I was stumped

No one knows?

Hello,

I am a new graduate so don't have any real experience to share with you. HOWEVER I just purchased Margot McCaffery's most excellent book "Pain: Clinical Manual" and here is little from that:

Pg. 455: Opioids must not be withheld from persons with pain who are suffering addictive disease. No scientific evidence exists that providing opioid analgesia to these patients in any way worsens the disease, or conversely, that withholding opioid analgesia increases the likelihood of recovery.... When possible, a single opioid agent shoud be used. Mixed opioid agonist-antagonists should never be used in the opioid-dependent patient because these will precipitate withdrawal. Analgesics should be ordered on an around-the-clock basis to avoid decreased opioid blood levels with associated breakthrough pain and withdrawal because both are risks for increased drug use." Elsewhere she points out that "No need exists to contribute to discomfort while the patient has acute pain, and during this time of acute stress detoxification should be avoided."

My thoughts are: Document that the patient is NOT opioid naive and make sure the doc understands that much - I am uncertain of the legality or appropriateness of stating the actual addiction ?? but the term "not opioid naive" might be okay? Then target titrating until the patient is comfortable. My understanding is that Dilaudid is more potent (some say 7:1 or 10 mg. ms = 1.5 dilaudid) but what I am reading states that it is uncertain. It does have a short duration (3-4 hours), if that helps.

I have worked with so many patients who had poor pain management from staff who were "scared" or "ignorant" about providing care. So, I am doing what I can before even working as an R.N. to gather resources to help me learn more. I am impressed that you are trying to as well. Sorry I couldn't give you more specific info.

Kristin

All done and waiting for graduation in Feb.!!!

Had a "friend" who was a heroin addict ,and she said Dilaudid didn't work for her either. hmmmmmm? Another of my classmates took it and had severe adverse reactions. I took Dilaudid and discovered it didn't work for me either and I'm not an addict. I've come to the conclusion that hydromorphone should come with a warning that there's a large chance of it not working:chuckle If I was you I would have asked the pt what he would be comfortable with taking, then ask the doctor to change the order (as per pt request) and possibly double the dose seeing as drug addicts have a higher tolerance to opioids.

(Pre-nursing student)

Holy smokes, had to edit twice for spelling!

In treating someone who is actively using, you have to take a dual approach.

First, medications that are not opioids and then use proper titration of opioids.

IV Toradol would be your first line drug here.

After that, titrate MS04 until proper pain releif is reached.

Dave

Well thanks, that gives me some more info than I had. I do think Dilaudid does work for many, and MS doesn't work for many. I guess a lot of it is body chemisrty.

Thanks so much 5150dx for your especially lengthy and excellent reply. MaCaffery is THE pain guru (the 1st one I learned in school anyhow).

Hi Dave,

I read you post with interest but am wondering if that would be most appropriate for someone who had a history of using large amounts of opiates - either legitimately or abusively - not a current addict. If a self-admitted heroin addict is hospitalized for surgery, when do we make sure he gets the opioid he needs to avoid withdrawal and heightened sensation of pain? By the time he/she is post surgery, hours have passed since his last "hit"... possibly bringing all sorts of complications related to withdrawal... I don't have the answers and am new to this but it still seems a little uncertain to me. Thanks for your feedback.

Kristin

This is my point. I believe that it is NOT my/our job as a "bedside" care provider to detox or cure addiction at THIS time. When the pt has an acute problem such as surgery or a med problem that causes pain. My question is still, what is the norm? Do we give methadone possibly on top of the narc painrelievers to keep him out of withdrawl syndrome or what? I am not pro drug abuse of any kind, but I still feel that as a nurse I have the ethical and legal responsibility to treat the patient without judgement, and this means treating the pain and discomforts.

Thanks

When I'm doing pain management for a admitted user, I get a Addiction Specialist consult STAT!

In may cases, Methadone is given to offset the lack of the drug of abuse. Sometimes they get pain releif from Methadone and don't need anything else. In other cases, we will order MS04 or Dilaudid on top of Methadone.

Treating acute pain in an addicted patient is very complex. It's not something even the best pain mangement specialist can do on their own (IMHO). Addction specialists are a must in this arena.

Dave

Thank you Dave for the info. I was concerned that this case was only being handled by the general surg, who IMHO is not fit to do autopsies.

JUST MY OPINION but, most surgeons I have noticed know very little about pain management. They cut em and leave em.... basically they want them on as little as possible for as short as time as possible and when you throw in the an admitted user, the surgeon is at a loss. I totally agree with md terminator....