, it is not addiction. So when someone says that his/her pain med no longer works, please don't assume addiction.

Obviously, this is a topic that stirs a lot of emotion. I would just ask that we use care and discretion when suspecting addiction; it is a complex illness that cannot be made in a cursory eval.