LTC Drug Addicts

dosamigos76, RN · Jun 22, 2003

Wow, thanks Pappy! I am hoping to start nursing school this fall and would like to work in LTC, and you have provided more motivation to do so. I am going to copy your post and keep it. Thank you so much for sharing your point of view and perspective.

Cheryl

pappyRN · Jun 25, 2003

Hello All,

Warning!LOL I always have SO much to say. Please don't leave yet!Hehe!

Thank you to each of you for your vote of confidence in my words. How very kind of you. I was really worried that my reply would be found offensive by some although that was NOT my intention. I appreciate the ability to have a healthy discussion without fighting or flaming etc. What a treat!

I so miss the discussions I had with colleagues.

With all of my heart, I hope to do everything possible within my physical limitations to increase awareness about not only reflex sympathetic dystrophy and fibromyalgia, but about chronic pain treatment in general. To be sure, I don't want to forget about promoting awareness of the experiences of LTC residents that are similar to those of my own Mom's.

I only wish that I had the strength to be able to pursue these subjects with the diligence and vigor they deserve. I can't thank you enough for being a thoughful and considerate audience in letting me speak my feelings.

I ask myself, why do I care so much about this subject? I can only conclude that deep within the spirit of this nurse's heart, I can not forget that I once pledged to dedicate myself to my pts. In my nurse's mind, I view almost everyone as a potential pt! Although technically my Mom and my sisters aren't my pts, I know that unofficially they would have been (and somewhat are) had I not also been ill. There's no doubt in my mind that you are all familiar with the concept of being the 'family' nurse. I lost count of how many times I have been called for advice which in most cases I willingly and lovingly gave.

I don't think that being sensitive to the needs of our pts also requires a vast pool of knowledge. Rather, one can minister to them by using your intuition and conscience and by trying to empathize with their feelings and their situations. Just 'put yourself in their shoes'. In many cases it CAN be as simple as that. Is this how YOU would want to be treated? Is this how you would want YOUR MOTHER to be treated? If the answer is NO, then you know in your heart what needs to be done. I can't think of any other prerequisites other than basic human decency and kindness. Of course, it goes without saying that knowledge of the pt's diagnosis is thought to already be present.

If the pt is displaying dysfunctional behaviors there is no reason to contribute fuel to the fire by projecting your behaviors of suspicion or intolerance on her. You may be unconsciously reinforcing her need to behave dysfunctionally and cause her to escalate her behavior. If this translates into the pt thinking "the nurse doesn't believe I'm in pain. Now, what can I do to show her the next time I ask for my medicine." This then encourages the pt devising ways to get you to believe they really do hurt.

Instead of going along with what every reporting nurse before you has said or done, be different. BE the one who has the kindness,courage and conviction to go the extra mile! It would be unrealistic to think that you will always be successful. But I believe that in many instances you will. This is a fellow human being who for one reason or the other is hurting whether physically or emotionally or BOTH. Tend to their needs.

It is entirely acceptable to reserve a spot for suspicions but save your suspicions for a situation that demands it. It is inappropriate to automatically think "addict" when you see that a person is taking regular medications for pain. It just shouldn't be your first thought UNLESS you KNOW this person to be an addict. You can save some room for it in the back of your minds if their are behaviors that point your thoughts in that direction. By no means do I intend to have you believe that you should NEVER be suspicious of whether or not a pt is an addict. But, give the person a chance. Don't decide how you feel about them before ever seeing them or talking to them.

There are some general ideas I can share that maybe you don't already know if you have never had any experience with them.

So, FYI: I am taking methadone for neuropathic pain from reflex sympathetic dystrophy aka complex regional pain syndrome, thoracic outlet syndrome and for two primary nerve injuries along with fibromyalgia, myofascial pain syndrome, osteoarthritis etc. to name a few of the pain syndromes from my alphabet soup of diagnoses. I was well managed on ms contin about 3 months ago and had been taking it for almost two years with few problems other than constipation. I took ms contin 60mg q 8h. Yes, I could still function on that dose. I am not 'opioid naive' and so would not most likely experience the complications and side effects that one who is not used to taking narcotics would have.

FYI:I am now on methadone 40mg/day in two or three divided doses for the reason that the generic ms contin was cosing me $375.00/month OUT OF POCKET as i have Medicare and am on disability after a long battle with SS. I have just initiated taking this new dose. Methadone has a half life of approximately 30 hours so I haven't yet arrived at the period of time where I would be able to tell if it will make me two drowsy taking 20mg at each dose bid. I have instructions from my pain doc, aka PMP=pain management physician, to take 20mg in the am and 20mg at hs. If that dose makes me too drowsy then I am to go back to 10mg in the am, 10mg 8h later and 20mg at hs. I'll just have to wait and see what happens.

FYI: Most pain patients do not experience a "high" from their pain med. Many studies have been done. They just experience relief and if not all the pain is taken away, hopefully even a fraction is. Whatever the amount is, they will gladly accept although they do reserve the right to need more medication to attain acceptable comfort.

FYI: It is likely that pts who have been on opioids for a while will require higher than usual doses of a pain med and that it probably will be an amount that makes you uncomfortable administering. You'd probably be surprised at how much medication a longtime pain pt can take without experiencing respiratory depression. Of course, one still has to observe them for that possibility but normal breathing rates could be accepted as respiratory depression if the medication has worked and the pt is now blissfully asleep!We tend to breathe more rapidly when in severe pain.

FYI: It is a MYTH that pts in pain can NOT sleep and that if they are, it must mean they really don't hurt that much after all. We experience a lack of deep, RESTORATIVE sleep. Just because we experience pain, it doesn't mean that our other bodily needs don't work to an extent although it is highly likely that the pt concurrently is dealing with some sort of sleep deprivation or disorder such as insomnia, restless legs syndrome and even narcolepsy.In my own case, I almost never drive anymore because I have a tendency to fall asleep. It's usually when I am stopped at a signal. I also know from experience that I can fall asleep in an instant if I am extremely tired from life or from my meds and there isn't ANYTHING that can keep me from dozing off. I have fallen asleep at my computer a few times these last couple of weeks. I woke up because my daughter awakened me. I had marks all over my face from falling asleep on my keyboard so being asleep is NOT a reliable parameter when observing pain pts.! Sleep is a blessing for pts whose medication isn't adequate to relieve their pain. Finding the patient asleep and who had just requested pain medication can simply mean that they either passed out or fell asleep from exhaustion associated with having to deal with chronic pain in addition to all the other activities in their lives. We get tired just as you do but we are also struggling with the drowsiness from our meds. It is entirely probable that the pt will also be taking adjunctive meds for his condition or for other illnesses he is being treated for. So, you have to factor in that possibility.

FYI: Pts with fibromyalgia can also suffer from CFIDS-chronic fatigue immune deficiencysyndrome but it is not automatic that if you have one you have the other.

FYI: Fibromyalgia or FMS can and is a very disabling disorder without proper treatment. Many physicians even to this day, question whether or not it is even a valid entity therefore making the diagnosis with these pts can be a very long drawn out experience. BUT...there is new research in which it has been documented that pts with FMS have a change in their brain MRIs as oposed to healthy pts. meaning a breath of relief that even our own docs may now believe our pain.

FYI: FMS pts should be encouraged to do as much low impact exercise as they can tolerate. Aquatherapy is a great therapy for FMS and also RSD.

FYI: FMS is just a problem where the pt has some aches and pains in his muscles. These are more than just aches and pains. They can even be of the intensity of other pain syndromes who's origins are neuropathic in nature. Although narcotics aren't the first drugs of choice in treating FMS, in pts whose pain is intractable narcotics are appropriate. It is very unusual to get complete relief. There is also joint stiffness.

FYI:FMS pts may have significant cognitive difficulties lovingly referred to by some as 'fibrofog'. You will not have to be around the FMS pt very long before the cognitive problems play out before you. We forget what we are saying in the middle of a sentence, we forget what an object is called even if it entirely familiar to us, and short term memory problems are glaring in some cases such as my own. I am driving my family crazy because I repeat myself so much. I relate a story to one of them and the same day or 1 day later, I have absolutely NO recollection that we had spoken and about what. I have been working on this post for several hours-have to sit and think hard about what I want to say because I keep forgetting. I'll think of a point I want to include but unless I write it down immediately-POOF it's gone and maybe forever. It's taking so long also because I type one-handed due to rt sided RSD involvement.

FYI: I still apply makeup even when I am feeling like I would rather do anything other than be awake. If you look too bad people say you are faking it or that they know someone with the same illness and THEY are doing so well so why don't you do what they are or they offer to have that pt call you to exchange war stories OR that it is just because of the drugs that you look this way and that if you would stop taking them you would get better along with all the other nauseating garbage they hand out like"you aren't trying hard enough to get better" and "you can do anything you make up your mind to do" and "pull yourself up by the bootstraps"?????? What the heck! Pull YOURSELF up as if this was something we WANT to have and we are just not trying hard enough!

FYI: IF you look too GOOD: they say you couldn't possibly be as sick as you say you are and a whole other load of poop. etc. You can't win for losing.

Remember, just because we are sick, some of us have managed to keep our pride about personal appearance. We can at least PRETEND to look normal although inside we may be screaming in pain.

FYI: RSD and FMS/MPS are disorders that can wax and wane.i.e. one day you may feel so bad you are praying that you will be delivered fromyour hell and 2 days later you feel SO good you begin to doubt yourself that there is ANYTHING wrong with you and that you must have been imagining your problems only to find that for the next three days after that, you are again asking God what you did that was so wrong that you deserve to feel like you are feeling!

FYI- Methadone is a med that does NOT lend itself well to large increases without slowly titrating upwards due to the long half life. It is also reported to be a living hell for anyone who has to withdraw from it without proper supportive measures and may even cause seizures and/or death if one is not withdrawn on a slow taper prescribed by a physician. It is definitely NOT a medication where a bolus is desirable due to the side effects.

FYI: The Duragesic or fentanyl patch is another drug that is frequently ordered for chronic pain patients. It is said to be inappropriate for acute postoperative pain. It is also not a good choice for opioid naive patients as it has the tendency to make them very drowsy, nauseated, feeling dizzy and c/o HA. It takes approximately 16-17 hours from when the patch is first applied for the pt to feel it's effectiveness which is also referred to as reaching a 'steady state'. The patch must be securely against the patient's skin and not over any areas of broken down skin as this can effect the rate of absorption. The patient should avoid hot showers or baths and hot tubs(hehe-for all the LTCs who have hot tubs AND the internet!).Another very important note about the Duragesic patch is that if the pt has a temp 100 degrees or higher you should call the doctor. Temp elevations can cause the pt to absorb the medication 25% fster than if he had a normal temp. This should alert you to watch for symptoms of a dose increase. The doctor may decide not to keep the pt on Duragesic with a prolonged temp over several days. Some pts get a rash from the patch. That alone is reason for the doc to d/c it. The manufacturer has a program to provide free bio-occlusive dressings to patients who call their 800 # to report that they are having difficulty with getting the patch to adhere to their skin. IF you also tell them that your skin is breaking down from the patch, they will REFUSE to send the dressings and will instruct you to call the doc to d/c the med as it is their belief that a pt with skin breakdown should NOT be using the patch. Many pts have the trouble with the adhesive on the patch NOT sticking to their skin so don't let the company have you think it is NOT a common c/o because it IS. My Mom had been on Darvocet prn and Percocet prn for pain after several months after her hip fx. She was having a rough period of time with pain from her hip and also her shouder subluxates due to her paralysis and the CNAs don't always put her sling on her. I have to go in and put her shoulder back where it belongs because the nursing staff at the LTC refuses to 'since we aren't trained'. During that time we were watching my Mom yo-yo with drowsy vs awake periods from her meds. There was also a problem with her receiving her prns in a timely fashion from when she requested them. In otherwords, it would take the nurse an hour from when she asked for her med for the nurse to give it to her. She had also been requesting them on a very frequent basis. For whatever reason she had an exacerbation of her pain.I asked her physician to order chronic pain medication around the clock to avoid all the problems inherent with using only prn meds even though she had been asking for her meds more frequently during that period for the most part they truly were prn and not more than a few times per week. Well, he ordered Duragesic 25mcg patch. She was snowed for 3 days!!! She just couldn't stay awake! I had been hoping that he would start with a low dose of one of the contin drugs, perferably ms. It was a good example of why it is important to start low and make the doctor totally aware of just how much prn pain meds the pt is asking for. He can then make a decision based on that info. It is NOT unsual for a pt's primary care physician, PCP, to be the one to order these meds so that is another reason that the nurse should be educated about the intricacies and/or idiosyncracies if you will, in regards to pain medication. Remember, that MOST PCPs have very little knowledge of pain management. That's another reason to encourage the PCP to order a PMP consult. The goal is NOT to snow a pt but to make the goal be for the pt to return to the most functional state as possible. It makes a world of difference in how and what is ordered.

FYI: Opioids have a propensity to make a patient nauseous. This can even happen after a patient has been on opioids for quite a while. So, some patients also take antinausea drugs on a prn basis. I have been on opioids for almost 8 years and I still experience bouts of nausea. My PCP had ordered Compazine prn but since compazine can cause tardive dyskinesia my PMP changed my med to Zofran-ouch it's expensive! (Read about tardive dyskinesia-never even heard of it until I saw something about it on a support group forum I participate in-it is very scary and will make you think twice before giving any drugs in the category of potentially causing TD).

FYI: Another common complaint from patients on opioid is itching. I am not talking about hives or even a rash you can see. Applying calamine will not help. There is an overall bodywide itching that feels like it is deep in your skin that can and does manifest itself to persons on opioid therapy. It's like the itch that you can't scratch becaues you literally can't get to it to relieve it.

For this, some take antihistamines or if they can be patient patients, it USUALLY goes away after a few weeks or months and only returns with dose increases or med changes. Don't worry unless you can see that the patient has hives or is complaining of dyspnea. If the patient is getting good relief from their med, then just try to encourage him that the itching may last for awhile but that it usually goes away. It may be tolerable for some and for others, intolerable and they have to d/c the med but only on a physician's order in case they need to be tapered off the med while titrating upward on the med replacing it.

FYI: When a doc changes a pt's narcotic medication, be sure to ask him about the period of time while the pt is in the process of achieving steady state and d/c his previous med. Ask if he wants to give a few more doses of the old med while starting the new med so that the pt's level doesn't drop off before the new level can reach steady state. That overlapping time period has the potential for putting the patient in a withdrawal state.

FYI: Be sure to ask the doctor if the dose of the new medication is equianalgesic to the old medication. It makes NO sense in starting a pt on a different drug because the old one didn't help the pain enough and then turning around and ordering a med dose that is not even close to the equivalent of the pt's previous medication. Would it make sense for someone who was taking 800mg of Motrin qid to be told to sstop that and then take 2 tylenos regular strength in the morning and at bedtime?

FYI:The above scenario can frequently be an issue especially if the doctor is a PCP who isn't qualified nor experienced enough in chronic pain management established by criteria set forth by organizations such as the American Pain Society or the American Board of Pain Management Physicians etc.to practice pain management. Anyone can just call themselves a pain management physician but it is a far cry from a doctor who has also received the training and therefore the board certification.

Well, I hope I haven't managed to bore you to death. I don't mean to preach to you but rather to share from the experiences of my Mom, sisters and myself. I hope it gives you another perspective on these subjects. I know that experiencing it firsthand sure changed my way of thinking about it. I am ashamed of myself for all those times when I was so afraid to give my pt anything other than the lowest dose of pain medication ordered. I hope I can be forgiven for covering my own hide instead of putting their comfort first before my own hangups about pain medications.

The old saying "Walk a mile in my shoes" has not only given me new shoes but has served as a real eye opener.

Thank you for taking the time to read my replies. I hope no one takes any offense. In addition, I have taken none from the many replies. This is a really good topic and to discuss it like mature adults is just a real pleasure. Thank you, again.

Warm personal regards,

PappyRN

gizzy76 · Jun 26, 2003

Thank you again Pappy

For typing one handed, you must have an awfully sore hand now! My god! Thank you for the information...I am going to print your information and share it with a co-worker. She and I were discussing this tonight at work and she said that she would love to read the posts.

Rapheal · Jun 26, 2003

To all the people who are on narcs long term. Please remember to do what you can to keep up your abdominal muscles and to increase your fiber and fluids. I have been seeing way to many long term narcotic patients with bowel obstructions that require surgery. It makes me so sad to see relatively young people with colostomies.

mattsmom81 · Jun 26, 2003

We have to balance pain control with safety issues and side effects. It can be a tough job. To relieve/control someone's pain they may become woozy, fall risk, etc. which increases risk for the facility.

I am very glad to see the new laws on pain control issues, as it has been neglected too long. And too many people still have misconceptions and bad attitudes regarding pain.

Good thread and good posts all. :)

Dr. Scully · Jul 2, 2003

I agree that this is a great thread to discuss. One that is only getting worse. I have always believed in the patient when they say they are in pain. I have come across the usual "drug seekers"but; try to put my feelings and opinions to myself. I have worked in many areas from hospitals, LTC, to Hospice. I have even had to educate doctors on basic pain control!! I read where the physician receives only about 2 hrs in his or her studies in med school!! I, too, have chronic pain and I am made to feel like I would "abuse" pain medication when I ask for it in the physician's office. I think so much harm is done with the news programs which frequently talk badly about abuse of pain meds, the horrors of oxycontin, etc. Many good doctors are put in a bind by having their "controlled substance" records reviewed. Some have been arrested. Where will it end?? I also pray that when I need some pain meds; that the dr. will believe me and not think I am drug seeking. Education seems to be the key; but, will our society's idea of pain meds change??

BillArnold1961 · Jul 2, 2003

It seems to me that if the majority of nurses are for pain control, we could eventually change the minds of narrow-minded nurses and doctors if only we would speak up when confronted with the situation. We need to be more agressive with our opinions like the ones that put pain control where it is now. Just a thought.

Thanks for reading,

Bill

Token Male · Jul 3, 2003

Token Males - Nurse Maid, Yes married nurses with 2 unforgiving children who pity every 2 nurse family - for lack of sympathy - NOT only in the Pain Area.

WHAT is PAIN ? a perceivded discomfort ? ; complete and utter agony ? ; anticipation of either of these and every feeling inbetween.

I think far too often pain / discomfort is actually totally overlooked in the Aged Care Field. Gizzy we've all (if we've been nursing long enough) experienced clients in LTC that exhibit similar traits - perhaps 'our' comments / attitide / bodylanguage instill in clients preconceived perseptions too. I'm sure when I'm working ND I'm FAR more amiable at 0100hrs than I am at 0500hrs - by then I'm in pain and I don't even feel it - not physically anyway.

Blame Token Male for my input - he knows my passion / addiction - apart from Chocolate - the Internet

adrienurse, LPN · Jul 3, 2003

Yes the list of medication seems excessive, but why would the person NOT have pain following hip surgery? I had hip surgery 15 years ago and I live with pain every day. I may not take narcotics for it, but that's not to say that others may not need them.