Prescription pain meds and their abuse by pt's.

[Stormy62]

How are each of you dealing with patients who are abusing prescription medications? There has been so much emphasis put on the patients right to pain control (over the past ten years or so). I understand and agree with this belief.

However, there are also many, many patients who (although not always a planned thing on their part) have become addicted to prescription pain medications.

I know clinically how we handle this (pain agreements, referrals to alternative pain control specialties such as massage therapy, psych counseling, etc), but my question to you all is: How do you personally deal with this on the patient level. We are trained as nurses not to "judge", yet I find myself growing increasingly angry at these patients who knowingly abuse there medications and then come in to the doctors office early for more. I feel I am being "played" when they hand me a line about losing there medications or tell me "they were stolen". How do you as nurses in both the hospital setting and office setting deal with your own feelings about their abuse of their medications?

[LasVegasRN]

KristiWhite, great post.

We can assist in identifying TO THE PHYSICIAN that there may be an issue, but not for me to decide if the patient should be "cut off" or not.

To cover yourself, document OBJECTIVELY what you have observed. This means being non-judgemental. Everyone here should know the signs and symptoms of an impending overdose or acute drug reaction of which to alert the physician.

How to deal with your emotions with perceived "drug-seekers"... I agree not to let their issues become your issues. Perceptions can be wrong and it is up to the PRESCRIBING physician that you have contact with to make the final decision on those medications.

[Fgr8Out]

Addiction exists...granted

Tolerance to opioids also occurs...this is not an addiction, however. People in pain deserve to have all avenues for pain control examined, until something that works for them is found.

In settings such as Hogan describes (Clinic), I'm completely unfamiliar with the protocol for prescribing/dispensing. But neither of those is a function of Nursing, rather of Physicians and Pharmacists. I can see no liability for Nursing, unless it is Nursing that is actually administering the medications. In those cases, the JCAHO protocols include observation for sedation. When I have a patient too sedated to safely administer a drug...I don't. And I explain to the patient the rationale. I also advise the physician that the current pain management isn't effective.

Are you liable for a physician prescribing or a pharmacist dispensing? I don't think so. If you have suspicions, I expect you would address this with the physician. Document your observations if they warrant. If you think the physician is not acting responsibly, address it with the local AMA. You're limited in what you can do in either direction.

[canoehead, BSN, RN]

If someone "loses" their prescription can we not have them rate their pain in the office, have them tell us when the last time they took the med was, then send them over for a lab draw for opiate levels, and prescribe accordingly?

On another note we've had a woman on a morphine PCA who consistently rated her pain a 9-10 out of 10. She would wake and push the button. Well one night her RR was down to 8, she would take a gasp of air every 10 seconds or so and push that damn button. Would wake to shouting, rate her pain a 10, and then immediately pass out again. Her symptoms, all except for the pain, resolved when she was taken off the morphine. (Or when her evil nurse nudged the pain button a bit out of reach). And extreme example, but the pain control advocates won't even acknowledge the most extreme cases or make recommendations to deal with them. That woman would have let us medicate her to death- and how would that play to her family?

[MollyJ]

This is always an interesting topic and I probably posted on the previous mentioned thread.

Pain problems can only be dealt with individually and severe and unalleviated pain ALWAYS demands re-evaluation.

However, I agree with Canoe and Stormy that there are a segment of clients who are getting their meds from as many sources as they can cultivate and using them all over the place and some of them are medically facilitated addicts. I also LOVE what Canoe says about the pain experts just don't have much useful to say about how to deal with them. Addicts need caring confrontation but the long and short of it is that alot of these addicted individuals have simply burned out their families and they just want them making the least amount of noise. In short, there is not enough energy in the system to affect change.

When I have teens who are in trouble with their chemicals but their is not enough energy in the family system to encourage change, the bottom line is that not much happens. When a medically addicted client is facilitated by family and doctors and there is not enough energy in the system to affect change, likely the status quo will prevail until something changes. However, nurses do have the obligation to document that patient gets narcs from multiple sources (which can be a violation of a pain management agreement) and routinely uses excessive doses. This can happen for a variety of reasons (inadequate pain mgment plan, new disease, OR escalating addiction) but the nurse should still document it.

The large and the small of it is that the problem of pain includes the over-treated and the under-treated and the addicted. Telling a hundred legitimate stories of the under-treated does not eliminate the fact of the addicted. However, looking at this aspect of the problem right now is not fashionable and hence we have the robotic thinking, "if a patient claims pain, treat it." This works fine for probably 95 to 98% of patients, but there is a segment of clients for which it is overly simplistic.

As holder of the narcotic keys, the nurse should always give the patient the benefit of the doubt but keep your eyes and ears open and document.

[Fran-RN]

Canoehead, you said this ladiy's symptoms went away except the pain,. What was done about the pain? Or were you inferring that there was no pain?

I will never forget the 18 year old I took care of as a student nurse. He had been in a car accident and had a fractured tibia. I was told in report that he had a" problem" with drugs and not to medicate his pain except with APAP. This guy seemed to me to be in genuine pain but what did I know. I talked to my instructor and finally the MD/ Surgeon came in and removed the cast. The smell just about knocked us all out. the whole calf was necrotic because the cast had been too tight. I don't know what happened to this kid but he was in pain and because he was labeled as having a drug problem he did not get appropriate care. This experience taught me a valuble lesson.

[Pammy]

Pain, as we all know, is highly subjective; and "normal" and "expected" outcomes of pain medications will vary for each individual.

In my line of work, I deal with pain management daily. When I assess my clients, I dig to determine what "type" of pain they are experiancing, in order to get the "right" type of med to relieve that pain. Narcotics may work well for organ or sever muscle pain, but they don't always work for neuropathic pain (we use Elavil for neuropathic pain with fantastic success). My point is, that if your client is "eating" pain meds, see if you can help him determine what KIND of pain he is experiancing; changing to a medication that will actually help may be all that is needed. (While we can't prescribe, we can pass on information to the physician, yes?).

Some of your clients probably are "addicts"; but before we give them that label, we need to look at the whole picture. I had a client who was using two weeks worth of Morphine in one week, and then said his "sister" got into them and that she was an addict. This man had a terminal dx and a variety of conditions; he had various types of pain. After a more in depth investigation, I found that he had organ pain, arthritic pain, anginal pain, and neuropathic pain. He was not sleeping at night due to pain, and was taking extra Morphine to try to sleep. We started him on some Xanax at bedtime, some Elavil at bedtime, some Ultram BID, and an NTG patch. No more stories, no more overuse of narcotic meds..and he admitted that he only told the stories out of fear that we would take away his pain meds.

My husband fell a couple of years ago, and has four lumbar discs that are messed up. He had to go to a "pain management" doc to get pain meds, after surgery was ruled out for him. This doc is an hour and a half away, and the only one around my area. The doc started him on Oxycodone 2x day, then took that away when the scare of lawsuits came up. He switched my hubby to Norco 10/325 ONCE A DAY.. and will not budge on that dose. If my husband needs more during the day, he suffers because the doc will not refill. This is pain management???? My hubby has to work, because SSI said that "pain" is not a disability... imagine my husband's back pain after he works on a golf course all day. These pain specialists are OVERLY cautious, because they fear lawsuits and addiction. In my opinion, they are under-educated and overpaid. If they would look into the TYPE and intensity of the pain, they could better treat it without most clients overusing pain meds.

[Fgr8Out]

Canoe,

It seems to me that a Morphine PCA was not the correct choice of medication for this patient, or perhaps she needed an adjuvant to help with an aspect of her pain that was not alleviated by the morphine.

If she says her pain was a 9/10, then that is EXACTLY what it was. Don't confuse side effects of opioids, such as sedation, with the idea that the patient should to all intents and purposes, have controlled pain. Perhaps an anti inflammatory such as Toradol was warranted in addition to the morphine. Maybe this patient would have faired better with Dilaudid or another opioid.

Pain IS subjective...nursing needs to remember this. And analgesics are NOT "one size fits all." Please try to remember this, too, when dealing with an individuals pain management

IMHO, from one of those "pain control advocates/pain experts."

Peace:)

[nursejer]

I personally agree with the fact that patients are allowed, and taught to abuse pain meds. However, pain is so subjective that it is not our job as health care professionals, to decide if a patient is abusing a drug, or if they are truly in need of it for pain control. On another note, patients may not appear to be in pain, or may not be in pain at all because their pain has been well controled from the pain meds they are taking.

[shay]

Umm, not to sound stupid, but isn't it a true physiologic condition where some people really and truly do not have opiate receptors and so certain pain meds honest to God don't work?

Just asking y'all...I'm ignorant.

[Fgr8Out]

Originally posted by shay

Umm, not to sound stupid, but isn't it a true physiologic condition where some people really and truly do not have opiate receptors and so certain pain meds honest to God don't work?

Just asking y'all...I'm ignorant.

::nodding:: And it's just as true that people can develop a physiologic tolerance to opiates and require a higher dosage than what we might generally see in the acute care setting. Opiates do not have a "ceiling" and can therefore be tolerated in increasing amounts in patients.

I disagree that we as members of the healthcare industry create addicts. Addictive behaviors are psychologic, and have been researched and clinically proven to be due to a variety of factors. Whether someone is addictied to narcotics, smoking, food, sex or whatever, addiction is a separate issue from true pain management issues.

Yes, we've all experienced those individuals who are psychologically addicted. These people are certainly difficult, if not impossible to manage. But please do not confuse psychological addictions to those of tolerance, poor pain control, or side effects of either the pain medications themselves, or some of the non-effective adjuvants (i.e. phenergan/inapsine) which are given to supposedly "potentiate" the narcotics effects, but in actuality generally only serve to further sedate a STILL poorly controlled patient in pain.

One additional comment. Patients in pain will learn whatever behaviors it is we expect in them, in order to obtain the amount of medication necessary to attain adequate pain relief. Think on this: How do YOU expect a patient to act in order for YOU to believe they are in the amount of pain THEY are describing?

THAT is exactly how they will very quickly learn to act....

Peace:)

[MollyJ]

Link to NIDA web site for their report on Prescription Drug Abuse

http://www.nida.nih.gov/ResearchReports/Prescription/Prescription.html

Here is Former Director Alan Leshner's introductory letter on the topic:

From the Director

Most people who take prescription medications take them responsibly; however, the nonmedical use or abuse of prescription drugs remains a serious public health concern. Certain prescription drugs - opioids, central nervous system (CNS) depressants, and stimulants - when abused, can alter the brain's activity and lead to dependence and possibly addiction.

An estimated 9 million people aged 12 and older used prescription drugs for nonmedical reasons in 1999; more than a quarter of that number reported using prescription drugs nonmedically for the first time in the previous year. We would like to reverse this trend by increasing awareness and promoting additional research on this topic.

The National Institute on Drug Abuse (NIDA) has developed this publication to answer questions about the consequences of abusing commonly prescribed medications. In addition to offering information on what research has taught us about how certain medications affect the brain and body, this publication also discusses treatment options.

This publication was developed to help health care providers discuss the consequences of prescription drug abuse with their patients. According to a recent national survey of primary care physicians and patients regarding substance abuse, 46.6 percent of physicians find it difficult to discuss prescription drug abuse with their patients.

Prescription drug abuse is not a new problem, but one that deserves renewed attention. We hope this scientific report is useful to the public, particularly to individuals working with the elderly, who because of the number of medications they may take for various medical conditions, may be more vulnerable to misuse or abuse of prescribed medications.

Alan I. Leshner, Ph.D.

Director

National Institute on Drug Abuse