need info on drug step down/holiday for pain pt and info

Hoozdo, ADN · Dec 16, 2009

if that patient didnt get her narcotic and it is only 7.5 mg of percocet tid and she doesnt get it....what happens, she goes into withdrawal right? but what happens? nauseau, vomiting, worst? can she seize?

from my experience working prn in a county jail - i have seen lots of people withdrawing from opiates. biggest symptoms are diarrhea and nausea. no seizures.

can it be worse?

i haven't seen it worse.

otoh, withdrawal from etoh or benzos is nasty. this is reason for hospitalization. nobody will die from withdrawal from meth, crack, or opiates.

i truly wasnt sure? every one talks about withdrawal but then i have have been told that for that small amount you cant have withdrawal but if you are taking it daily why not?

next....we had a discussion about how over time you build a tolerance, right? or not? ok, if you do, can you take a drug holiday? or go to a clinic for a sort of withdrawal to get to a lower level? or does that not work?

does not work for chronic pain. how will you control chronic pain if you go on a drug holiday?

and if you did that, would your insurance pay for it (lets say for sake of argument you had great insurance) or would you now be considered an addict and you now wouldnt be able to use narcotic meds? would a pain dr make that decision? but say for someone that doesnt want to keep mounting up to a huge amount, more and more, if they start to build a resistance, what is their option?

a pain management doctor would up their dose. as a nurse, you will find that you don't have the time to worry about insurance options. it is the least thing on your mind. you barely have time to do your job safely, let alone worry about the pt's insurance.

i really appreciate input!! this is not anything i could an answer to and when i brought it up, i was sort of brought around to oh, that wouldnt happen? i often see these pain patients that go to these clinics become like zombies with their meds and patches....you know?

sometimes it is better to live as a zombie than commit suicide because they are in constant chronic pain. at least they are able to walk around rather than being bed bound due to pain issues.

angelsmommy.

anangelsmommy, ADN, BSN, RN · Dec 16, 2009

Even if the patient expresses that she wanted to try the drug holiday or to go down on the amount. She said that at one time she was only on a very low dose, that she had been taking .25 and not even on a regular basis. That she didnt understand how it had progressed to this but her doctor didnt give her answers and just said that this is how it sometimes is with pain and gives her the drugs. She said she tried to discuss feeling withdrawal even now with her doctor, the doctor said that was impossible. She said that she starts to feel that she has more withdrawal symptoms than pain, again when I asked my instructor I got very little information and there was very little on the internet and none in my text. I feel like an imbecile.

one clarification, you said you cant die from withdrawal from crack, meth and opiates, can they die from alcohol and benzos withdrawal because of of seizures and the impact? that actually makes sense to me, my son had been on valium prn and one night didnt take it and I hadnt ever realized that he had been taking it so often it should have been something that was every night (it was before I was a nurse/my son was disabled and lots of issues, anyway not having it triggered a 45 min seizure, so I can see that effect clearly.

But if the patient expressed a desire to decrease her meds, isnt there some way to try it? there isnt another thing to give her temporarily if she thinks she may be able to handle the pain for a short term? of course from what I read when you are in detox just being in detox makes you think you are in more pain...would she be just as likely to go back up to her last dose? - that was my concern was that the old tolerance would still be there somehow naturally and what they naturally give you anyway is 5's so if they you get you off wouldnt you just end back on it in no time? thanks again for the discussion!

keba · Dec 16, 2009

I have seen clients that indicate their wishes and refuse pain therapy as ordered and request information on the effects of the such therapy from relatives and nursing staff as well as doctors. What we do is we get the drug package and the infor mation that is easily understood we explain to the client. the client has the right to refuse proposed therapy and or request other lower doses, however that depends on the doctor. Some doctors refuse to allow client input in the treatment of the client and thus conflict persists. In most cases the doctor actually works out a lower and safer dosage with the client and the client as well as nursing staff evaluates the effects. For sicklers, there is no compromise as many are addicted to the opiates and even feel relief with placebos and 5%DW, some are genuine in their complaints.

You are concerned with the client withdrawal from opiates, well here is a funny, an addict was hospitalized for multiple fractures to the lower legs however no opiates were given, he recieved Diclofenac sodium instead and it worked well. He was hospitalized for 18 days and during that time he showed no signs of withdrawal, even though he said he used cocaine more than 3 times daily.

thus sometimes as a nurse you will notice that some clients have a greater tolerance due to their perception of pain and whether the clienhas low, medium or a high pain threshold.

Hope this helps in planning care. Remember used your eyes ears and assessment sheets well.:w00t:

anangelsmommy, ADN, BSN, RN · Dec 17, 2009

THANK YOU! The one thing I forgot to include, sorry is that for several years, patient refused opiates. was on many other non opiate form of meds but developed esophagitis (sp?) and doctor was concerned about her bleeding. so finally was forced to move to opiates. The more I thought about this...the more i wondered is this really much of a dose? but she is concerned that she is moving up and is probably needing to move up now to 10mg. And if she needs to move up now, where does it end. now here is a question, do you know, does a patient often find a place where they stabilize?

and for goodness sakes, why would a physician NOT take a doctors input if a patient wanted to reduce medication? if she is in her right mind? She expressed concern that she didnt feel that she could be around friends and family if she was going through withdrawal and I didnt know what she would be able to expect - I said that I would try to find out - thus my ignorance - I honestly was expecting something out of one of the tv shows. I wasnt sure if she would need to check into a facility. I figured that they would need to medicate her with something else to ease her symptoms but does she just basically grin and bear it and in a few days she is over it and ok with a lower dose?

And finally - if the patient says that she would like to just take half the dose - am I allowed to half the pill? or do I need to get an order for a lesser dose? We had a big debate last semester, our instructor had said that we could only half a pill if the pill is scored. We often cut a pill with a pill cutter, if it is ordered to halve a pill. but I wondered if she decided to only take half, I know I cannot leave half at the bedside...I normally work homecare and we do things so differently than we do at the hospital and as I write this up, I am trying to think of things that I could suggest such as lowering her dose...but the doctor would need to order this or the patient would need to refuse the med, but I was wondering if she decided herself to step down, if I am even allowed to half it, I know she can refuse, I just didnt know if I can halve it?

again, thank you SOO much, I learn more here about REAL nursing than I do at school!! :bowingpurshhshhss, dont tell my instructors!!

thanks again!!!

angelsmommy

kids · Dec 17, 2009

I truly want to know. If that patient didnt get her narcotic and it is only 7.5 mg of percocet tid and she doesnt get it....what happens, she goes into withdrawal right? but what happens? nauseau, vomiting, worst? can she seize? can it be worse? I truly wasnt sure? every one talks about withdrawal but then I have have been told that for that small amount you cant have withdrawal but if you are taking it daily why not?

Most likely all the patient will experience at the dose you posted is a lot of pain all over and irritability.

but she is concerned that she is moving up and is probably needing to move up now to 10mg. And if she needs to move up now, where does it end. now here is a question, do you know, does a patient often find a place where they stabilize?

It never ends unless you have a condition that is 'cured'. If the patient is hell bent on not increasing the meds or going off them they they are making a decision to live with the pain.

of course from what I read when you are in detox just being in detox makes you think you are in more pain.

You don't think you are in more pain, you ARE in more pain.

I often see these pain patients that go to these clinics become like zombies with their meds and patches....you know?

No, I don't know.

I've been a pain clinic patient for 10 years due to a spinal cord injury. I work 36 hours a week, keep house, take care of my family. If the pain clinic is gorking a patient out other than during a period of acute titration, someone is doing it wrong.

A good pain clinic does more hand out higher and higher doses of opiates. The beginning can be a challenge as through trial and error the best medications (pain and others) are titrated to find the lowest effective dose.

Sustained release pain meds are VERY often used as they impact the opiate receptors in the brain less than the ups and downs of short acting meds do. Sustained release meds can also slow down how quickly a patient becomes tolerant to the meds. Once stabilized a patient can go a year or more before needing an adjustment but it's highly individualized.

Good pain clinics provide education regarding pain, how the meds work, non-pharmacological strategies to reduce pain.

Good pain clinics have a psychologist or psychiatrist on staff to help the patient improve their coping skills as a person with whose life often revolves around pain and medication schedules.

anangelsmommy, ADN, BSN, RN · Dec 17, 2009

I took my friend to a pain clinic visit and it was the movie version visit so I guess that is what is in my head sorry - I know they arent all like that and I did a clinical rotation where there was one doctor who just handed out the narcs like crazy so it just reinforces that but I do believe that you have to treat pain I just cant seem to learn enough from my instructors!!

now you gave me some good infor but the only long acting opiate I know of is oxycontin? is this what you mean? so this would actually keep this from happening because you dont get a up and down effect? are there other meds like this or this it? and does this come in this low of a dose, do you know? is it equivalent? like if she is on 10 mg, she would get 10 mg? if you dont know, maybe I can look it up. I appreciate your input!! thanks!!

JP

Home Health Columnist / Guide · Dec 17, 2009

take a stroll over to our pain management nursing forum.

read the info in stickied posts at top of forum for more indepth understanding of pain mgmt, pain ladder, adjunctive meds and chronic pain managment.

anangelsmommy, ADN, BSN, RN · Dec 17, 2009

well golly:bugeyes:. i guess that would have been the place to look and ask in the first place. didnt know it was there. Thank you!! you guys! :chuckle always keeping me straight! thanks again. here I learning some more! there should be a all nurses. com degree!

angels mommy