Is current thinking on pain control creating drug addicts?

[GardenDove]

The current approach to pain control has been to believe the pt's self report of pain no matter what. Is this creating drug dependency, and or addiction, in emotionallly susceptible people? Should we be concerned? Is there going to be a backlash to what has been a more liberal policy towards pain relief in the past 20 years.

I bring this up for a few reasons. For one thing, our hospital let go one well liked doctor, the reason we heard being that she was catering to the drug-seeking community with too many prescriptions. We were all aware of her liberal attitude on this and that she was a soft touch in that dept, but when she was apparently suddenly fired, it was a shock.

The hospital clinic does happen to attract more of the misfit population btw. It's a small town, and there aren't too many docs that take new pts. The clinic tends to get more of the riff raff, if you'll pardon me using that term.

Then, our weekend hospitalist got paranoid. He actually told a nurse who called him for pain meds that he didn't want to be fired like Dr So and So was. I also noticed that he was being reluctent to give narcotic orders when I called him.

I was reading the new ANA magazine an article titled Improving Pain Management. It takes the approach of believe the pt no matter what, don't allow people to be in pain. One thing the article condemns is the use of placebos.

I haven't seen placebos used myself, but I personally think they might have a place with a certain type of pt. The reality of the situation is that there ARE drug seekers who are good at manipulating the system. Any nurse who doesn't see that in some people must have his/her blinders on, in my opinion.

So, how do we address that reality without punishing the many people who truly are in pain? Sometimes I think the whole pain control industry is a self-perpetuating machine, and a classic case of the fox minding the henhouse. On the other hand, I wouldn't want to go back to the old days when pts were expected to grin and bear it for fear they'd all end up druggies.

Any thoughts?

[clemmm78, RN]

Considering that pain is extremely subjective and that psychological (phantom, etc) can be just as excrutiating as physical, I don't feel that there can be a protocol or one way of thinking in terms of pain control.

I have an extremely high tolerance for analgesia. Add to that a low tolerance for pain. If I come across a nurse or physician who feels I may become dependant, then I suffer needlessly. It's not my fault that my body doesn't process analgesia as effectively as someone else's. It never has, even as a child it didn't.

I went to a conference, many years ago (early 80s) on the topic of pain control and addiction. I can't recall references any more, but I do remember one statistic in particular. The speaker said that only about 1% of patients who truly need narcotics for analgesia become addicted.

Perhaps, a big difference in the way I see things and the way many on this board might, is that I'm in Canada and we don't have the rabid drug war here that appears to be going on in the US (to my eyes). In any place I've worked, if a patient needs an opioid for pain relief, unless there was good reason to believe that it was drug dependancy, the patient received it.

[PANurseRN1]

Using placebos without the pt. consent is unethical, if not illegal. Research it before you form an opinion; there is a lot of information out there about using placebos.

Should we go back to the bad old days when people suffered in excruciating pain and were basically told to "suck it up"? Have you done any reading about the physiological effects of chronic severe pain?

Of course there will be seekers. That's why the best approach is a multi-tiered treatment, not just someone writing pain scripts indefinitely. All things considered, I'd rather err on the side of giving a "seeker" meds than deny someone who is truly sufferring pain relief.

[marilynmom, LPN, NP]

Pain is what the patient says it is, plain and simple--I just believe that 100%. A drug addict can have pain, no different than me and you. The rif raf still experience pain. An addict can still experience pain. My uncle is a drug addict and has been for years, he still has issues with pain at times (he has a lot of health problems). His addict status doesn't negate his pain relief needs.

My dad is like the above poster, most pain relievers do jack crap for him, he takes morphine for back pain and has for years, it is the only thing that works for him. My mom suffers from chronic pain and takes opiods. If anyone were to even suggest to her about addiction or offer placebos I would be livid because that is distegarding the pain and the quality of her life.

I would much rather see the vast majority of people who are truly in pain get the relief they have a right to, even if that means a few drug addicts get opiods to use for their addiction.

Good topic!

[General E. Speaking, RN, RN]

My Dad is on Morphine for chronic back pain. He also has taken Valium for years (anxiety). He has built up a tolerence to meds. He needs more than the average person to control his pain.

Sometimes, I question (in my head) a patient's pain rating of 10/10 cause they just don't appear to be in excruciating pain, however, pain is subjective (period). It is not up to me to decide what their pain level is- that's why we ask the patient. Of course, this wouldn't apply if the patient had excessive somnolence/decreased respirtations, etc...

[Tweety, BSN, RN]

The reality is that of the people in pain, not many addicts are created. Nurses worry too much about this.

I agree with the approach that placebos should not be used.

Also the reality is that if their pain can't be cured, tolerances and perhaps addiction might occur. Why would you give placebos or worry about addiction in this case. I'd rather have an addiction/tolerance to pain meds and be pain free than not take pain medicines and needlessly suffer.

It's hard taking care of chronic pain patients when they are in a trauma or surgical situation.

[Noryn]

I think it is a hard question that doesnt have easy answers. If the only consequence was feeding the addiction of a few addicts then it probably wouldnt be an issue. The problem is that prescription drug abuse is rising and it is causing serious harm to our communities. I think we have had 2 teenagers dies from abusing the Fentanyl patch in the past year.

I am starting to hear movements from the communities (and of course lawyers) to make doctors more accountable for what they prescribe. I dont want to see anyone in pain, and I dont want to see a bottle of oxycontin being sold to kids. It is rather easy to deal with in the hospital as you can utilize injections. In the ER and doctor offices though it becomes much more complicated.

I wish I had the answer but I dont. I do think the drug companies have a responsibility to try to curb the abuse of their products. Good topic to discuss!

[TazziRN, RN]

ERs do not create addicts. We contribute to the addiction, but we do not create them. A good ER doc will give someone a prescription for just enough narcs to carry them through until they can get in to see their PMD.

[nursemary9, BSN, RN]

"Pain is what ever the patient says it is". I remember that quote from the VERY first Seminar on pain management that I went to many years ago!!

I believe the current statistic is that only 0.6% of the people become addicted to there pain killing drugs.

Adequate Pain management is one of my BIG things. I have been to Many pain management seminars & taken pain management courses.

Yes, Doctor's DO NEED to know who they are prescribing pain meds to.

Remember that the Pain score, today, is the fifth vital sign. The Nurse will be & should be held accountable if our patient is needlessly kept in pain.

One of the major problems in pain management is that the Dr's who are prescribing the drugs don't know all they should know about pain management--they don't know the drugs available, they don't know how to use them, and they don't know there patients.

For instance, they often don't know about all of the other classes of medicatiions that can be used as an adjunct to opioids.

Certain ly a good portion of them don't even try any other pain relief measures--like-- guided imagery,or relaxation techniques.

As a Nurse, I go to MANY pain seminars. I study, study, study & I can't even write a prescription--yet ask ant Dr. & most of them have not gone to any pain management seminars or programs.

This is where much of the problem lies.

Remeber, drug addicts CAN be in real pain, too & they also deserve pain relief just as much as you or me.

Sorry, I get on my soap-box regarding pain management!!

Mary Ann

[GardenDove]

We had a pain seminar a few years back. It was run by a nurse in a nearby town. She espoused a similar spiel such as nursemary does. She runs a pain clinic. I asked a nurse friend of mine about her and found out that she is one of the pain clinics biggest clients, and also has alot of personal problems. I think that's what I mean by the fox guarding the henhouse. Yes, I think that there are people who use pain meds, along with other pharmaceticals, as an emotional crutch to help them cope with life.

If this wrong? I'm not sure if it is any more wrong than a couple of glasses of wine. But, I do think that people do it. I've taken care of some of these pts who take massive doses of pain meds. Many of them have a hx of psychological problems.

Frankly, the pain seminar that I mention reminded me of a brainwashing session. This gal wanted us to change our vocabulary even. She was very offended by the word 'narcs' for instance. And she wanted to stamp out the term 'drug seeker'.

I have no doubt that people have chronic pain, let me clarify that. And I'm very quick to call the doctor for something in the acute care setting. But I'm not blind to the fact that there are saavy pts out there who know how the system works.

[grandee3]

I hate it when we tell the doc a pt is taking pain meds every 4 hours and still complaining about pain but have no problem going outside to smoke or laugh and joke on the phone.

The doc would tell us he is going to lower the dose and after seeing the pt, he gives them even more pain meds and the pt down the hall who just had a foot amputated or a CABG only has Tylenol ordered. :angryfire

[P_RN, ADN, RN]

I have a problem with telling a doc that a patient goes outside and smokes and laughs.

That and pain are not mutually exclusive. I have had pain, at times I still have what I consider fairly bad pain. I also like to laugh and be silly.

As far as I believe pain is what the patient states it is, and we should respect that. It isn't up to us in a care setting to judge.

I do realize that people doctor shop and some people are savvy as to what to say to convince a PMP into prescribing. But as nurses we don't prescribe, we administer.