Pain meds for the addicted

[bellehill]

Hey Everyone!

I have a real problem with giving narcotics to pts with known addiction. I understand the pain concept and I am usually very aware of my pts pain level, but when is enough. I had a pt who slept very hard all night, even through a blood draw, woke up and in a slurred voice asked me for his "rise and shine medicine". Demerol 75mg would not get me going in the morning. I held the med until he had woke up more. Was this wrong?

Another pt I had wanted something for nausea. The MD ordere Phenergan 50mg IV. I started with 12.5 mg. She asked for it every 2 hours, when I went it to give it she was fast asleep. She was also on a morphine PCA.

I guess my question is how do you determine when to keep giving narcotics or "rise and shine" meds.

Thanks!

[SmilingBluEyes]

I believe pain is subjective and it is what the patient says it is. We use the 1-10 pain scale and if the patient says it is a high number, I feel obligated not only to believe it but to chart and to DO SOMETHING ABOUT IT! And we can remember, THERE ARE NON-PHARMACOLOGIC means to deal with discomfort and pain. Sometimes, holding a hand, talking soothingly, LISTENING, repositioning, using heat or cold, and using diversionary tactics work very well, too. Also, it MAY BE the medication they are on is NOT doing the JOB and they need re-evaluation and a change of pharmacologic treatment.

But NEVER do I put myself in a position where I say a person is not in the pain they say they are, just cause they appear to be drug-seeking or addicted. NOT for me to judge this.....only for me to try to help and *chart* what works and what does not and contact a doctor if I need to. I would leave the diagnosis of addiction and its treatment to the doctor and/or psychiatrist.

[nrw350]

I dont know if the patient's side of this topic. I will admit that if I am in pain, I will often times ask for something to help deal with the pain. But I personally do not like taking medicine if I can do without it. If I am forced to take medicine and it does make me feel "good" I will enjoy it while I am on it. But I will not let that make me addicted to it. Like the Lortab I am on right now for after my oral surgery, it is nice for removing pain, but I do not want to stay on it forever.

Nick

[nrw350]

Upon re-reading my post there, I realize that I need to clarify it. Can you tell that I was under the influence of lortab? lol! Anyway, What I meant to say is as follows.

I do not know if you would find this patient's side of the topic interesting or not, but here goes. I will admit that if I am in pain, I will often ask for help. But there are times that I will not ask for help because I do not want people to know that I am hurting (pride issue there). Also, I hate it when I am forced to take a medicine for something like a head-ache or what not. But if like in the sitaution for my oral surgery yesterday where I really need a strong pain killer that can make me feel ''good'' I will enjoy the medicine while I am on it. But I will respect the medicine, and not abuse it. I will also try to take as little of it as possible because I am aware of the side-effects and the addictive qualities of the drugs. I am aware of how adversely it effects my mental capabilities and coordination. As was illustrated in the previous post.

It has been about 5 hrs since my last dose of the lortab and now my head is cleared up signifigantly. But my jaw is now hurting again, so I will take a lortab after finishing this post.

Anyway, I look forward to hearing everyone's comments about this.

Thanks.,

Nick

[eagleRN]

If the narcotic is ordered, and it is time, you have to give it, unless of course they are overly sedated, then they wouldn't be asking for it right? Unless laws have changed, we really do not have the choice to withhold prn pain meds unless resp. or b/p aren't within acceptable parameters.

[nrw350]

That makes sense about being overly sedated. How can someone who is out cold ask for a demerol shot?

Nick

[LilgirlRN, ADN, RN]

50 mg's of Phenergan IV is too much, you'll get the bad side effects that you see with phenothiazines...twitching drooling etc. I work in the ED, we get lots of "seekers", people looking for narcotics. Some go to great extremes to get their fix...breaking their own extremities, cutting their own hand with a circular saw etc. Sometimes pain is quite obvious, like people with kidney stones are often pale, diaphoretic, elevated BP etc. We have lotsa migraines too, those are harder to make sense of. If someone is asleep when I go in to see them before they even get a shot for their HA, I begin to doubt that they are really in pain. Myself, if I am hurting I get really quiet and still unless its a stone then nothing but pain medication helps. Some patients seem to be shy about their pain when the doctor is in the room, doc leaves and I ask how much pain on a 1-10 scale, they say 8, I tell the doc, he says they didnt say anything...have to make them go back in and ask thmselves lots of times. I give lots of narcotics at work, depends on the doc. Have one we refer to as the candyman, sends a broken toe out on mepergan. Another wants to send kidney stones home on Darvocet, he however will admit to never having bad pain himself so he can't relate, we have to educate him. There are a few docs that give give demerol IV in 12.5 increments, spend half the night wasting 12.5 of demerol...lol. As far as treating addicts for pain goes, there's always toradol, most will say they are allergic to aspirin to get around that. We have some patients say they are allergic to everything except exactly what they want..allergy list says Toradol, tylenol, MSO4, demerol, nubain...but they can take dilaudid just fine :)

[micro, RN]

Originally posted by boggle

Pain is what the patient says it is. We are not going to "cure" an addiction problem by withholding a dose!!

boggle and others you said.....

pain is what the person says it is......

as needed is as needed.....

as well if you look at the physiology of pain.......dang nab it....

to withhold pain medication would cruel.....

assess your patient, medication as ordered and needed, monitor for the effects and side effects of medication, communicate your concerns with physician, etc...

:stone :stone :stone

[nrw350]

Communication is the most important thing in everything.

nick

[fergus51]

As a side note, my dad was almost killed when he was given Toradol despite an allergy to asprin and he had an anyphylactic reaction. I always believe whatever the patient says, it's safer!

[nrw350]

That really sucks, unfortunately I do not know if I am allergic to any drugs. So, whenever I am asked if I am allergic to anything I just say "nothing that I know of".

Nick

PS: Is there anyway to tell safely and easily if I would allergic to any meds?

[bellehill, RN]

Let me clarify that I have never witheld pain medicine from any pt. I too believe pain is subjective and it is my job to trust my pts and medicate them appropriately. Some pts are just harder to believe than others.

As for the Phenergan 50mg IV, I would never give that high a dose. I started with 12.5mg and worked my wasy slowly up to 25mg. Oversedation is too easy with Phenergan, especially every 4 hour doses.

Thanks for all the input from everyone!

[zapperbapper]

I work in a neuro ICU and have to be very carefull with pain meds. I frequently give half a dose or sometimes even withhold a dose for fear of masking a neuro change. From experience I know that you cannot medicate someone with a subarachnoid bleed enough to relieve the pain but you can certainly decrease their LOC. But in the case of someone in DTs or narc addiction I will give as much as allowed. Acute illness is not the time for rehab. We even give beer w/meals to try to ward off DTs.