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.
If a patient is a drug-seeker, you're not going to cure him during the hospital stay; unless you're working acute rehab. In spite of addiction/dependence, you can't not treat a patient's pain. The fact that he/she may be addicted doesn't negate the fact that he may be in real pain. That's what pain service is for. Many of the pt's who were drug seeking were actually reluctant to deal with a pain service consult because we were giving out "better stuff" in the hospital.
As for the kids overdosing on fentanyl or being sold oxycontin, it's not because of prescriptions being handed out. Most of them who have used it have taken it from mom or dad without their knowledge. It's not the doc's responsibility if the parents don't keep it locked up. So many people subscribe to the "my kid would never do that" mentality or "I don't want Johnny to think that I don't trust him, it would damage his self-esteem :rolleyes:" school of thought, that it's not hard to see how they can gain access to those meds. And the ones sold on the street, many, if not most, aren't legally obtained in the first place. So should the rest of society be punished for the illegal acts of others?
One solution that I have mixed feelings about is keeping a database to prevent polypharmacy for narcotics and other meds as well. It would cut into the doctor, ED, pharmacy shopping to get more scripts. On the other hand, what kind of slippery slope would it start? Could I be prevented from getting a second opinion if one doc wasn't treating my pain? Do I want use of certain meds to be public knowledge? A lot of the information could be prejudicial. Hmmm . . . .
Good thread and its interesting to see everyone's different views.
I believe pain is what the patient says it is. Of course there are drug seekers but if their vitals support it I will gladly give a medication that their doctor has prescribed. Especially in a critical care situation its my opinion that any type of weaning down could be counter productive to their healing process and especially in the cases of elderly people with chronic disease, pain control is very important. I've had families worry that their 80 yo father with lung cancer would get "hooked" on the narcotics. C'mon folks, that should be the least of your worries, imvho.
Sadly there are always going to be unscrupulous docs writing scripts for people they know are addicts and I'm not really sure how to prevent this but my guess is that most of them are in private practice rather than operating out of a hospital.
Always a hard topic! Pain is what the patient says it is. But you are always going to have that patient that had their gallbladder out 3 years ago that is still taking 2 Percocet every 4 hours to control the pain creating situation corrected years ago. That's where I have a problem. Are we treating the pain of addiction with more of the addicting substance?Is that really what pain management is all about? Hard call, but a subject that is coming up more and more with the new criteria for pain management.
I don't feel that the "new approach" to pain management in acute care is anything but positive. The risk of creating addiction problems is really low - like some have mentioned,
That isn't to say there aren't some huge loopholes and "drug seekers", but I think those are the exception rather than the rule.
In my own limited personal experience as a hospital (o/p surgery, if that counts) patient, the fear of being in pain produced a lot more anxiety than any actual pain I felt.
And I really don't care if someone uses drugs. So what? Why does it matter?
The government should keep out of medicine and then good doctors as the one mentioned wouldn't be fired for actually treating pain or addiction or whatever it is that needs to be done to allow people to live without pain, be it physical or mental.
The government should keep out of medicine and then good doctors as the one mentioned wouldn't be fired for actually treating pain or addiction or whatever it is that needs to be done to allow people to live without pain, be it physical or mental.
But are we really doing the best by our patients if we are treating "mental" pain with a narcotic? What happens when the tolerance to the drug of choice is reached? God forbid they find themselves in a trauma situation with a huge tolerance and now they are in an uncontrolled situation for pain management.. is this good medicine? No answers, just lots of questions.
I think, to add another piece to the puzzle, that there's an important difference between addiction and dependence. Dependence is when a person's body actually requires the drugs to function normally, where addiction has a very psychological component along with physical need.
I work in PICU, so we get lots of kids "hooked" on their narcs. After about a week on continuous gtts, you can pretty much bank on a kid going into withdrawl when they're extubated due to for-real physiological dependence. However, once we give them a nice morphine/ativan taper, they do just fine and don't end up with any sort of addiction.
I guess my attitude is if they're in pain, they need the med. I've never (ha, in my oh-so-illustrious 1.2 year career!) seen a kid get addicted.
Is there a difference between peds and the adult world in this area?
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?
You know, this is a very hot topic. And what I am going to say in the next few paragraphs may offend some, and if it does, I apologize, but I must say it: It seems to me that doctors cater entirely too much to drug addicts!!!!
At my facility, if you are truly sick, you don't stand a chance of being admitted to the hospital from the ER. You are sent home and then left to fend for yourself. If you are reporting a migraine, abdominal pain, or chest pain, and even though enzymes and EKGs have ruled out an MI, or CT scans, US, PIPIDA scans and the whole shabang has ruled out any cause you are still admitted. You are admitted and you are given drugs around the clock. Never mind trying to get to the cause of the problem, you are given drugs q1-2 hours and more if you ciomplain enough. This is what i've seen in only 2 years of nursing aften having worked in over 7 facilities.
My daughter was sent home from the ER with a very high fever and no further diagnostics run. (You know this was before I became a nurse, because I would've raised the roof otherwise). After about a day, we had to bring her back to the ER because she was not getting better. Come to find out, after the second visit, she had pneumonia and almost died because it had gotten so bad. But had she had been a junkie, who reports abdominal or chest pain, but just happens to be allergic to codeine, merperidine, toradol, NSAIDs, ASA and everything else, you get to stay all week if you'd like. What is wrong with these doctors?
From my experience, the people that are post-surgical, have cancer, renal disease and are truly in pain, as indicated by physiological and non-verbal cues, are the ones that NEVER, and I mean, NEVER ask for pain medicine. They sit there and take the pain and you have to almost beg them to take the pain medicine. But these young, otherwise healthy young people, with out chronic diseases, that come in with these vague symptoms and "multiple allergies" are on the call light every hour wanting to know when they can their next "hit", I mean pain shot are getting their way. And I tell you, I am not here to judge, but I do have common sense to smell a rat. And these doctors are often so money hungry that they'll admit them because they can come and see them 100 times.
So, in a nutshell, yes, the current thinking IS creating drug addicts. These doctors are legal drug pushers.
Lots of great contributions to this discussion. I absolutely agree that the acute care setting isn't the place to address someone's dependence on pain meds. I think ER does deal with the fall out from drug seeking behavior the most, and I don't know what the solution for that dilemma is.
The problem with the doc who got fired was the amt of prescriptions she was writing in general to people who came to her clinic. I heard that it was a situation that already existed there when she got hired on, which escalated while she was there. It was too bad, many of her pts were upset.
Yes, you describe perfectly the dark side to our current approach, and it's cost to the healthcare system. These types of people are also a drain on our Emergency Depts. I think part of the problem is fear of litigation.
my current pharmacology textbook explains that the goals of pain relief and performance of actitivities of daily living are not always met effectively by health care providers, especially in case of moderate to severe pain associated with surgery and cancer (because of improper or inadequate use of opioid analgesics, including administering the wrong drug, prescriptions for inadequate dosages, or leaving long intervals between)
the drugs maybe are not being administered effectively
and a humane approach to pain managemnt explains that no person should suffer pain needlessly; pain occurs when the client says it does, and that pain should be relieved by whatever means are required, including pharmacologic, and nonpharmacologic tretmetns, doses of opioids should be titrated to achieve maximal effectivenesss and minimal toxicity; and that dependence rarely occurs from drugs taken for physical pain.
In the section on morphine - it is a nonceiling drug because there is no upper limit to the dosage that can be given to clients who have developed tolerance to previous dosages (other nonceiling drugs are hydromorphone, levorphanol, and methadone)
NurseyBaby'05, BSN, RN
1,110 Posts
If a patient is a drug-seeker, you're not going to cure him during the hospital stay; unless you're working acute rehab. In spite of addiction/dependence, you can't not treat a patient's pain. The fact that he/she may be addicted doesn't negate the fact that he may be in real pain. That's what pain service is for. Many of the pt's who were drug seeking were actually reluctant to deal with a pain service consult because we were giving out "better stuff" in the hospital.
As for the kids overdosing on fentanyl or being sold oxycontin, it's not because of prescriptions being handed out. Most of them who have used it have taken it from mom or dad without their knowledge. It's not the doc's responsibility if the parents don't keep it locked up. So many people subscribe to the "my kid would never do that" mentality or "I don't want Johnny to think that I don't trust him, it would damage his self-esteem :rolleyes:" school of thought, that it's not hard to see how they can gain access to those meds. And the ones sold on the street, many, if not most, aren't legally obtained in the first place. So should the rest of society be punished for the illegal acts of others?
One solution that I have mixed feelings about is keeping a database to prevent polypharmacy for narcotics and other meds as well. It would cut into the doctor, ED, pharmacy shopping to get more scripts. On the other hand, what kind of slippery slope would it start? Could I be prevented from getting a second opinion if one doc wasn't treating my pain? Do I want use of certain meds to be public knowledge? A lot of the information could be prejudicial. Hmmm . . . .