Pain control in narcotic addicted pt

OCNRN63, RN · Aug 30, 2011

"Confessed"?

I'd rather err on the side of the patient's statement. I don't want us to go back to the "bad old days" where you practically had to do a polygraph before a pt. proved he was in pain.

sunnycalifRN · Aug 30, 2011

Hello all:
In my practice I have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. May I make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. They will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds.
My question/comment is this: After all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain?
Perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?

I've definitely had my share of this type of patient! Unfortunately, even though you are correct, that they are seeking narc's to maintain their addiction, you cannot withhold prescribed medications because of your suspicions. However, you can speak with the patient's MD to get them transferred to the pain management service so they can deal with the addiction.

FancypantsRN · Aug 30, 2011

We have many people on "care plans". They are not supposed to receive narcotics unless their PCP ok's it (or unless they really have something going on). These are the people that show up sometimes up to 3 times a week for generalized body pain with unknown etiology (multiple CT scans negative, entire work ups negative).

It takes one a long time to get a care plan and some of the doctors do not honor them, so they get the narcotics anyway. Yes, for these people I know we are contributing to addiction - but there is nothing we can really do about it. For these people, every time I pull the same combo of narcs out of the pyxis, I feel guilty.... but if the doctors keep ordering it, we have to give it. We are not a detox unit.

That being said, sometimes there are things going on with the pt that every test may be negative and we just haven't tested for the right thing to pinpoint the problem.

KYGirl1976 · Aug 30, 2011

As an ER nurse I can tell you that whomever came up with the adage, "a patients pain is, whatever they say it is" never worked in an ER. Rule #1--- Pts lie. The 1-10 pain scale is so ridiculously misused that many patients arrive in triage and immediately explain to me how their pain is a 10/10, (with normal vitals and while they laugh along with the friends they brought with them, text, sneak outside to smoke, eat, drink, and otherwise be merry!!!!) What about using the FLACC scale? Implement something that takes into account a patients demeanor and what would be considered innate human physical responses to pain. FLACC has been used in infants and patients who lack the ability to communicate (i.e. trach&vented, MR, brain injury etc). I chart against patient demeanor, and behavior when I am in triage. Our frequent fliers and narc seekers can tell me their pain is a 10/10 and I will chart that, right along with..."pt observed laughing with friends while in waiting area" "pt reports continued abdominal pain and rates 10/10, with increasing nausea and vomiting. Pt eating Taco Bell Beefy Cheesy burrito, hard shell taco supreme, and Mexican Pizza at this time. No vomiting observed" "Pt observed smoking multiple times and advised by security there is a No Smoking policy within 100 feet of hospital entrance. Reports increase in cough at this time."

psu_213, BSN, RN · Aug 30, 2011

On one hand, I agree that too many narcotics are given out to some people. Working in the ER, some of the same people show up again and again with the same pain complaints, and it is very frustrating.

On the other hand, those addicted to narcotics develope conditions that are truly painful, and they will require high doses of narcotics if we are going to effectively treat them. Pain is so subjective we have to take a person's word for it. Consider the opposite...I was taking care of a young man (late teens) who had dislocated his shoulder playing sports. He said it did not really hurt and refused conscious sedation when the MD reduced his shoulder. I would have thought that of anyone, he could have claimed 10 out of 10 pain. Point being, you could also have a pt who rates his/her pain as being way higher that what you would think considering his/her condition.

LuxCalidaNP · Aug 30, 2011

One word: Buprenorphine. It's a magical magical drug...turns our crabby, opiate-hookde patients whose pain is NEVER in control to pleasant, relieved, non-doped up humans.

leslie :-D · Aug 30, 2011

One word: Buprenorphine. It's a magical magical drug...turns our crabby, opiate-hookde patients whose pain is NEVER in control to pleasant, relieved, non-doped up humans.

and what about those "crabby, opiate-hookde" pts, who have legit pain?

some do, you know.

leslie

xtxrn, ASN, RN · Aug 30, 2011

Hello all:
In my practice I have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. May I make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. They will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds.
My question/comment is this: After all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain?
Perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?

Not all sources of pain show up on a conventional test. I can understand the concern, but I also think that if there's that much concern, refer them to an addictionologist/pain specialist (who isn't in it for a constant selection of paying patients) for an evaluation, and get feedback about appropriate medications. And don't depend on some test for all answers. A migraine doesn't show up on a test, but can lay someone out for days. Cluster headaches can't be found by bloodwork- but I've seen grown men in the fetal position with them. Sickle cell crisis (which can be diagnosed- but often scoffed at) is horrific for the patient- and through no fault of their own, the patient needs increased doses because of repetitive crises and physical tolerance (not addiction). Some medications cause pain- can't measure that. Fibromyalgia can't be seen on an MRI or lab work.... still hurts BAD. Peripheral neuropathy is often diagnosed by verbal history... hurts a lot from patients I've seen w/it.

I took care of a guy on methadone maintenance, who also had a decub the size of a dinner plate in is sacrum/back.... could count vertebrae... :eek: I don't care how addicted he was- he hurt. And the doc refused to give him anything but the 'usual' dose of methadone that wasn't being used for pain control at all- it was cruel. I refused to be assigned to him if I couldn't treat him humanely. The guy didn't manipulate at all- just was in agony, and nobody who could do anything cared. I'd try to get meds for him on the weekends I worked- but the doc put a stop to that, so that was it for me. Wanted no part in deciding who was dealing with "real" pain.... I know this is different in some ways- but forcing the patients to "prove" how bad they hurt isn't going to help them.

This is from the FWIW pile.... I have had chronic pain for 15 years- various causes; never a pain free day in that time- some better than others, but never gone. If I have available meds at home, I'm more likely to NOT take them, because I have the ability to take them if I can't deal with the pain in any other way- there's not the anxiety of not having something that helps. Often, a non-narcotic helps just fine- but if it doesn't, I have something. Not anything "major"- but 'enough'. And I guard those meds. I'm afraid of the pain... that's different than craving drugs :) A month's rx of a mild narc lasts at least 2-3 months...but I get the refill monthly, so I know that I'm covered if I can't get to the pharmacy.

Yeah- nobody wants to enable an addict. But who wants to be a party to someone NOT getting some sort of relief for pain? We can't always know who is or isn't being manipulative-- sometimes the fear of the pain can make folks sound pretty desperate, and that is judged by healthcare professionals as "proof" they're just looking for drugs.... People with pain DO want relief- is that so weird? :confused: When I worked drug/alcohol rehab, the patients still got narcotics for a short period if they had medical procedures (many had neglected their teeth, and had dental procedures that would have been cruel to not deal with). Addicts can hurt, and those who hurt a lot can sound desperate- which can be perceived as drug-seeking (and in a way they are- but for the right reasons).

If the docs are prescribing oxycodone for a hangnail, that's a problem with the doc- not the patient :)

If someone is medicating emotional pain, of course narcs won't help- but you can't get a test to prove that pain is ONLY emotional.... you might get more info from them with some sort of questionnaire about past trauma- both physical and emotional- and if it's something they can fill out, without the inadvertent sound of judgment in someone asking questions, you might get all sorts of info about the real cause of any type of pain, and either be able to treat it better, or send for referrals .... jmho :)

OCNRN63, RN · Aug 30, 2011

and what about those "crabby, opiate-hookde" pts, who have legit pain?
some do, you know.
leslie

You make them suffer. Then you can feel self-righteous when you deny them pain meds.

KYGirl1976 · Aug 30, 2011

On one hand, I agree that too many narcotics are given out to some people. Working in the ER, some of the same people show up again and again with the same pain complaints, and it is very frustrating.
On the other hand, those addicted to narcotics develope conditions that are truly painful, and they will require high doses of narcotics if we are going to effectively treat them. Pain is so subjective we have to take a person's word for it. Consider the opposite...I was taking care of a young man (late teens) who had dislocated his shoulder playing sports. He said it did not really hurt and refused conscious sedation when the MD reduced his shoulder. I would have thought that of anyone, he could have claimed 10 out of 10 pain. Point being, you could also have a pt who rates his/her pain as being way higher that what you would think considering his/her condition.

I agree that those addicted need specific intervention, which is not more of the very drug for which they are addicted. Doctors are becoming smarter and prescribing far fewer narcotics through the ER, and many hospitals in my area have developed new policies with stringent rules on the type, quantity and uses for certain narcotics in the Emergent setting.

I completely agree that pain is subjective. As the matter of fact...patients don't have to say a word. As part of a study I did in a statistics class, we evaluated patients coming into an ER with complaints of pain. Statistically, regardless of the TYPE of complaint approx 90% of patients told the ER MD their pain was a 9 or greater using the 0-10 pain scale when asked. When FLACC was used with these patients, the average score was a 4 or 5. When the smiling to crying faces were used the average number decreased further to a 3 or 4, with almost no 9 or 10's. (Duh... I'm not crying or grimacing...I'm smiling... the doctor can see that...I better not choose the grimacing or crying face or they might know I'm lying!!" This study shows there are issues with a 0-10 scale. Other evaluators tend to be of higher accuracy with use in the adult general public. Still SUBJECTIVE. Pts are SAYING what their pain level is. They are just using a different TYPE of COMMUNICATION. They can still indicate they have pain and whatever their "pain is"...we just need to provide these ADULTS with a more accurate way to do so.

Trekfan · Aug 30, 2011

hello all:
in my practice i have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. may i make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. they will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds.
[color=sandybrown]my question/comment is this: after all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain?
perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?

that means nothing , all that means is that thay have not found the the problem that is causing the pain "yet"