I work in the ER, therefore encounter many people with opiate problems. A lot of them, frankly, are unsophisticated people with low levels of education. We use the pain scale because we are required to. Many of these folks have been working the system for years, and are conditioned, like Pavlov's dog, to give a number that will give a result they need. We play along because we are required to put a number in.
I think the whole system is mostly highly inaccurate and subjective. A 10 often means how much they want the drug. The pain scale has contributed to our national sense of entitlement to be pain free through drugs.
I do find the pain scale useful with cardiac pain, but by and large, for the opiate seeking population, it contributes to the nationwide drug problem we are facing.
I work in the ER, therefore encounter many people with opiate problems. A lot of them, frankly, are unsophisticated people with low levels of education. We use the pain scale because we are required to. Many of these folks have been working the system for years, and are conditioned, like Pavlov's dog, to give a number that will give a result they need. We play along because we are required to put a number in.
I think the whole system is mostly highly inaccurate and subjective. A 10 often means how much they want the drug. The pain scale has contributed to our national sense of entitlement to be pain free through drugs.
I do find the pain scale useful with cardiac pain, but by and large, for the opiate seeking population, it contributes to the nationwide drug problem we are facing.
OMG....you have really hit on something there! Agree 100%! I have had (thinking of the most recent cases) when I was absolutely sure the patient was still under the effects of the last dose and through their groggy state was, just waking up, rating their pain 10/10 immediately, without any outward signs of pain and without any supporting diagnosis's that would substantiate that kind of pain. Some clearly just "like" the medications, IMO.
Or just much more caring and compassionate than the rest of us. What good is a thread where we don't all get put in our place?
"She" didn't put anyone in their place though. Just because there is a thing called addiction and a thing called habituation, doesn't mean the pain scale works any better! lol
I did not put anyone in their place. I stated there has to be a better way. It just gets old getting patients transferred to our section, without meds and feeling as if they are being judged. At some point, the system needs to be changed. I've been in the other side and fully understand how difficult it is for them when they run out of options for their meds. Nurses are getting jaded with the current system, and patients are over using narcotics.
I work in the ER, therefore encounter many people with opiate problems. A lot of them, frankly, are unsophisticated people with low levels of education.
And...?
I'm a Mensa member and the child of two loving parents, both with PhDs and healthy bank accounts. I only have two Master's degrees but I reckon that still qualifies as reasonably well educated. Does that make me a better class human being? I don't think so.
Emergent, I think that you know that you're one of the posters that I appreciate here on AN. But I must admit that I don't understand your line of thinking here.
I'm not sure why you added this information to your post but it's a well-known problem that some societal problems are overrepresented in lower socio-economic groups. Some phenomena may occur in disproportionately large numbers. Also keep in mind that a well-to-do addict has many more avenues of drug acquisition available to him or her. So it's not strange if you see mostly the poorer segment of addicts in an ER.
I personally think if you are a 10, you are screaming in agony and unable to do much else.
How long do you think the human body can keep that up? An hour? A week? A year? A decade?
Of course a "10" pain can look like you described. But it doesn't always. It's been mentioned so many times before. Many nurses seem woefully undereducated on the different presentation of acute and chronic pain.
Acute pain is brought on by a specific disease or injury. It serves a useful biologic purpose and is self-limited. It is associated with skeletal muscle spasm and sympatheticnervoussystemactivation.
Acute pain is accompanied by the changes in vital signs and symptoms that some nurses seem to think is theonly way that pain can present as.
Chronic pain is different. It serves no biological purpose and there isn't no identifiable end-point in sight. There are often both physiological and psychological mechanisms involved. The reasons for the body to activate the sympathetic nervous system and various cascades when acute injury occurs, are absent in chronic pain.
Because the physiological response is different it stands to reason that people will also react and behave differently depending on the nature of the pain. You literally can not stay awake for a month even if you are in agonizing pain. So yes, you can sleep despite experiencing severe pain.
Chronic pain sufferers need to be helped with a multi-modal, multidisciplinary approach. Their problems will not be solved in an ER setting.
I will tell people, "0 is no pain, and a 10 is like I'm sawing your arm off without anesthesia", and they'll have the barefaced audacity to still say a ten.
Why are you making up your own scale? It's "0 is no pain, 10 is the worst pain imaginable". There's a reason it's phrased that way. Ten is not an absolute level of pain. (If such a level could actually be reliably measured). What a person thinks is a ten isn't constant through life. It will be affected by what that person has physically experienced and what coping skills they have and what kind of emotional state they are in.
Honestly, if a nurse asked me how my pain was and added a fanciful and graphic personal interpretation of a ten, I'd be annoyed and ask why s/he can't simply ask the question without the embellishment.
Also, aren't you setting up yourself for a good dose of frustration/annoyance when the patient still answers "10" after your Chainsaw Massacre description of "10-pain" when you seem to think it's not that high/severe? I don't know, but I sense some nurse eye-rolling here..
This is in my opinion a good article if anyone wants to learn a bit more about acute pain and how chronic pain develops.
The transition from acute to chronic pain appears to occur in discrete pathophysiological and histopathological steps. Stimuli initiating a nociceptive response vary, but receptors and endogenous defence mechanisms in the periphery interact in a similar manner regardless of the insult.
Chemical, mechanical, and thermal receptors, along with leucocytes and macrophages, determine the intensity, location, and duration of noxious events. Noxious stimuli are transduced to the dorsal horn of the spinal cord, where amino acid and peptide transmitters activate second-order neurones. Spinal neurones then transmit signals to the brain. The resultant actions by the individual involve sensory-discriminative, motivational-affective, and modulatory processes in an attempt to limit or stop the painful process.
Under normal conditions, noxious stimuli diminish as healing progresses and pain sensation lessens until minimal or no pain is detected. Persistent, intense pain, however, activates secondary mechanisms both at the periphery and within the central nervous system that cause allodynia, hyperalgesia, and hyperpathia that can diminish normal functioning.
Neuroplasticity, or the physical remodelling of neuronal cytoarchitecture, occurs shortly after the onset of persistent acute pain and leads to the transition from acute pain into a chronic pain state. As a result of a peripheral lesion that persistently generates pain impulses to the spinal cord, inhibitory interneurones responsible for modulating painful nerve transmission impulses eventually die. Furthermore, glial cells remodel neuronal synapses to intensify nociceptive transmission. These pain-transmitting neurones become more sensitive, react more intensely to stimuli, and grow more connections to second-order neurones within the CNS. In short, this process of neuroplasticity leads to central sensitization in which activity dependent phenotypic changes are seen in the dorsal horn neurones and other CNS structures, including higher centres.
This isn't an easy article to read, especially if this isn't an area which you have studied before. Still, there's knowledge in there that's good to possess.
This article is old but the quote I'm including is still valid today.
Despite the existence of evidence-based guidelines, acute pain is not adequately addressed by health care professionals. Suboptimal pain management is not the result of lack of scientific information, considering the explosion of research on pain assessment and treatment. Yet reports documenting the inability of health care professionals to use this information continue to appear in the literature. Studies have found that two of the chief barriers for health care professionals are poor pain assessment and lack of knowledge about pain. Additionally, clinicians' personal belief systems, attitudes, and fears can directly influence the manner in which they and their patients respond to the varied dimensions of pain management.
Poorly managed acute pain can lead to chronic pain. I think that pain and pain management is an important subject and one that we should all be proficient in.
Everytime I see a thread like this one pop up (and it does on a regular basis)
I get real frustrated.
Some random thoughts:
Even a drug addict can experience pain that needs to be and should be treated.
If I had still worked in the ER, I would rather medicate ten individuals whose primary motivation turned out to just be to get their next "fix" then not provide pain relief to one single person suffering from moderate/severe pain. I'd hate to let even one person suffer unnecessarily because of my prejudices, ignorance or "jadedness". It's as simple as that.
If someone feels like all that they're doing is to enable drug addicts it might be a good time to find a new job. You won't cure an addict in an acute care hospital but if this is a societal problem that you want to help improve/solve, nurses can do a whole lot of good in the rehab milieu. Use the frustration regarding the drug addiction problem that plagues society and do something helpful and productive.
Focus on having a meaningful and healthy life outside of work. That makes us much more prepared to deal with various stressors at work.
Realize and accept that none of us are going to change a person's behavior if they don't want to or can't change. People aren't perfect. They sometimes make very poor decisions for themselves. We can educate and support, but beyond that it's out of our control.
Whenever I have a patient that looks relaxed and they report a pain of 7-10/10, I also cover myself by charting a behavioral scale. Don't use FLACC, it's only for babies and children. There should be an adult equivalent. I use the behavioral scale if I've reached the limits of what meds I can give in PACU, and the anesthesiologist can't or won't give me any more med orders. Which is reasonable. Last thing both the anesthesiologist and I want is the patient to go into respiratory depression.
I agree that many of our patients have been conditioned to rate pain a 10 if they want IV diluadid. There are many acute conditions that are painful so in the emergency room, giving IV diluadid may be appropriate, however for chronic pain, I think Ibuprofen is very effective and under used because providers are afraid of side effects, bleeding. Toradol is another wonder drug for pain that is not narcotic and may work for acute pain and again under used because of possible side effects to the kidneys.
Personally I wish providers would start prescribing Ibuprofen and Toradol/Ketorolac.
The socioeconomic and educational level of my patients is pertinent. Less sophisticated people, with poor adaptive skills, are easily swayed by a healthcare system that doled out opiates the past 30 years like candy.
The healthcare system set these people up for this. Now there is a gnashing of teeth about addiction.
Enshrining the pain scale as sacred contributed, in my opinion. The most vulnerable members of society were like sheep to the slaughter, lacking coping skills.
I agree that many of our patients have been conditioned to rate pain a 10 if they want IV diluadid. There are many acute conditions that are painful so in the emergency room, giving IV diluadid may be appropriate, however for chronic pain, I think Ibuprofen is very effective and under used because providers are afraid of side effects, bleeding. Toradol is another wonder drug for pain that is not narcotic and may work for acute pain and again under used because of possible side effects to the kidneys.
Personally I wish providers would start prescribing Ibuprofen and Toradol/Ketorolac.
Of course, Toradol is not always the answer, but you are right...I see a lot more of it being ordered.
I personally think if you are a 10, you are screaming in agony and unable to do much else.
I will tell people, "0 is no pain, and a 10 is like I'm sawing your arm off without anesthesia", and they'll have the barefaced audacity to still say a ten.
I just put the number in the computer and move on...
That's about what I tell people when they rate their pain. I love when someone says 10 and is sitting quietly, no grimace, no outward signs of pain, vitals stable/baseline. I want to say to them "Have you ever had a kidney stone ripping it's way down your ureter? What about as it passes from your bladder through your urethra feeling like a piece of glass cutting it's way out from the inside?That's a 10. This calmness you display is not a 10. At least get with the program if you think you are a 10." But of course, we can't!
The socioeconomic and educational level of my patients is pertinent. Less sophisticated people, with poor adaptive skills, are easily swayed by a healthcare system that doled out opiates the past 30 years like candy.
The healthcare system set these people up for this. Now there is a gnashing of teeth about addiction.
Enshrining the pain scale as sacred contributed, in my opinion. The most vulnerable members of society were like sheep to the slaughter, lacking coping skills.
The city I live in has, according to stats, has more PhDs per capita than any other place with comparable population size in the USA. The prescription opioid abuse epidemic is raging here just as well.
It is not just coping skills. It is over-stressful work schedules, it is working three jobs instead of one (it is not pertinent why - to feed the kids or to keep up with "everybody else"; latter thing being definitely more common locally); it is insurance which doesn't pay for PT but does for monthly visits to fill yet another script, it is $0 copay refills, it is 2 months wait time for root canal, 3 months for orthopedic surgeon and 6 for podiatrist while being in pain every day and still having to go for these three jobs, it is firm belief in existence of instant gratification of every wish, including momentary relief from every ill by taking some special pill. It is lack of planning in life, loss of understanding of what is important and what isn't and that some things are just what they are.
My kid was attempted to be put on opioids for quite an ordinary, absolutely uncomplicated trauma and when I refused I was treated as a bad mother. Teens are routinely given them so that they could not interrupt their exhaustive sports practices. I'd seen people with two PhDs and MBA coming in and demanding classic "something for pain" because some strain or sprain which MUST be 110% relieved tomorrow, 10:00 AM sharp because they have to play golf with some SVIP or fly across the globe. You may educate these people all you want - they have other prerogatives in life right now, and they will always have them, putting their health and common sense aside... till it too late, for them or for their loved ones.
Even such a radical change as single-payer insurance system will not do anything with the problem till people change the way they go about their lives. "Something is rotten in the state of Denmark".
NursesRmofun, ASN, RN
1,239 Posts
OMG....you have really hit on something there! Agree 100%! I have had (thinking of the most recent cases) when I was absolutely sure the patient was still under the effects of the last dose and through their groggy state was, just waking up, rating their pain 10/10 immediately, without any outward signs of pain and without any supporting diagnosis's that would substantiate that kind of pain. Some clearly just "like" the medications, IMO.