I have been taking care of a pt. every weekend since she has been admitted. I would like to start off by saying I am a big pain advocate, however I believe that her pain needs to be reassessed. I do find pain management very therapeutic when used appropriately, and it is easier to prevent pain that relieve it. However, I believe my pt. is developing an addiction to her pain medication or we may be feeding a long-standing addiction. I noticed a certain "uncomfortable" feeling when speaking initially with her and her husband about pain management. Her husband became very quiet, did not keep eye contact w/ me and she was looking at him at times with a look like you better not say anything. I did not think too much of it at the time but did notice she wanted her pain meds around the clock, right on time, every time. I thought ok, no big deal, she has just had back surgery and she has a long list of past surgeries and DJD so she must be in pain. However something else peaked my suspicion which was that while getting report, the dayshift nurse told me she was speaking about pain medication w/ the pt. in-front of the pt's sister and that the sister had the most disgusted look on her face. So, with the husband's reaction plus the sister's reaction, there must be some history there we do not know about. Also, the pt. is constantly scratching herself. She states it's because she gets an allergic reaction to the pain medication and that Benadryl helps it, but I also know that scratching is a symptom to narcotic addiction. She also always seems to rate her pain at a constant 7 or 8 but objectively, she does not look to be in distress. I do not say anything because as nurses we are taught that a patient's pain is whatever they say it is, so I give her the medication but just feel like I am feeding into something but maybe that is what she needs to function. She gets Oxycontin 20mg qAM and 10mg qHS plus Soma q6 plus 2 tabs Norco 10 q4. And believe me...she watches the clock. So how can you tell?? Do you think any of the things I mentioned is enough to bring up to the Dr. and ask them to reassess her pain and perhaps prescribe her a lower dosage or possibly even dc one of her meds??? Thanks for your input...
the family reaction you are seeing, may the preception that they have, (subjective) that any use of narcs is addiction......and now that the surgery has been done, the patient should be "all fixed, no more pain" and the family is viewing this as confirmation of their opinion........good luck
That's exactly what I was thinking, but at the late hour, couldn't think of a way to articulate it. Thanks, morte.
Sorry in advance for the length, I get rambly when I'm tired...
I think there's a difference between "how can I tell if they're addicted" and "how should I treat someone I think is addicted"...and I think from my reading of your post that the second is really what you're looking for answers on.
For the first, when they come in and are allergic to morphine, demerol, ibuprofen, tylenol, toradol, vistaril, hydrocodone, and darvon, but "oxycontin and that dil stuff work great...and when you give me that dil stuff, push it through the closest port, and don't bother diluting it" it is a big red flag. Those get our policy on pushing the said "dil stuff" explained to them, and every nurse is scrupulous to follow it.
But, and this goes with the second portion, the how to treat...we give it, and when they ask for it assuming it's actually due. I'm not an addiction nurse. It's not my job to wean them off of or treat a narc addiction. I can and do actively seek input from their MD/DO's regarding the possiblity of a pain specialist consult or referrals from case management regarding treatment centers, if the docs also see those red flags going up. If it's someone in chronic pain which is becoming harder and harder to control, the pain specialists can help immensely. If they're drug seeking, we can provide them with the information they need but it's up to them what they do with it...just like my docs give me info about quitting smoking but it's up to me to heed their advice or keep lighting up. (On the other hand, as a tongue in cheek side note, they get their drugs in the hospital and all I get is that stinking patch...)
Depending on what the pain issues are and how long they've been on the narcs, you can see people with high function claiming high pain levels and needing (what seems to us) huge doses. I've had chronic pain issues related to gyn issues in the past. When it started, I was taking about 600 mg of Advil three times a day. Over the years, that increased to a total of up to Aleve 1500 mg/day plus Advil 3200 mg/day and increasingly uncontrolled pain...it was not unusual for me to have pain that I'd rate at a 7-8 and still be plastering on my smile and cheerful tone while caring for patients. Thankfully after surgery and the initial recovery I'm down to one or two Aleve in a shift, and nothing when I'm off work. But if the surgery hadn't worked, I can't imagine the amount of NSAIDs I'd eventually be on!
Have you seen any of the recent research into how chronic pain issues affect the nervous system? I found it to be fascinating and think it gives some insight into those patients who complain of increasing pain despite aggressive pain treatment. http://www.sciencedaily.com/releases/2008/09/080929123935.htm
It speaks specifically about arthritis pain, but seems like it would apply to any kind of chronic pain regardless of trigger.
Excuse my ignorance, addiction is not my specialty, but aren't DTs related to alcohol withdrawal, not opiate withdrawal?
I guess I should have said withdrawals instead of DT's.
You can have withdrawal symptoms if I don't get my coffee or some other form of caffiene in daily, some have it to nicotine, and narcotics are fair game as well.
This is an interesting thread. Having worked Psych and Medicine I have cared for numerous patients that have been "chemically challenged". At the beginning of substance us a person is not an addict. Over time a person builds a tolerance and a need for the drug. Just because a person is chemically dependent does not mean that they are an addict. An interesing question would be, "At what point does on become an addict". I personlly think that theer are specific behaviors associated with addiction. When they begin attempting to manipulate getting ALL their pain meds and anxiety meds at the same time I start looking closely. I have had to call the Doc on occasion and inform him of behaviors and explain that for the patients sake I cannot comply with certain requests. When it starts getting dangerous I balk. Otherwise I give what is ordered without delay.
You know they are addicted when immediately after giving dilaudid 4 mg IV to them, they ask you for a cup of coffee and if you will walk them outside to the smoking area. when it is 20 degrees outside.
But seriously, whether they are addicted or not you still need to take care of their problem and their pain. If they are addicted it is not any problem for you to deal with.
I don't have time to fool around with trying to figure who is or isn't a seeker. If their r/r is high enough and they are arousable, I give the med as ordered based on what the patient tells me about their pain. Period.
Judging the situation based on how people are looking at each other is extremely subjective and dangerous.
BTW, I have had small children who've never had a pain med in their little lives, scratch themselves like crazy d/t narcotics after surgery. It is an expected side effect - benadryl is part of the standard order set. It is not in any way, shape, or form a sign of addiction. I've had kids who we've had trouble getting adequate pain relief for, d/t excessive itching barely controlled by benadryl.
Thanks everyone for their comments and opinions :) Very helpful for me to see the way other nurses deal w/ these situations. Ultimatly, I never brought it to the dr's attention, pain is something that is very complex and it helped to read all of your posts to get a different perspective. She will be discharged this week and I probably will never see her again. I don't want it to seem like I take all my time thinking about if these woman was addicted or not, I liked her very much, she is a former nurse herself but being a new nurse I guess I just wanted some input b/c this is the 1st time I have encountered since graduating, someone who may have a narcotic addiction. So again, thank you all for commenting, it was enlightening and I always get good advice from this community!!!
Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.
Sounds to me like she has chronic pain at baseline and acute pain post op, not unusual she is watching the clock, she is in all probability under-medicated, they should up her oxy, she is probably tolerant but not necessarily addicted.
These issues should be left to her md to deal with, but as her nurse, in the acute setting, I would still advocate for more pain med , JMTC
The nervous system, specifically the nerve endings are all so different per patient, hence the pain tolerance. I find that very interesting in dealing with chronic pain patients and hope in the future there is more discussion on this.
First of all, a person becomes dependant, and "addicted" automatically if on a pain med for a length of time.
But at any rate, as a RN, at the bedside, or even in an ED, we have no business even thinking about if the patient is an "addict". Yeah, we all know the signs, and we will bet our mortgage money on who is an addict and who isnt. Guess what? its not your problem..... a physician ordered the medication..... unless it is unsafe, such as giving pcn to a person with an allergy to it, guess what???? YOU GIVE IT. period, and at that point in time , nothing else really matters. The pt states they have pain, the MD orders it you give it.... dont you think the doc knows the score? sometimes they have to write the scripts for a mulitutde of reasons.......but the most important one is : THE PT STATES THEY ARE IN PAIN
So in answer to your original question, yeah, I would bet my first born the pt is dependant on those pain meds, therefore "addicted"..... but its irrelevant...
Virgo_RN, BSN, RN
3,543 Posts
That's exactly what I was thinking, but at the late hour, couldn't think of a way to articulate it. Thanks, morte.