LTC Drug Addicts - page 4

Has anyone else ever worked with LTC residents that were on a lot of pain medications but it was not clear why they were being given them regularely? I hope I worded that right...I'll explain... ... Read More

  1. by   BillArnold1961
    We have a couple of residents like the one that you described and two of them are <50 years old. We call the one "Ole Faithful" because she is at the desk asking for her PRN Lortab at the exact minute that it is due. It's so bad that we sign the meds out as soon as we come on because we know what time and reason she will give. The worst part is...she's a retired nurse(age <50). I'm 42 this year and the other person I was talking about is younger than me. I work everyday with pain and I struggle some days with pain. The only thing I do is concentrate on I'm taking care of my patients and if they're pulling the wool over my eyes, they'll answer for it in the next life.....One resident asks for her Darvocet and then asks if I think she's doing the right thing. I respond with, "If you are in severe pain, ask for the medicine, if not, don't" I try to divert their attention as much as possible but it always comes down to the pain pills. Pain management is a very difficult area to undertake whether with or without narcotic supplements in my opinion. If you find a sure fire way, let me know, I know of a lot of physicians that would be interested in the miracle cure....
  2. by   angelbear
    If I were retired and me or my insurance were paying for LTC I'd be danged if I'd fold laundry either. I am only 35 and I have already had my fill of folding laundry. The lounge chair and tv sound pretty dang good to me. I hope by the time I need LTC they have internet and I can still use it. That is what I am addicted to. And by the way if anyone cares I work 3rd shift and I would shoot you if you tried to make me get ready for bed at 6p or even 11p. When the time comes I do not want to be a 3rd or 1st shift get up I want 2nd to get me up. See what I mean? They have to conform their entire lives around LTC enviro. I say cut them some slack wherever possible. Hopping down off my soap box.
  3. by   moonshadeau
    Originally posted by angelbear
    ... I hope by the time I need LTC they have internet and I can still use it. That is what I am addicted to. ...
    My husband's grandmother is in a nursing home and wasn't I quite pleased that I saw that the facility is wired for internet. Each sunroom had a computer that any resident could use. There also is a computer room that had about 20 computers in it too.

    Then they also had all there residents sitting in the hallway all lined up in their wheelchairs waiting for nothing. I hate that, but that is another thread.
  4. by   ktwlpn
    Originally posted by moonshadeau
    My husband's grandmother is in a nursing home and wasn't I quite pleased that I saw that the facility is wired for internet. Each sunroom had a computer that any resident could use. There also is a computer room that had about 20 computers in it too.

    Then they also had all there residents sitting in the hallway all lined up in their wheelchairs waiting for nothing. I hate that, but that is another thread.
    We have many residents that sit in the hall in front of the nurse's station also-for various reasons.Approx 10 want to be there and most of the rest join them because they do not want to be alone...We purposely sit about 8 there daily for close observation-unless there is an activity going then we can not leave them in any of the other sitting rooms on the unit-too many falls and fisticuffs...In a perfect world we would have scheduled activities from 10 am until 8 pm 7 days a week -but I don't see that happening anytime soon...I also agree about folding laundry-I ,too am looking forward to NEVER doing another load-perhaps next time you can ask her to join the group just for the company-and offer everyone a cold drink,cup of tea or coffee...I think that maybe the staff now just do not like her-no matter what she says or does.....But we don't have to like our patients to give them the treatment that they deserve.(that's a good thing-I have known plenty that I would not SPIT on if they were on fire)BUt I gave them good care........
  5. by   BillArnold1961
    I agree with angelbear, if the nursing home has an internet hookup, I'll be no problem to anyone....and also, they better not wake me up period, I'll get up on my own!!
  6. by   pappyRN
    Hello All,

    What a great thread! Many points were made on which I'd like to offer my opinion.
    I, too am a chronic pain patient from an ojt injury lifting a small patient on a vent. It has now been 8 years since my life completely changed and mostly NOT for the better. It's a long and complicated history of RSD-CRPS/TOS/DDD/DJD/CTS/TMJ/OA/GERD/IBS/FMS/CFIDS/MPS/POTS/AI/SI joint dysfunction, bursitis rt shoulder, bilat. trochanteric bursitis, rt brachial neuritis, rt femoral neuritis and possible SLE so you see why I won't get into my own complicated hx to explain why I require pain management.

    I was thinking about some of the things that the staff finds offensive about this patient. I hope I can speak to some of them. I also have some comments regarding her physician.

    In regards to her medication. I can tell you for sure that in almost all instances oxycontin and ms contin do NOT provide adequate pain coverage for twelve hrs. As a matter of fact the pharmaceutical house of Purdue -Frederick is being taken to task for an explanation and/or solution to this very real problem. It is way closer to 7-8 hours that is the duration of these 'contin' meds. It is not at all unusual to experience nausea, sweating, etc. when either of these drug levels start falling. It is becoming more the norm for patients to have their dosing changed to every EIGHT hours to avoid this situation. I know from my own experiences. It is a reason why many on this med every 12 hrs are calling for a prn probably around 7-10 hrs after the dose was given. It is also indicative of the patient clearly being UNDERmedicated with their maintenace med. The dose of her maintenace med should be adjusted to either give it q8 hrs or increase the q 12 hr dose. It would be much better for the pt if a q8h dosing was initiated. IMHO, it is extremely likely that she is requesting her 4pm med before the med nurse goes to the dining room for a med pass, because she is experiencing this med level drop off and taking a prn is just enough to both relieve her breakthru pain and prevent the withdrawal symptoms from physical tolerance. In addition, she very likely knows that by the time the dining room med pass is done she will have to wait for at least an hour before they can get to her. That would just be a behavior she learned from being a resident. When you are in pain the minutes seem like hours and if you also have very little to occupy your time for distraction, 1hr may seem eternal to her. It is also a behavior that alerts to the very real probability of "clock watching" which can happen when a pts meds are not adjusted to provide continuous, steady state coverage. These drop- offs may be what's making her request her meds on a rigid schedule. That's why it is so important that a pt' s maintenance dose is adequate and that it has been adjusted to accommodate for tolerance to the dose especially if it hasn't been adjusted in quite some time.

    Someone said that it was also likely that she is aware of the staff's attitude about her. How right you are! I'm not even in an LTC and I have been on the hind end of attitude, opinions, intolerance etc. It is SO easy to tell when someone is not pleased with you. I am positive that she has endured not only "the look" from the staff, but has also overheard them.

    In an attempt to try and 'get into her head' I was thinking about possible scenarios. I appreciate that a few may seem far-fetched but still they can be possibilities. I'm just trying to be devil's advocate for a while. In regards to her looking away when meds are brought to her and to her behaviors in general,
    maybe she looks away for several reasons: she doesn't want to see "the look", she is about to cry and doesn't want you to see it, she tells stories because she feels she has to justify her need for the medication- it may have taken her so long to get her pain treated that she feels she has to have a story to legitimize her request, she may just be a drama queen with a flair to convince-her stories may seem perfectly plausible to her, maybe she feels guilty for needing them, maybe she fears appearing weak, she may be a rapid metabolizer and her level drops off because of it,she is proud and hates what her life has come to and on top of that she knows that staff doesn't approve of her need for her meds, and how about she may be AFRAID of what has happened to her, the staff is too busy to take the time to get to know her, it is humiliating to her to have to depend on everyone else to get her meds, the bedtime injection makes her drowsy more quickly and is just enough to fall asleep and therefore possibly not needing additional meds until her morning dose, maybe she is also afraid that her need for all this medication means she is addicted and she is worrying about that possibility because no one has taken the time to explain physical tolerance , pseudoaddiction from not being medicated either enough or undermedicated-withdrawal-TRUE addiction-and she starts feeling the withdrawal symptoms when the level drops off and that completely scares her that she is an addict, AND 100 other possibilities! I just think that it is important to realize that things like this situation can be very complex. It may have taken her YEARS to get to the point where anyone even remotely believes her about her pain for whatever reason including her spoiled child personality, so she is going to hang onto whatever relief she can get.
    The possibilities are ENDLESS but I believe that it is most likely that she is experiencing level dropoffs and therefore pseudoaddiction AND that it is probable that her scenario is a combination of many instances that I listed. One other thing I should mention, don't forget about the stigmas from her era about addiction when you ponder behaviors. Pride was a big issue back then and one strived not to do anything that could potentially embarrass their family or themselves and that too, may be an explanation if she is afraid of her need for pain meds. This could also be as simple as her doctor has never sat down with her and discussed the goals and intricacies of pain management as we know it today. It is more likely that he has had a simple and quick patroninzing discussion with her and doesn't want to take the time to help her understand these goals and he just wants to order her meds with little or no discussion. He, too, may mistakenly believe that she is very near the end of her life-however 67 is young by many standards. Try approaching the physician in a non threatening wasy so he doesn't immediately get defensive about this sensitive subject. Ask him to tell you about Mrs.X in order to better care for her. Decide that someone is going to work with her on getting her to open up and establish an atmosphere of trust and communication. Who knows when you get through that outer shell she may be a very pleasant woman to you. Does she have family or friends that visit her?

    I can not say it strongly enough- do NOT judge a person's pain by their outward appearance or on whether they are laughing etc. NO one with chronic pain has the energy to cry continuously for the rest of their lives. I have remarkable abilities to hide the fact that I am in pain. You see, when I have cried or grimaced etc. I get just as much flack and stupid comments like "suck it up. You are a strong person. You don't need to take pain pills. You just have to learn to live with this etc." So, you are darned if you do and darned if you don't. One person puts you down for crying and the other puts you down for NOT crying. What's the answer? BELIEVE the patient when they say they have pain. I try very hard not to cry because it is too energy draining but also because it makes my eyes swell and itch, my nose gets stuffy and I have to mouth breathe and I get a headache.

    Have someone volunteer to take the time to get to know this patient. Give her a chance instead of taking the easy way out by giving her the pain meds and then rip on her behind her back and sometimes inexcusably within earshot of being overheard by her. Wouldn't you be afraid if your fate was to be dependent on people that you KNEW disapproved of you and your need for pain meds? I think it would be frightening to wonder what was going to happen to you when you realized they think you are a fraud AND have the power to withhold your meds from you. No wonder she wants to isolate herself. Perhaps she's also afraid that the staff will embarrass her in the dining room in front of all the other residents. Perhaps someone already has and that's what started her wanting to eat in her room. Could it be that looking at others in the same or even worse shape makes her afraid that she really is getting old although maybe inside she doesn't feel that way? Maybe it bothers her to be eating around others who look so old and sick and who have to be fed or cry out. And maybe she simply enjoys eating alone! I can think of numerous reasons and possibilities that could be going on in her head. Why should she have to suffer when we are perfectly capable of relieving her pain except for the attitude and/or lack of knowledge about pain management from the staff that she is PAYING to take care of her? She expects to be taken care of. That is where her money is going.She has the right to expect good care. She is not a prisoner and it is a violation of her rights to refuse her request to take her meals in the privacy of her room unless she has a condition that renders her a choking hazard. Remember, this is her HOME. Would you be happy if someone came into your home but wouldn't let you eat there and made you go to the neighbor's house for your meals? Would it be acceptable for you to be forced to have meals in your home with people you didn't even know except in passing? That's what it is like for those confined in an LTC. I don't care what is done in regards to decor, it would NEVER be like home for me or my Mom.

    Every time I visit my Mom in the LTC where she is existing, I hear of yet another thing that was either denied or withheld from her. Things like-"you can NOT go to bed before 7pm in the evening. You HAVE to wait up until 6pm OR If we lay you down for a nap you HAVE to stay in bed for two hours!" So, she stays up in her w/c from 3pm until at least 8pm with NO change in position and she lays in BED crying because she wants to get up but knows they WON'T get her up since it is under two hours! This is done despite the reassurance from the admin and DON that she can NOT be forced to nap any longer than she wants and that she can retire for the evening at an hour of her choosing while understanding that she may have to wait a few minutes until her CNA is available.

    I think one of the best ways to approach a subject in order to better understqnd is to think of how you would feel if she was YOUR Grandmother or Mother and the staff treated her the way you say they treated this woman with chronic pain. Shame on them if they are guilty of being so quick to judge. Until you have walked a mile in someone's shoes remember this may be one of THEM one day who has to put up with living every day of their lives maybe even several times per day, surrounded by people they know don't care for them or that accuse them falsely without proof. And why? Because of the misfortune to be dealing with chronic pain. I wonder if they have ANY idea what it feels like to be in burning pain so bad that they could barely stand to move or even wear clothes because it hurts to wear them? Are they aware of what it feels like to feel like they are on fire from a simple gentle breeze blowing across their arm or leg or wherever the pattern of pain is? How about imagining they are 85 years old andhaving to sit in a w/c for HOURS(6am-1pm) with NO change in position? All this is while they are made to sit on the hip that was fractured under their CNA's care because of her carelessness in giving appropriate care to a 85 y/o post CVA hemiplegic.

    That's what it is like for my Mom.

    I cry every time I see her and every time I have to leave her there. The administrator is psycho and the DON is her DAUGHTER! It is pointless to attend family care conferences. IT is all a bunch of lies to satisfy some need on paper. They are chronically understaffed. The owner thinks the administrator walks on water.
    My sister and I pray every night that my Mom will pass peacefully in her sleep and this will all be over for her.

    Can I understand about this woman in pain? Yes, but more than I ever wish I had to.

    This was a great thread and in no way meant to be directed at you personally. I have been a pain long enough to try and get in this lady's head. While no one really can but her, I think I can get reasonably close.

    Warm personal regards,
  7. by   gizzy76
    thank you very much have opened my eyes even more to this situation...this woman's doctor is on an extended vacation right now and the doctor filling in for him has not even taken the time to see this woman at all in the past 6 months. I do plan on speaking with her doctor once he returns next month. Like I said before, I am trying to be more understanding of this woman. It's just so hard sometimes. My mother lives with fibromyalgia and always has different aches and pains and ailments. I'll admit that I may be slightly biased because of this...I am definitely trying to be more open though...It's a learning process for me...

    I thank you again for your post...
  8. by   kids
    Wonderful post Pappy, you have raised some very good points.
  9. by   nrw350
    Sounds like if I was in LTC, that I would want Pappy as my nurse lol! WAY TO GO PAPPY!
  10. by   dosamigos76
    Wow, thanks Pappy! I am hoping to start nursing school this fall and would like to work in LTC, and you have provided more motivation to do so. I am going to copy your post and keep it. Thank you so much for sharing your point of view and perspective.
  11. by   pappyRN
    Hello All,

    Warning!LOL I always have SO much to say. Please don't leave yet!Hehe!

    Thank you to each of you for your vote of confidence in my words. How very kind of you. I was really worried that my reply would be found offensive by some although that was NOT my intention. I appreciate the ability to have a healthy discussion without fighting or flaming etc. What a treat!
    I so miss the discussions I had with colleagues.

    With all of my heart, I hope to do everything possible within my physical limitations to increase awareness about not only reflex sympathetic dystrophy and fibromyalgia, but about chronic pain treatment in general. To be sure, I don't want to forget about promoting awareness of the experiences of LTC residents that are similar to those of my own Mom's.

    I only wish that I had the strength to be able to pursue these subjects with the diligence and vigor they deserve. I can't thank you enough for being a thoughful and considerate audience in letting me speak my feelings.

    I ask myself, why do I care so much about this subject? I can only conclude that deep within the spirit of this nurse's heart, I can not forget that I once pledged to dedicate myself to my pts. In my nurse's mind, I view almost everyone as a potential pt! Although technically my Mom and my sisters aren't my pts, I know that unofficially they would have been (and somewhat are) had I not also been ill. There's no doubt in my mind that you are all familiar with the concept of being the 'family' nurse. I lost count of how many times I have been called for advice which in most cases I willingly and lovingly gave.

    I don't think that being sensitive to the needs of our pts also requires a vast pool of knowledge. Rather, one can minister to them by using your intuition and conscience and by trying to empathize with their feelings and their situations. Just 'put yourself in their shoes'. In many cases it CAN be as simple as that. Is this how YOU would want to be treated? Is this how you would want YOUR MOTHER to be treated? If the answer is NO, then you know in your heart what needs to be done. I can't think of any other prerequisites other than basic human decency and kindness. Of course, it goes without saying that knowledge of the pt's diagnosis is thought to already be present.

    If the pt is displaying dysfunctional behaviors there is no reason to contribute fuel to the fire by projecting your behaviors of suspicion or intolerance on her. You may be unconsciously reinforcing her need to behave dysfunctionally and cause her to escalate her behavior. If this translates into the pt thinking "the nurse doesn't believe I'm in pain. Now, what can I do to show her the next time I ask for my medicine." This then encourages the pt devising ways to get you to believe they really do hurt.

    Instead of going along with what every reporting nurse before you has said or done, be different. BE the one who has the kindness,courage and conviction to go the extra mile! It would be unrealistic to think that you will always be successful. But I believe that in many instances you will. This is a fellow human being who for one reason or the other is hurting whether physically or emotionally or BOTH. Tend to their needs.

    It is entirely acceptable to reserve a spot for suspicions but save your suspicions for a situation that demands it. It is inappropriate to automatically think "addict" when you see that a person is taking regular medications for pain. It just shouldn't be your first thought UNLESS you KNOW this person to be an addict. You can save some room for it in the back of your minds if their are behaviors that point your thoughts in that direction. By no means do I intend to have you believe that you should NEVER be suspicious of whether or not a pt is an addict. But, give the person a chance. Don't decide how you feel about them before ever seeing them or talking to them.

    There are some general ideas I can share that maybe you don't already know if you have never had any experience with them.

    So, FYI: I am taking methadone for neuropathic pain from reflex sympathetic dystrophy aka complex regional pain syndrome, thoracic outlet syndrome and for two primary nerve injuries along with fibromyalgia, myofascial pain syndrome, osteoarthritis etc. to name a few of the pain syndromes from my alphabet soup of diagnoses. I was well managed on ms contin about 3 months ago and had been taking it for almost two years with few problems other than constipation. I took ms contin 60mg q 8h. Yes, I could still function on that dose. I am not 'opioid naive' and so would not most likely experience the complications and side effects that one who is not used to taking narcotics would have.

    FYI:I am now on methadone 40mg/day in two or three divided doses for the reason that the generic ms contin was cosing me $375.00/month OUT OF POCKET as i have Medicare and am on disability after a long battle with SS. I have just initiated taking this new dose. Methadone has a half life of approximately 30 hours so I haven't yet arrived at the period of time where I would be able to tell if it will make me two drowsy taking 20mg at each dose bid. I have instructions from my pain doc, aka PMP=pain management physician, to take 20mg in the am and 20mg at hs. If that dose makes me too drowsy then I am to go back to 10mg in the am, 10mg 8h later and 20mg at hs. I'll just have to wait and see what happens.

    FYI: Most pain patients do not experience a "high" from their pain med. Many studies have been done. They just experience relief and if not all the pain is taken away, hopefully even a fraction is. Whatever the amount is, they will gladly accept although they do reserve the right to need more medication to attain acceptable comfort.

    FYI: It is likely that pts who have been on opioids for a while will require higher than usual doses of a pain med and that it probably will be an amount that makes you uncomfortable administering. You'd probably be surprised at how much medication a longtime pain pt can take without experiencing respiratory depression. Of course, one still has to observe them for that possibility but normal breathing rates could be accepted as respiratory depression if the medication has worked and the pt is now blissfully asleep!We tend to breathe more rapidly when in severe pain.

    FYI: It is a MYTH that pts in pain can NOT sleep and that if they are, it must mean they really don't hurt that much after all. We experience a lack of deep, RESTORATIVE sleep. Just because we experience pain, it doesn't mean that our other bodily needs don't work to an extent although it is highly likely that the pt concurrently is dealing with some sort of sleep deprivation or disorder such as insomnia, restless legs syndrome and even narcolepsy.In my own case, I almost never drive anymore because I have a tendency to fall asleep. It's usually when I am stopped at a signal. I also know from experience that I can fall asleep in an instant if I am extremely tired from life or from my meds and there isn't ANYTHING that can keep me from dozing off. I have fallen asleep at my computer a few times these last couple of weeks. I woke up because my daughter awakened me. I had marks all over my face from falling asleep on my keyboard so being asleep is NOT a reliable parameter when observing pain pts.! Sleep is a blessing for pts whose medication isn't adequate to relieve their pain. Finding the patient asleep and who had just requested pain medication can simply mean that they either passed out or fell asleep from exhaustion associated with having to deal with chronic pain in addition to all the other activities in their lives. We get tired just as you do but we are also struggling with the drowsiness from our meds. It is entirely probable that the pt will also be taking adjunctive meds for his condition or for other illnesses he is being treated for. So, you have to factor in that possibility.

    FYI: Pts with fibromyalgia can also suffer from CFIDS-chronic fatigue immune deficiencysyndrome but it is not automatic that if you have one you have the other.

    FYI: Fibromyalgia or FMS can and is a very disabling disorder without proper treatment. Many physicians even to this day, question whether or not it is even a valid entity therefore making the diagnosis with these pts can be a very long drawn out experience. BUT...there is new research in which it has been documented that pts with FMS have a change in their brain MRIs as oposed to healthy pts. meaning a breath of relief that even our own docs may now believe our pain.

    FYI: FMS pts should be encouraged to do as much low impact exercise as they can tolerate. Aquatherapy is a great therapy for FMS and also RSD.

    FYI: FMS is just a problem where the pt has some aches and pains in his muscles. These are more than just aches and pains. They can even be of the intensity of other pain syndromes who's origins are neuropathic in nature. Although narcotics aren't the first drugs of choice in treating FMS, in pts whose pain is intractable narcotics are appropriate. It is very unusual to get complete relief. There is also joint stiffness.

    FYI:FMS pts may have significant cognitive difficulties lovingly referred to by some as 'fibrofog'. You will not have to be around the FMS pt very long before the cognitive problems play out before you. We forget what we are saying in the middle of a sentence, we forget what an object is called even if it entirely familiar to us, and short term memory problems are glaring in some cases such as my own. I am driving my family crazy because I repeat myself so much. I relate a story to one of them and the same day or 1 day later, I have absolutely NO recollection that we had spoken and about what. I have been working on this post for several hours-have to sit and think hard about what I want to say because I keep forgetting. I'll think of a point I want to include but unless I write it down immediately-POOF it's gone and maybe forever. It's taking so long also because I type one-handed due to rt sided RSD involvement.

    FYI: I still apply makeup even when I am feeling like I would rather do anything other than be awake. If you look too bad people say you are faking it or that they know someone with the same illness and THEY are doing so well so why don't you do what they are or they offer to have that pt call you to exchange war stories OR that it is just because of the drugs that you look this way and that if you would stop taking them you would get better along with all the other nauseating garbage they hand out like"you aren't trying hard enough to get better" and "you can do anything you make up your mind to do" and "pull yourself up by the bootstraps"?????? What the heck! Pull YOURSELF up as if this was something we WANT to have and we are just not trying hard enough!

    FYI: IF you look too GOOD: they say you couldn't possibly be as sick as you say you are and a whole other load of poop. etc. You can't win for losing.
    Remember, just because we are sick, some of us have managed to keep our pride about personal appearance. We can at least PRETEND to look normal although inside we may be screaming in pain.

    FYI: RSD and FMS/MPS are disorders that can wax and wane.i.e. one day you may feel so bad you are praying that you will be delivered fromyour hell and 2 days later you feel SO good you begin to doubt yourself that there is ANYTHING wrong with you and that you must have been imagining your problems only to find that for the next three days after that, you are again asking God what you did that was so wrong that you deserve to feel like you are feeling!

    FYI- Methadone is a med that does NOT lend itself well to large increases without slowly titrating upwards due to the long half life. It is also reported to be a living hell for anyone who has to withdraw from it without proper supportive measures and may even cause seizures and/or death if one is not withdrawn on a slow taper prescribed by a physician. It is definitely NOT a medication where a bolus is desirable due to the side effects.

    FYI: The Duragesic or fentanyl patch is another drug that is frequently ordered for chronic pain patients. It is said to be inappropriate for acute postoperative pain. It is also not a good choice for opioid naive patients as it has the tendency to make them very drowsy, nauseated, feeling dizzy and c/o HA. It takes approximately 16-17 hours from when the patch is first applied for the pt to feel it's effectiveness which is also referred to as reaching a 'steady state'. The patch must be securely against the patient's skin and not over any areas of broken down skin as this can effect the rate of absorption. The patient should avoid hot showers or baths and hot tubs(hehe-for all the LTCs who have hot tubs AND the internet!).Another very important note about the Duragesic patch is that if the pt has a temp 100 degrees or higher you should call the doctor. Temp elevations can cause the pt to absorb the medication 25% fster than if he had a normal temp. This should alert you to watch for symptoms of a dose increase. The doctor may decide not to keep the pt on Duragesic with a prolonged temp over several days. Some pts get a rash from the patch. That alone is reason for the doc to d/c it. The manufacturer has a program to provide free bio-occlusive dressings to patients who call their 800 # to report that they are having difficulty with getting the patch to adhere to their skin. IF you also tell them that your skin is breaking down from the patch, they will REFUSE to send the dressings and will instruct you to call the doc to d/c the med as it is their belief that a pt with skin breakdown should NOT be using the patch. Many pts have the trouble with the adhesive on the patch NOT sticking to their skin so don't let the company have you think it is NOT a common c/o because it IS. My Mom had been on Darvocet prn and Percocet prn for pain after several months after her hip fx. She was having a rough period of time with pain from her hip and also her shouder subluxates due to her paralysis and the CNAs don't always put her sling on her. I have to go in and put her shoulder back where it belongs because the nursing staff at the LTC refuses to 'since we aren't trained'. During that time we were watching my Mom yo-yo with drowsy vs awake periods from her meds. There was also a problem with her receiving her prns in a timely fashion from when she requested them. In otherwords, it would take the nurse an hour from when she asked for her med for the nurse to give it to her. She had also been requesting them on a very frequent basis. For whatever reason she had an exacerbation of her pain.I asked her physician to order chronic pain medication around the clock to avoid all the problems inherent with using only prn meds even though she had been asking for her meds more frequently during that period for the most part they truly were prn and not more than a few times per week. Well, he ordered Duragesic 25mcg patch. She was snowed for 3 days!!! She just couldn't stay awake! I had been hoping that he would start with a low dose of one of the contin drugs, perferably ms. It was a good example of why it is important to start low and make the doctor totally aware of just how much prn pain meds the pt is asking for. He can then make a decision based on that info. It is NOT unsual for a pt's primary care physician, PCP, to be the one to order these meds so that is another reason that the nurse should be educated about the intricacies and/or idiosyncracies if you will, in regards to pain medication. Remember, that MOST PCPs have very little knowledge of pain management. That's another reason to encourage the PCP to order a PMP consult. The goal is NOT to snow a pt but to make the goal be for the pt to return to the most functional state as possible. It makes a world of difference in how and what is ordered.

    FYI: Opioids have a propensity to make a patient nauseous. This can even happen after a patient has been on opioids for quite a while. So, some patients also take antinausea drugs on a prn basis. I have been on opioids for almost 8 years and I still experience bouts of nausea. My PCP had ordered Compazine prn but since compazine can cause tardive dyskinesia my PMP changed my med to Zofran-ouch it's expensive! (Read about tardive dyskinesia-never even heard of it until I saw something about it on a support group forum I participate in-it is very scary and will make you think twice before giving any drugs in the category of potentially causing TD).

    FYI: Another common complaint from patients on opioid is itching. I am not talking about hives or even a rash you can see. Applying calamine will not help. There is an overall bodywide itching that feels like it is deep in your skin that can and does manifest itself to persons on opioid therapy. It's like the itch that you can't scratch becaues you literally can't get to it to relieve it.
    For this, some take antihistamines or if they can be patient patients, it USUALLY goes away after a few weeks or months and only returns with dose increases or med changes. Don't worry unless you can see that the patient has hives or is complaining of dyspnea. If the patient is getting good relief from their med, then just try to encourage him that the itching may last for awhile but that it usually goes away. It may be tolerable for some and for others, intolerable and they have to d/c the med but only on a physician's order in case they need to be tapered off the med while titrating upward on the med replacing it.

    FYI: When a doc changes a pt's narcotic medication, be sure to ask him about the period of time while the pt is in the process of achieving steady state and d/c his previous med. Ask if he wants to give a few more doses of the old med while starting the new med so that the pt's level doesn't drop off before the new level can reach steady state. That overlapping time period has the potential for putting the patient in a withdrawal state.

    FYI: Be sure to ask the doctor if the dose of the new medication is equianalgesic to the old medication. It makes NO sense in starting a pt on a different drug because the old one didn't help the pain enough and then turning around and ordering a med dose that is not even close to the equivalent of the pt's previous medication. Would it make sense for someone who was taking 800mg of Motrin qid to be told to sstop that and then take 2 tylenos regular strength in the morning and at bedtime?

    FYI:The above scenario can frequently be an issue especially if the doctor is a PCP who isn't qualified nor experienced enough in chronic pain management established by criteria set forth by organizations such as the American Pain Society or the American Board of Pain Management Physicians practice pain management. Anyone can just call themselves a pain management physician but it is a far cry from a doctor who has also received the training and therefore the board certification.

    Well, I hope I haven't managed to bore you to death. I don't mean to preach to you but rather to share from the experiences of my Mom, sisters and myself. I hope it gives you another perspective on these subjects. I know that experiencing it firsthand sure changed my way of thinking about it. I am ashamed of myself for all those times when I was so afraid to give my pt anything other than the lowest dose of pain medication ordered. I hope I can be forgiven for covering my own hide instead of putting their comfort first before my own hangups about pain medications.

    The old saying "Walk a mile in my shoes" has not only given me new shoes but has served as a real eye opener.
    Thank you for taking the time to read my replies. I hope no one takes any offense. In addition, I have taken none from the many replies. This is a really good topic and to discuss it like mature adults is just a real pleasure. Thank you, again.

    Warm personal regards,
  12. by   gizzy76
    Thank you again Pappy

    For typing one handed, you must have an awfully sore hand now! My god! Thank you for the information...I am going to print your information and share it with a co-worker. She and I were discussing this tonight at work and she said that she would love to read the posts.
  13. by   Rapheal
    To all the people who are on narcs long term. Please remember to do what you can to keep up your abdominal muscles and to increase your fiber and fluids. I have been seeing way to many long term narcotic patients with bowel obstructions that require surgery. It makes me so sad to see relatively young people with colostomies.