Drug seeking or real pain? How do you tell?

[JudyPRN]

I'm a new nurse on the list so please pardon my ignorance. I was quite interested in the pain links and explored several and probably will use some for staff training. I did not see any mention of dealing with chemically dependant people who may or may not be having pain. I work in a mental health facility which also serves chemically dependant people. We have a constant struggle with determining who is in pain and who is drug-seeking. We have isolated a few cues, but over-all are probably treating the wrong patients. Does anyone on this list have ideas on this subject, who can steer me to a few resources? I appreciate all the help offered.

[psalm, RN]

The nurse should be using her critical thinking skills and assessing the situation/patient. There are some orders on the floor I work where the docs will write to withold a PRN pain or phenergan "if pt. is sedated". I then have to document the nonpharm I do/suggest instead of giving the med, the pts. reaction to not receiving the med, etc.

I find, not always, but most of the time, that the patient population that oldnewnurse46 is referring to, are the pts. who are very upset and act out until they get their med. Even sedated!! So that tells me something is going on there.

[Nurse Salt]

I find, not always, but most of the time, that the patient population that oldnewnurse46 is referring to, are the pts. who are very upset and act out until they get their med. Even sedated!! So that tells me something is going on there.

I completely agree. I had a pt once whose RR was 10-12, Sats dropped from high 90s to mid 70s and kept requesting Morphine. She was saccharine sweet to me until I decided it was in her best interest to hold d/t "excessive sedation". Then she had the nerve to accuse me of giving her saline and taking her Morphine. She even went so far as to tell the MD (who was no help, but that's a different thread). Good thing I had documented the heck out of my actions! Later during her stay she tried everything to get more meds and when she realized we were on to her, she began "falling" and threatening to sue. Too bad was seen by a maintenance worker (several times) positioning herself on the floor before she started screaming she fell... Unfortunately, every drug seeker will not be this obvious, but I think you will develop a gut instinct regarding these patients.

[nanacarol]

Your response supports my contention that documantation and communication between the doctor and nurseis critical in establishing a united front and valid treatment plan for this particular patient presentation. KUDOs to you and your team. nanacarol

[oldnewnurse46]

Doctor and pharmacy shopping are the objective tip offs. Also, when the pain mgt practice tells them they are no longer welcome for noncompliance. That's objective. The rest I suppose is nursing intuition. Now I work in the ER where all the addicts end up eventually with "chest pain" when they have exhausted all legal and illegal sources and they're really jonesing. So, that is the population I see.

[alwayslearnin]

Just another aside,

I know alot of people who are in recovery for alcohol/drug addiction. I wonder what their take on this thread would be? I have heard a number of stories about going from doc to doc, er to er using complaints of pain to get pain meds and using them to get high or selling them to get money for their "drug of choice" When are we going to quit medicating for pain for these people and treat them with honesty and true respect-sit them down and say,"you have a disease-lets talk about that and get you into treatment and on the road to recovery-not just keep writing out scripts. Ok, I don't think it is goodto generalize, but many of us who work in the ER have seen the addicts in action-its time to get honest

[Josh L.Ac.]

When we fire a patient, we do offer to taper them off for six days and also encourage them to do an inpatient detox.

There is always a choice.

[Patient]

"Vital signs will always show some reaction to pain."

Not necessarily. I've been a chronic pain patient for a few years, and in addition to opiate therapy I use self-hypnosis to keep me out of the hospital. I've seen too many nurses look cross-eyed at me and heard too many snarky comments to ever willingly set foot in a hospital.

Self-hypnosis actually works during a pain crisis, but it took me years to reach this point. My pulse and BP decrease to nearly normal when I'm in "a state." It doesn't help that my underlying condition is pretty much invisible. I have abdominal adhesions out the wazoo and live with pretty constant SBO, and as you know they don't generally show up on imaging studies. It makes no difference if I show up with 10 years of medical records proving my condition, some nurse or doctor will always believe I'm a drug seeker. No, I would rather die than go to a hospital - and probably will some day. At least then I won't have to deal with pain any longer - or doubting, second-guessing medical staff.

[jerenemarie]

i didn't see this thread before i posted my pet peeve regarding pain issues. i've always treated patients who ask for pain meds as the expert on their pain, no matter what the reason they are in the facility for. i work in a ltc facility, we have alot of short rehab patients for hip fx, etc. some of these people do have a hx of etoh abuse, drug use in the past. i look at it this way, they are with us for treatment of their current problem, if we don't manage the pain for the hip fx or whatever, they are not going to rehab to home as quickly as possible which is our goal. we are not a drug rehab. facility, we only look at their main diagnosis and treat it accordingly.

thanks,

jerenemarie

[10MG-IV]

RANT: I resent the 1-10 pain scale. we have to "ASK" which in my opinion is a "PROMPT" " on a scale of 1-10, 10 being the worst pain you ever have experienced, what is your pain now?" Of course the answer is 10/10. NOW I don't ask..... I chart what I see. I went to 4 years of school and have 30 years of critical care, I THINK I KNOW HOW to assess PAIN. SO,I chart what I see or hear, "none stated by "client" no facial grimace, skin w/d, watching TV talking on phone, no resp distress, chewing gum, eating chips, drinking coke,playing gameboy, listening to I-Pod, no vomiting, etc. you get the picture... and record the vitals which we trend. and I trend EVERYONE q 15 min I want them to get their $$$'s worth. :chuckle HA HA HA now, I know my Patient Demographics are different than yours and I have been selective on my rant. Not all Patients in pain are this way... THESE make me crazy, that is why it is a rant.....

@ Triage is insane! CHEST PAIN w/ back pain w/SORE THROATx3wks .. 10/10 THEY are talking on the cell, chewing chips,gum, drinking cola no obvious distress, no difficulty w/sitting standing,smooth steady gait. PAIN??? oh its a 10 yeah 10.(the day before the rock concert) Since they c/o CHEST PAIN....We do a "TIMI RISK card" boot them back to the waiting room ACCORDINGLY.

now the Acute MI,:redbeathe presents with SYMPTOMS nausea, diaphoretic, ashen, anxious,shallow or labored respirations, syncope, but they are in DENIAL BUT THEY tell me it is a dull ache, 3 or 4 "I think it's indigestion that burger I ate" GET THEM BACK NOW.... OH all the rooms are full of sore throats and back pains.......GO FIGURE!!!!!

Become a real EMERGENCY ROOM NOT A CLINIC.

MY OPINION..& vent..NOT A HUMBLE ONE EITHER....

[pggrn]

I gotta say, I have been to a few rodeos and my feeling is, "You just never know!"

Several years ago we had a fellow come into our ER that I would have sworn was totally drug seeking. He c/o abdominal pain and then said, "I need a shot." The I would ask him anotehr question and he said, "I need a shot." He always came back to his premise statement, "I need a shot."

So, what would anyone think? Drug seeking, right? Well anyway, we sent him for x-ray and he had quite a bit of stool, but not by far the worst I had seen. Anyway, the doc says, "Give him a couple of soapsuds enemas." I almost said something about going to a plan "B" but it was late and slow and I thought what the heck, at least when he meets up with his other drug seeking buddies at the local pub he can tell them, "Jeez, you wouldn't believe what you gotta go through to get a shot of Demerol over there!" So, anyway, by the time I finished with his second soapy 3-H enema (and I made sure they were the epitome of the 3-H enema) he came walking out of the bathroom and said, "I don't need any shot, I feel fine now." Ten minutes later he was walking out the door a happy camper!

Like I said, you just never know! But on a closing note I have to say, it is one of my better stories that I like to tell.

[CapeCodMermaid, RN]

I am the expert on me. I know when I'm in horrible pain and when I'm not. I know what works for my pain and what doesn't. I've been a patient more than once and have had to argue sometimes with the nurses to get non-pharmacological relief from pain. Was in the hospital...post op...Morphine pump...had a killer headache. I knew it was from caffeine withdrawal so I asked for a cup of coffee...use the morphine the charge nurse kept telling me. I told her it was a caffeine withdrawal headache and I just needed a cup of coffee NOT morphine...she wouldn't listen and actually harrumphed at me and left the room. One of the student nurses heard the exchange and got me a cup of coffee from the nurses' lounge. Headache gone. Sometimes you really gotta listen to what the patient is telling you.

[morte, LPN, LVN]

I am the expert on me. I know when I'm in horrible pain and when I'm not. I know what works for my pain and what doesn't. I've been a patient more than once and have had to argue sometimes with the nurses to get non-pharmacological relief from pain. Was in the hospital...post op...Morphine pump...had a killer headache. I knew it was from caffeine withdrawal so I asked for a cup of coffee...use the morphine the charge nurse kept telling me. I told her it was a caffeine withdrawal headache and I just needed a cup of coffee NOT morphine...she wouldn't listen and actually harrumphed at me and left the room. One of the student nurses heard the exchange and got me a cup of coffee from the nurses' lounge. Headache gone. Sometimes you really gotta listen to what the patient is telling you.

can we say an apt student of the science of caring?