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.
The problem being that the ED really is swamped with addicts seeking to score, so they have no choice but to address addiction behavior. I actually agree that easy access to legal drugs thru the ED has contributed (but not caused) the spike in addictions. It's a tough nut to crack (pun intended ) The trick is to avoid enabling addicts as much as possible while staying responsive to people with real pain issues that need assessment and relief.
I've read that some facilities have had some success with "no-fly" lists and enhanced access to patients' prescription histories across pharmacies and hospitals. Of, course, you need docs and administrators able to stand firm when it's time to say no ... and junkies don't make it easy. Once word gets around, though, they tend to take their business elsewhere.
Yes, I'm afraid your last statement is one of the major problems facing the country today: they WILL take their business elsewhere--like the local heroin or crack dealer. Refusing to "enable" their behavior in the ER doesn't help anyone, but it can certainly worsen the problem, and not just for the addict. If addiction were treated more like a medical problem, and addicts had access to help when they want to change and safe drugs and clean needles when they don't, the criminal element would lose much of its clientele. The war on drugs has been an abject and dismal failure, for the very simple reason that it has historically tried to cut off supply; any first-semester economics student can tell you that where there is a demand (and money) there WILL be a supply.
And to be honest, the idea of a "no-fly" list for perceived abusers of the system positively sickens me. Don't we all know that addicts have heart attacks, strokes, appendicitis, and genuine injuries--you know, just like everyone else? How depressing that some healthcare professionals, who should know better, could actually be in favor of such an idea. Wow.
Yes, I'm afraid your last statement is one of the major problems facing the country today: they WILL take their business elsewhere--like the local heroin or crack dealer. Refusing to "enable" their behavior in the ER doesn't help anyone, but it can certainly worsen the problem, and not just for the addict. If addiction were treated more like a medical problem, and addicts had access to help when they want to change and safe drugs and clean needles when they don't, the criminal element would lose much of its clientele. The war on drugs has been an abject and dismal failure, for the very simple reason that it has historically tried to cut off supply; any first-semester economics student can tell you that where there is a demand (and money) there WILL be a supply.
And to be honest, the idea of a "no-fly" list for perceived abusers of the system positively sickens me. Don't we all know that addicts have heart attacks, strokes, appendicitis, and genuine injuries--you know, just like everyone else? How depressing that some healthcare professionals, who should know better, could actually be in favor of such an idea. Wow.
I pretty much agree with everything you wrote. As an aside, I should have said no script/no narcs instead of no-fly.
That being said, almost by definition EDs are not dealing with addicts who want help with their addiction. They are, for the most part, looking to get high or stave off withdrawal and have no interest in getting sober.
In in the same way that jails and prisons bear the brunt of untreated mental illness, the ED is expected to absorb the abuse of EMS by addicts and somehow make that be therapeutic. In my opinion, practically the only therapeutic intervention the ED can offer an active addict is the refusal to cooperate with gaming the system.
There are very few treatment options for addicted people and, consistent with our ethics-free version of capitalism, many of those are nothing more than scams to milk public or insurance funds. That fact does not automatically give addicts - or anyone else - a free pass to abuse the EMS system. Many urban jurisdictions are now filing charges for such abuse and many facilities are now banning known abusers of hospital services as a matter of public safety.
Shielding addicts from the consequences of their behavior, while supplying their drug of choice is not a solution for anybody. Believe me ... like many nurses, I have strong codependent tendencies and i'm here to tell ya it just doesn't work.
No, my thoughts are pain scales haven't caused addiction - people with little self control are the root of addiction.
There will always be pain in health care, which requires humane management. When I use a pain scale trying to get a feel for level of pain I give them verbal cues, such as, "If 0 was no pain at all, and 10 was being in a meat grinder, what level would your pain be?". Rarely do I get a 10/10 that I would doubt, but then again I'm not administering narcotics any more in my job - I do telephone triage now, so I help them decide what next to do (home care, appt in clinic, or ER/UC).
There has always been people who milk anything, which is unfortunate, because people who really are suffering many times keep right on suffering.
Dear Orphan RN,
You proclaim to have years of experience, and have some letters behind your moniker- yet you fail to understand the basic mechanism of addiction.
I could go on about the conversations you are not able to have with patients and co-workers because of your chosen ignorance, but I assume at this point in your career you must like the smugness you project.
As a fellow RN-BSN, former ICU nurse (with my last job being telephone triage), and unwitting addict- I can attest that the root of addiction is beyond "people with little self control".
The anger that I feel from your statement- the thought that I would purposefully sideline my 15 year career out of the blue... because I have little self control.
You proclaim to have years of experience, and have some letters behind your moniker- yet you fail to understand the basic mechanism of addiction.
I could go on about the conversations you are not able to have with patients and co-workers because of your chosen ignorance, but I assume at this point in your career you must like the smugness you project.
As a fellow RN-BSN, former ICU nurse (with my last job being telephone triage), and unwitting addict- I can attest that the root of addiction is beyond "people with little self control".
The anger that I feel from your statement- the thought that I would purposefully sideline my 15 year career out of the blue... because I have little self control.
Insulting.
Dear 1sttime,
I am not a young woman, I've encountered addiction more than once, both professionally, and in my personal life. I've seen addiction to things I would never have thought of as something a human being would possibly become addicted to as little as 20 years ago - not just substances. Respectfully, my personal experience with addiction is none of your business, but I will say during the peak of each user's addiction cycle self control was not part of the equation. And none of the people experiencing it purposefully got there by their own choosing. I am also a proponent for appropriate pain management, having both personal and professional experience with those suffering from chronic pain.
"Loss of control" and "powerless" are two words defining the same meaning. The very first step in Alcoholics Anonymous is:
We admitted we were powerless over alcohol [or insert whatever substance, or behavior here]—that our lives had become unmanageable
The statement in the First Step that the individual is "powerless" over the substance-abuse related behavior at issue refers to the lack of control over this compulsion, which persists despite any negative consequences that the person may endure as a result.
: compulsive physiological need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly: persistent compulsive use of a substance known by the user to be physically, psychologically, or socially harmful.
My comment was not said with conceit or superiority, or to judge (glass houses and all that) it is from personal first hand experience. I guess it just boils down to intent and meaning being misinterpreted on an internet chat site resulting in hurt feelings (see "Some Days" thread).
Your response is hot tempered and poised for firing, purposefully adding insult to injure. You achieved exactly what set out to accomplish: in your view I hurt you (without intent), you hurt me right back (willfully). I'm not sure where you are in your 12 step program, but I'm guessing anger is still something yet to be worked on.
Regardless, I injured you without intention. I realize now my statement could be construed two ways - one of those as thoughtless - and I genuinely apologize for what you clearly view as a slap in the face, and for hurting your feelings. This is not said with snark, or smugness - I am truly sorry for hurting you 1sttime. You don't know me, therefore owe me nothing. I don't expect forgiveness from you, but I sincerely feel remorse for causing you more pain than you've already endured. I'd like the opportunity at some point to make amends to you, and anyone else unintentionally hurt by me, if possible. Please know if I could take back the hurt you felt that I would do so in a heartbeat.
Having the strength to stand up and fight an addiction head on makes you someone very much in control. I wish you well in your recovery.
The difference between the administrators and the ED patients is the admins get their drugs elsewhere. Don't think the people making policy aren't often addicts themselves. They might have OK physicians who get them onto SSRI s in time to avoid opiates and then make their kids docile with meds so that they can spend more time making money. Plus, well off people have many more acceptable ways to hide or dress up their addictions.
Years ago I had a patient admitted with a severe headache. The hospitalist kept saying "I know this guy, he's a seeker" and giving him Tylenol, Motrin, and low dose oxycodone all night as he writhed in pain. The next day a head MRI showed a massive, untreatable tumor. He died a week later.
Since the purpose of the Emergency Department is to rule out/stabilize life threatening injury/illness, we are concerned primarily with acute pain.
The numeric pain scale is one dimensional. It only evaluates the patient's verbal report of the intensity of their pain. Since the goal in the ED is to determine the cause of the acute pain in order to treat the cause (i.e. appendicitis, myocardial infarction, bowel obstruction, long bone fracture, etc.), a multidimensional pain assessment is appropriate.
A multidimensional pain assessment includes the patient's subjective report of the intensity of their pain, but also the quality, the clinical progression, any alleviating or exacerbating factors, as well as objective observations such as splinting, grimacing, moaning, crying, etc. as well as abnormal vital signs.
It is the multidimensional assessment that should be guiding the prescriber's decision making regarding appropriate analgesia, not simply a number from 1-10.
Treating pain related to a long bone fracture is different than treating pain from renal colic. Treating a migraine is different from treating a small bowel obstruction.
There is no one-size-fits-all pain management strategy.
When you triage a patient who presents to the ED for a pain related complaint, it only takes a few minutes to perform a comprehensive, multidimensional pain assessment. Part of this means that when you ask the patient to rate the intensity of their pain on a 0 (no pain at all) to 10 (the worst possible) scale, it is completely appropriate to explain the scale to assist them in selecting the appropriate number to represent their experience. For example, 1-3 is mild pain that can be ignored and doesn't interfere with their activities of daily living. 4-6 is moderate pain that is difficult to ignore and interferes with concentration. 7-9 is severe pain that interferes with activities of daily living. 10 is the worst possible pain that requires bedrest. Obviously, if they drove themselves in and are calmly sitting in an upright position with no grimacing, splinting, tearfulness, and with normal vital signs, then they cannot be a 10.
Keep in mind that I am speaking of acute pain only. I'm perfectly aware that chronic pain is different. But again, in the ED, we are not in the business of treating chronic pain. If a person with chronic pain at baseline presents, it is appropriate to ask about their chronic pain, but also to explain that we're concerned here today with what is new or different from their baseline. We are not going to adjust their oxycontin dose or prescribe a fentanyl patch- that is for their primary care provider or pain specialist to do.
Having said all of this, I would say, Emergent, that if the providers in your ED are prescribing analgesia based only on the unidimensional, subjective, verbal report of the intensity of pain and not taking into account the physical exam, objective signs, differential diagnosis, etc, to select the most clinically relevant pain management strategy, then it's probably due to a host of factors such as pressure from administration to speed up throughput and increase patient satisfaction.
Honestly, it might feel like what number you plug into the computer under the pain score really matters, but in the end, that's not what the bean counters are auditing. They're looking at things like how long it took for the physician to order pain medication for a long bone fracture, or how long it took to give antibiotics to a person who met sepsis criteria, or whether a repeat lactate was drawn within six hours, or how long it took from the time the decision to admit was made until the person finally got to the floor, or how many patients a provider saw in their shift. Providers are under so much pressure to meet these demands, that they just click the boxes and give the patients what they want because they don't have time to actually practice medicine- i.e. dilaudid for a pinky toe sprain.
In other words, it's bigger than you or me or the stupid 0-10 pain scale.
Since the purpose of the Emergency Department is to rule out/stabilize life threatening injury/illness, we are concerned primarily with acute pain.
Keep in mind that I am speaking of acute pain only. I'm perfectly aware that chronic pain is different. But again, in the ED, we are not in the business of treating chronic pain. If a person with chronic pain at baseline presents, it is appropriate to ask about their chronic pain, but also to explain that we're concerned here today with what is new or different from their baseline. We are not going to adjust their oxycontin dose or prescribe a fentanyl patch- that is for their primary care provider or pain specialist to do.
My ED is constantly full. I get where OP is coming from. While I am treating your chronic pain that your PCP/pain management doc has not adequately managed, Grandma with a broken hip is waiting in the ambulance bay for an open bed. Baby with a history of febrile seizures is in the lobby with a rising temp. The patient sent in by their doc for an emergent thora/para is trying their best to breathe around all that fluid. If I seem unsympathetic to your plight, it is because otherwise I would be unsympathetic to theirs.
) The trick is to avoid enabling addicts as much as possible while staying responsive to people with real pain issues that need assessment and relief.
nursemcsleepy, BSN, RN
52 Posts
I'm so glad I work with children and we have a wide variety of pain scales we use.