Questionable Pain - page 3
Hi. I know that we are supposed to take our patient's word for what there pain level is, but has anyone ever experienced questionable pain in a patient that even the doctor can find no known cause.... Read More
Dec 17, '03Joined: Dec '03; Posts: 19As a nurse who is a recovering addict, I have been through many years of therapy, drug treatment, self help programs, nurse support groups, etc.
I wish to share my experience. If an addict was requiring say 250 mg of demerol or 20 mg of morphine to have any effect, even if they are clean for 1 month or 10 years, the tolerance remains. Addicts often say that the disease of addiction is doing pushups constantly so when an addict relapses or takes any narcotic for any reason be it pain control, or whatever, the person still requires as much pain medication as they did when they quit using if not more. So in that sense, addicts even those that are clean for many years, do require higher doses of narcotics than non-addicts.
Many addicts in recovery try to avoid taking narcotics at all costs as to not re activate the addictive trap that occurs, but yet we do not need to suffer any more than anyone else just because we have the disease of addiction.
There are current addicts out there for sure, still active in their disease who will abuse the system, and though sometimes it seems obvious that they are not in the pain they say they are, by law we must accept their pain for what they say it is.
I totally agree with the person who said that it is better to take the risk of providing the addict with drugs (he or she will get them somewhere somehow anyway) than to take the risk of not providing medication to a patient who is really suffering.
Jan 3, '04Occupation: registered nuse Joined: Apr '03; Posts: 3,118; Likes: 840Was taught that pain level is what patient stated it is. DO NOT judge, accept what they say. Most people with a Hx of addiction do require more meds. Accept it. I would rather give meds even if my personal opinion is that they are drug seeking, than have a truly ill patient, even with a Hx of drug addiction, not get the med and find out later they were truly ill. So sometimes a patient does a scam on the staff, what is new? We get scammed all of the time by administration, HN, docs and our own co-workers. I want to do no harm and do the best for the patient, I may not agree with it all of the time, but as a nurse I should be able to accept that my personal thoughts and my professional obligations are often different.
Jan 3, '04Joined: Sep '03; Posts: 1,214; Likes: 63A patient with a history of abuse will MOST CERTAINLY require more medication. They will often get little effect from antagonistic drugs, and often NO effect from PO's.
Also, in refrence to "clock watchers". That would be more CORRECTLY identified as psuedo addiction, which is defined as patient using any means possible in order to ease the suffering they are having. It is a direct result from no or inadquate pain managment orders.
Read up on it before comming up with cute names. People could say we're monitor watchers, but we do that for a REASON.
Jan 3, '04Joined: Apr '03; Posts: 1,438; Likes: 14Good points everyone is making.
Dave, thanks for defining that. I often wonder though, based on your definition of psuedo addiction...perhaps it's not just pain that's making them suffer. Perhaps there is an element of anxiety that is not being adressed. perhaps w/ the right emotional support/coping mechanisms, or heck even a prescribed anxiolytic, they might not need as much pain medicine. Just a thought.
Jan 3, '04Joined: Dec '02; Posts: 1,055; Likes: 14Just wanted to give a quick update to my earlier post about my TAH/BSO. Turns out the pain was not well controlled due to the fact that I had developed a hematoma which had to be surgically evac. Then they left a 4x4 gauze pad in the wound. YOUCH!!!!FOR REAL!!!
Jan 3, '04Joined: Sep '03; Posts: 1,214; Likes: 63Jadednurse,
You are very correct. ALOT of things effect pain. Effective Pain Management is very complex, and can involve alot of polypharmacy. Anxiety, depression, psyc dx's.... just to name a few. It all goes hand in hand, and providers need to understand this when planning a treatment. You can't just order pain medicaiton, while in the same sense everyone in pain doesn't need Prozac and Valium.
Jan 3, '04Joined: Sep '03; Posts: 1,214; Likes: 63I forgot...
Anyone know who we'd ask about getting a Pain Management Nursing Section on here?
I think it would be a great place to share ideas.
Jan 3, '04Joined: Jul '03; Posts: 409; Likes: 8If they are in pain and the med is ordered, give it to them. If there is no med ordered, get the order for them. I doubt seriously we will trigger a raging addiction in the ER or during a stay in the hospital. If they exhibit signs of dependency, get them a consult for a chemical dependency evaluation while giving them the pain medication. As the recovering nurse said, if they are addicted they will get the med one way or another.
Jan 6, '04Occupation: Sales... former EMT... future Nurse Joined: Apr '03; Posts: 37; Likes: 7Boy is it interesting to read these posts. I just finished school to become a Registered Nurse (A.S.) and am 14 days post head-on MVA which thankfully only left me with bruises and severe muscle strain in my upper body. Several years ago I repeatedly strained my lower back while working as an EMT on ambulance. During that time I used Vicodin (in increasing doses) to control the periodic episodes of acute pain. That finally resolved over a year ago.
With this pain I have noticed that it takes the max. dosage of Vicodin (2X 5/500) to effectively treat the sternal pain I have, though 4-800 mg. of ibuprofen works very well on the rest of the pain. My point is that even those who were not "abusers" can have a tolerance to the meds. I don't appreciate the raised eyebrows from several people involved in my care -- the pharmacist and office nurse as well as the physical therapist. Thankfully the sternal pain is now resolving and handled by the ibuprofen so I will not be asking for more Vicodin - it just frustrates me to confront such ignorance.
Thanks again for the posts!
Dec 8, '05Occupation: RN Joined: Dec '05; Posts: 6Just read your posts about these "pain patients". I work in a large hospital where we have a GI doc who specializes in Diabetic Gastroparesis. This is a disorder in which the gut is somewhat lazy or even paralyzed due to the long term effects of uncontrolled DM 1. My usual patient is a 30 something white female with uncontrolled diabetes, pain of 10, and vomiting. They all have g-tubes for feeds and get Dilaudid 2-4mg q3-4 hr with phenergan 25mg SIVP. They are also on Methadone, Cymbalta, and Reglan. Some are even on Marinol for nausea. They are admitted at least every 1-2 mos for 3-7 days at a time for uncontrolled pain/nausea. This a very interesting and sad disease. It is hard on the patient and the nurse. These patients lead very difficult lifes and are addicted to their pain meds. It is becoming increasingly common (gastroparesis) and there are even gastric pumps or pacemakers that can be implanted to stimulate digestion. Just some info I though would be interesting and useful.
Dec 9, '05Joined: Sep '05; Posts: 7,767; Likes: 1,230Quote from Fgr8OutI know this is an old post but you said it sooo well what I've been trying to say for years. Everyone has different pain levels. I have twin nieces who are a year old. The youngest, Kennedy, when she gets sick she's whiny, crying, has to be held all the time. Emma, the oldest doesn't whine or cry and doesn't need to be held. Different people, different pain levels. We cannot look at a pt. and tell them that a migraine doesn't hurt that bad, because you've had one before. I think nurses should leave themselves out of it. No "my labor wasn't that bad", etc. We need to look at it objectively. Pt. states he's having pain, pain meds ordered, pain meds given. Why oh why is there such a stigma associated with pain meds? Please, someone enlighten me. Is this a recent thing or has this been going on for a while?Someday, Nursing will accept that pain is whatever the individual experiencing pain says it is. Why do we persist in this need to control an issue that is out of our hands, namely a patient's report of pain? There is no way to measure pain through biomechanical means, no magic machine that pinpoints the exact site or severity of pain. Pain is completely subjective, yet there are those in Nursing who simply can't or won't accept the fact that we don't have the ability to say "Yes, here is proof you have or haven't pain" with any reliability.
Patient's with a history of drug use/abuse can certainly develop a tolerance to opioid narcotics which require that they receive a dose higher than that of an opioid naive patient. This does not mean that individual is making their pain up and even if they are, again, Nursing cannot accurately assess this. The best we can do is administer pain medication as ordered once we've assessed our patient to determine there is no respiratory depression, and continue to monitor and intervene if it becomes apparent that an individual is overmedicated. Patient's who are awake do not code from respiratory depression, especially not with the dosage of opioid generally ordered. This is not to say Nursing should be cavalier in administering narcotics. We need to realistically look at our patient's level of sedation in relationship to the amount of narcotics they've been receiving and, with our critical thinking skills, assess the effectiveness of their pain management and treat them accordingly.
As for the use of placebos, who does this benefit? Certainly not the patient, who should have every right to expect that they are being cared for in a professional manner. Placebos are deceptive at best and can be considered malpractice. Physician's should be discouraged from ordering placebos and Nursing should never substitute NSS for a narcotic to verify if a patient does indeed have pain. To do so is completely presumptuous.
People in pain may or may not display behaviors that we consider indicative of "being in pain." Coping mechanisms such as distraction or avoidance, may often mask a person's true pain level. I believe that if health care professionals expect someone in pain to act a certain way, some patient's learn to adopt those very behaviors. They become concerned that if they don't "look" as if they are having pain, their report of pain won't be believed and they won't receive the proper pain management. What exactly does that say about our practice?
So long as a patient has appropriate respirations and arouses easily, their report of pain should be believed and appropriate measures taken to alleviate it. Pain assessment, including sedation and respiration, should be ongoing to determine efficacy of the medications and ensure no undesirable effects are occurring.
Lastly, the use of adjuvants such as vistaril and phenergan should be discouraged. These products DO NOT enhance the analgesic effects of opioids and may actually contribute to over sedation and other side effects. Because the opposite has been reported for so long, (that phenergan and vistaril potentiate the effects of opioids) destroying this myth is ongoing.
The American Society of Pain Management Nurses has a website with research based information for Nurses to better care for their patient's in pain.
Dec 9, '05Joined: Sep '05; Posts: 7,767; Likes: 1,230Quote from hjmcentiVery interesting post. I have one question about it though. You make it sound like a very painful disorder. If you take pain meds only when you have pain is it still possible to become addicted? Recently, a nurse told me as long as I only take my pain medication when I'm in pain I won't become addicted. I have Crohn's and ulcerative colitis and I'm very, very, fearful of becoming dependent. I see those people where I work and I don't want to become one.Just read your posts about these "pain patients". I work in a large hospital where we have a GI doc who specializes in Diabetic Gastroparesis. This is a disorder in which the gut is somewhat lazy or even paralyzed due to the long term effects of uncontrolled DM 1. My usual patient is a 30 something white female with uncontrolled diabetes, pain of 10, and vomiting. They all have g-tubes for feeds and get Dilaudid 2-4mg q3-4 hr with phenergan 25mg SIVP. They are also on Methadone, Cymbalta, and Reglan. Some are even on Marinol for nausea. They are admitted at least every 1-2 mos for 3-7 days at a time for uncontrolled pain/nausea. This a very interesting and sad disease. It is hard on the patient and the nurse. These patients lead very difficult lifes and are addicted to their pain meds. It is becoming increasingly common (gastroparesis) and there are even gastric pumps or pacemakers that can be implanted to stimulate digestion. Just some info I though would be interesting and useful.