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.
To deny pain relief to a suffering human being flies in the face of everything I thought a nurse should be. But nurses are human too and we all come with our own set of rigid beliefs, as flawed and predjudiced as they may be. The older I get and the more I read and learn about chronic pain, addiction, and drugs, the more I realize just how wrong my view on these subjects have been all of these years. At least for me, they were wrong. See, I use to believe that when I went to the doctor for stitches, fractures, or whatever, that the "all-knowing doctor" would know exactly how much pain medicine each injury or illness was worth. If he didn't give me anything for pain, I supposed I must not be hurting bad enough to warrant pain medicine.
As far as pain was concerned, I kinda felt that only "wimps, pansies, and drug addicts" would dare ask for anything for pain, but in reality I didn't really know what a wimp, pansy, or drug addict looked like other than the negative stereotypical image I had of them. It wasn't until about 4 or 5 years ago that I began to "change my tune" about how I viewed pain. It wasn't as if a lightbulb went off in my head but it was rather a very long process that continues to evolve even to this day.
The evolution of my views regarding the bureaucracy of pain control and management was due, in most part, to the whirlwind of doctors, nurses, hospitals, clinics, and everything in between that my husband and I were subjected to once he became ill. Not only was I angry at my husband for being ill, I was also angry and dissolusioned with the myriad of healthcare providers that we came into contact with. As my husband suffered incredible pain, he was poo-poo'd by some doctors because they could find no reason for his pain, he endured painful procedures from specialists who were treating him based on a misdiagnosis and then, when he continued to complain about the pain, was passed to other doctors. Never once was he given anything more substantial than a Darvocet or 5mg lortab for his pain, and only then was it very sparingly given. My husband didn't care...at that point, he would have eaten anything if it promised the slightest relief in his pain. He was loaded up on Bextra, Vioxx, ibuprofen, naproxyn, and all NSAIDS in between, he was taking SSRIs and anti-seizure medications, but nothing helped with the pain that he was experiencing. My husband began to question himself saying, "this couldn't all be in my head could it?" After 2 years of hell and a marriage almost in shambles (because the doctors had me convinced that there was nothing wrong with the man I had been married to for over 10 years and he was just seeking drugs), he was referred to a pain clinic who in turn took over all aspects of his care. Finally someone believed him. There really was something wrong. They didn't immediately and without disregard start writing large amounts of strong opiates, but they did help to keep him comfortable while searching for the reason for his pain. They set up appointments with hemotologists, orthopedists, oncologists, internists, and surgeons and they coordinated the care between all. In all honesty, now that I look back on it, these doctors saved my husband's life. Not only did they get to the root of his medical problem, but just the simple fact that they believed him gave him hope for the future because I believe that if he had to go another 6 months like it was, he would have killed himself. He was in that much despair.
It would be nice to believe that all of the doctors who treated my husband did so sincerely and to the best of their ability. However, since becoming a nurse, I know better. Although my husband never onced asked for certain prescriptions, I'm sure that most of the doctors and nurses were thinking behind his back that he was just looking for drugs. That seems to be what a lot of healthcare workers think based on comments that I've heard from other nurses in the hospital and from some comments made on this board.
I know that there are bad people out there, but I also believe with all of my heart that most people are good, sincere, honest, and law-abiding. 9 times out of ten, if someone tells you that they are in pain, then just maybe they really are in pain. To deny anyone adequate pain control of any kind, for any reason (other than if it's not in the patient's best interest at the time),is heartless and inhumane.
I don't know about any of you here, but try as I might, I'll never be able to see through the eyes of another human being or physically feel what they are feeling, just as no one will ever be able to see through my eyes or feel what I feel. If we really could "walk a mile in each other's shoes," I think we would have a much kinder and gentler society. After 2 years of going through what we went through, I would never want any patient to have to needlessly suffer because I doubted their sincerity or because they didn't look the part of someone in pain. I did not go to nursing school to police and ferret out drug abusers. If I wanted to do that, I would have gone into law enforcement.
I'm not sure we are creating addicts, I feel we are aiding in their addiction. Heck, we are now starting Iv's in the loby at triage ,giving Dilaudid. (I havn't done this but other nurses have , I personaly will refuse...If they're that bad they should be in a room, that is a law suit waiting to happen !)./ But any way, Other hospitals in the area don't do that but by gosh we have to keep up our pres gainy scores. Seems any more the idea of "striving for 5 " on the presgainy equated into leaving with a script for narcotics. I work in Ohio, One of our docs moved to Denver. He said he about fell over when he gave a script to a pt with a fairly bad injury ,for vicodin and the pt told him. oh no...that's way to strong, can I get just some motrin.
I think it's the same as with guns, guns don't kill people, people kill people. Drug addicts create drug addicts. My doctor will only give me Darvocet for my chronic pain. I have herniated discs, sciatica, degenerating spine, several pieces of metal (plates) and he says after taking this medication for 6 years that I am becoming used to narcotics; NO MY PAIN HAS GOTTEN WORSE!!!!
As nurses, we need to insure that we believe a patients pain is where they say it is and how bad they say it is. Period. It's not up to us to pass judgement on whether or not they really "need" the pain relief or whether or not they have an addictive personality or a "junkie" mentality or an exsisting drug issue. We are supposed to be a patient advocate, trying to insure they are as comfortable and as pain free as possible. Offering alternative therapies, if possible and available, help for patient comfort but bottom line is we all feel pain, and react to it, differently, and none of us are capable of actually knowing how much pain (physical, emotional or spiritual) another human is in. Empathy, regardless of what our patients faults and shortcomings are, is part and parcel of what being a nurse is all about.
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
ONLY TYLENOL?? That person must have been in a lot of pain, and that sure wasn't right.
I hate the term clock watcher. I had 4 impacted wisdom teeth removed years ago and got a Tylenol #3 Rx that was q4h. Sure enough, when 4 hours passed my jaw was hurting. If I was in a position to have to ask a nurse for the pill, would this mean I'm a clock watcher?
Besides, in a general sense we are all drug seekers. When we get a headache we reach for the OTC pain relievers, when we get heartburn, we reach for the antacids, when we are constipated, we reach for the laxatives, and so on.
I think it should be outlawed to mix phenergen + analgesic IVP to give as a pain remedy. We all know these patients are looking for an extra kick! And nausea doesn't occur spontaneously with MS!:angryfire
I think it's the same as with guns, guns don't kill people, people kill people. Drug addicts create drug addicts. My doctor will only give me Darvocet for my chronic pain. I have herniated discs, sciatica, degenerating spine, several pieces of metal (plates) and he says after taking this medication for 6 years that I am becoming used to narcotics; NO MY PAIN HAS GOTTEN WORSE!!!!
Please get thee to a pain specialist. Darvocet went out with Dodge Darts.
I work on a psych/substance abuse unit - I don't know the answer to the problem of people with genuine chronic pain developing addictions, but I do know for certain that an increasing number of people who intentionally abuse drugs are learning to take advantage of the current attitudes about pain management. I get patients all the time who use IV oxycontin for the high then demand their "rights" and want opiates prescribed while they are in the hospital. One client actually quoted a line from a pain article to me, saying " I have a right to pain meds and I don't have to prove my pain to anyone. My pain is whatever I say it is!" How exactly do you document medicating a patient like that ( the quote itself is probably right out of a nursing magazine, and it's hard to describe the smirk on her face in medical terms!) It's frustrating....
They studied this in Boston in the mid 1980s. They followed 10,800+ patients who had been given narcotics in hospital. Guess how many new addictions they found!
Wait for it.
Got a guess?
FOUR.
If your patient says he is in pain, he is. Even if he's a drug addict. Even if you think he's taking too much pain med. Even if you think he's a whining crybaby. Even if he's exhibiting classic drug seeking behavior, something I've seen in every post op patient I've cared for after Nurse Tylenol reported off to me.
The statistics are with him that he won't develop an addiction.
You know, I agree totally about that. When I started the thread though, I was more thinking about the whole chronic pain movement and the fact that there are people who take advantage of the liberal attitudes regarding prescriptions. I wasn't really talking about acute pain, to tell you the truth.
I think the ER sees alot of this behaviour, where drugseekers come with general abd pain, labs are normal, and the scruffy looking pt is carrying on in a melodramatic demanding way. They always know all about the pain scale and they are always a 10/10.
I don't have any easy answers for this one. I've been interested in pain management since the early 70's ... worked in acute medicine taking care of many folks with sickle-cell, pancreatitis, cancer and such-like. Back then, I was appalled at the power struggles that would occur between patients and docs re pain control. An example: a 34 year old sickle cell pt maintained on dilaudid 8mg q4h at home being forced to go to demerol 50 IM q4 DURING A CRISIS!!! I could hear her screaming at the other end of a 50ft hallway with her door closed! The intern wouldn't modify the order ... he didn't want to get her addicted! 25 years later, I took care of an end-stage AIDS pt on a morphine drip (around 160mg/hr at the time) who was lying rigid in the bed with the pain of neuropathy, various CNS infections and spinal TB ... the attending refused to allow escalation of medication and, in fact, REDUCED the dose!!! He felt the pt was "drug-seeking". The poor b-----d was actively dying ... luckily this idiot only covered us for a weekend and when our regular attending came in, we were able to address the pain rationally and do something about it. These are 2 fairly extreme examples of the way we often get tangled up in conflict over whether we are treating pain or treating an addiction. I agree with something I read years ago ... in order to do effective pain management, we have to accept the fact that some addicts are going to "get over". It is reasonable and necessary to try to screen out addictive drug-seeking ... but we also need to hold to the fact that addiction and pain are two different problems and decide which is the priority. My personal opinion is that our society has placed a higher priority on making sure addicts don't get high than on relieving pain...but that's just me.
Working with addicts who are also in pain is the greatest challenge of all ... I don't think anyone is expert at it ... I just know that there is no 100% accurate objective measure of pain ... pts with chronic pain have nl vitals and look/act normal (my partner a case in point ... chronic pain @ 8/10 for years from arthritis and scoliosis ... couldn't tell from looking at her) So ... until someone invents a God-pill that will let me read minds, I still have to treat the pain the pt reports ... if I think there's addicitve drug-seeking going on, that's what psych consults are for.
I don't have any easy answers for this one. I've been interested in pain management since the early 70's ... worked in acute medicine taking care of many folks with sickle-cell, pancreatitis, cancer and such-like. Back then, I was appalled at the power struggles that would occur between patients and docs re pain control. An example: a 34 year old sickle cell pt maintained on dilaudid 8mg q4h at home being forced to go to demerol 50 IM q4 DURING A CRISIS!!! I could hear her screaming at the other end of a 50ft hallway with her door closed! The intern wouldn't modify the order ... he didn't want to get her addicted! 25 years later, I took care of an end-stage AIDS pt on a morphine drip (around 160mg/hr at the time) who was lying rigid in the bed with the pain of neuropathy, various CNS infections and spinal TB ... the attending refused to allow escalation of medication and, in fact, REDUCED the dose!!! He felt the pt was "drug-seeking". The poor b-----d was actively dying ... luckily this idiot only covered us for a weekend and when our regular attending came in, we were able to address the pain rationally and do something about it. These are 2 fairly extreme examples of the way we often get tangled up in conflict over whether we are treating pain or treating an addiction. I agree with something I read years ago ... in order to do effective pain management, we have to accept the fact that some addicts are going to "get over". It is reasonable and necessary to try to screen out addictive drug-seeking ... but we also need to hold to the fact that addiction and pain are two different problems and decide which is the priority. My personal opinion is that our society has placed a higher priority on making sure addicts don't get high than on relieving pain...but that's just me.
Working with addicts who are also in pain is the greatest challenge of all ... I don't think anyone is expert at it ... I just know that there is no 100% accurate objective measure of pain ... pts with chronic pain have nl vitals and look/act normal (my partner a case in point ... chronic pain @ 8/10 for years from arthritis and scoliosis ... couldn't tell from looking at her) So ... until someone invents a God-pill that will let me read minds, I still have to treat the pain the pt reports ... if I think there's addicitve drug-seeking going on, that's what psych consults are for.
From a chronic pain sufferer, I thank you for your input. I am going to print out your posting and give it to the ER where I work. They are more concerned with addiction than pain control. I was appalled at their attitudes before my pain escalated, but now I have a much better understanding.
You have a very caring and empathetic personality.
:angryfire.thumb.jpg.ccc2deb5c83ef722c05e530ac420d6fb.jpg){kind=small}
scarta105
22 Posts
To deny pain relief to a suffering human being flies in the face of everything I thought a nurse should be. But nurses are human too and we all come with our own set of rigid beliefs, as flawed and predjudiced as they may be. The older I get and the more I read and learn about chronic pain, addiction, and drugs, the more I realize just how wrong my view on these subjects have been all of these years. At least for me, they were wrong. See, I use to believe that when I went to the doctor for stitches, fractures, or whatever, that the "all-knowing doctor" would know exactly how much pain medicine each injury or illness was worth. If he didn't give me anything for pain, I supposed I must not be hurting bad enough to warrant pain medicine.
As far as pain was concerned, I kinda felt that only "wimps, pansies, and drug addicts" would dare ask for anything for pain, but in reality I didn't really know what a wimp, pansy, or drug addict looked like other than the negative stereotypical image I had of them. It wasn't until about 4 or 5 years ago that I began to "change my tune" about how I viewed pain. It wasn't as if a lightbulb went off in my head but it was rather a very long process that continues to evolve even to this day.
The evolution of my views regarding the bureaucracy of pain control and management was due, in most part, to the whirlwind of doctors, nurses, hospitals, clinics, and everything in between that my husband and I were subjected to once he became ill. Not only was I angry at my husband for being ill, I was also angry and dissolusioned with the myriad of healthcare providers that we came into contact with. As my husband suffered incredible pain, he was poo-poo'd by some doctors because they could find no reason for his pain, he endured painful procedures from specialists who were treating him based on a misdiagnosis and then, when he continued to complain about the pain, was passed to other doctors. Never once was he given anything more substantial than a Darvocet or 5mg lortab for his pain, and only then was it very sparingly given. My husband didn't care...at that point, he would have eaten anything if it promised the slightest relief in his pain. He was loaded up on Bextra, Vioxx, ibuprofen, naproxyn, and all NSAIDS in between, he was taking SSRIs and anti-seizure medications, but nothing helped with the pain that he was experiencing. My husband began to question himself saying, "this couldn't all be in my head could it?" After 2 years of hell and a marriage almost in shambles (because the doctors had me convinced that there was nothing wrong with the man I had been married to for over 10 years and he was just seeking drugs), he was referred to a pain clinic who in turn took over all aspects of his care. Finally someone believed him. There really was something wrong. They didn't immediately and without disregard start writing large amounts of strong opiates, but they did help to keep him comfortable while searching for the reason for his pain. They set up appointments with hemotologists, orthopedists, oncologists, internists, and surgeons and they coordinated the care between all. In all honesty, now that I look back on it, these doctors saved my husband's life. Not only did they get to the root of his medical problem, but just the simple fact that they believed him gave him hope for the future because I believe that if he had to go another 6 months like it was, he would have killed himself. He was in that much despair.
It would be nice to believe that all of the doctors who treated my husband did so sincerely and to the best of their ability. However, since becoming a nurse, I know better. Although my husband never onced asked for certain prescriptions, I'm sure that most of the doctors and nurses were thinking behind his back that he was just looking for drugs. That seems to be what a lot of healthcare workers think based on comments that I've heard from other nurses in the hospital and from some comments made on this board.
I know that there are bad people out there, but I also believe with all of my heart that most people are good, sincere, honest, and law-abiding. 9 times out of ten, if someone tells you that they are in pain, then just maybe they really are in pain. To deny anyone adequate pain control of any kind, for any reason (other than if it's not in the patient's best interest at the time),is heartless and inhumane.
I don't know about any of you here, but try as I might, I'll never be able to see through the eyes of another human being or physically feel what they are feeling, just as no one will ever be able to see through my eyes or feel what I feel. If we really could "walk a mile in each other's shoes," I think we would have a much kinder and gentler society. After 2 years of going through what we went through, I would never want any patient to have to needlessly suffer because I doubted their sincerity or because they didn't look the part of someone in pain. I did not go to nursing school to police and ferret out drug abusers. If I wanted to do that, I would have gone into law enforcement.