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Pain relief without fostering addiction

Posted

Has 27 years experience.

How can we, as nurses, encourage adequate pain relief, yet help our patients avoid the pitfalls of addiction? Let's face it, many people get their first encounter with narcotics after surgery. Some have a hard time weaning themselves off of them afterwards. It's a real problem that can destroy lives.

We don't want to cripple our patients' recovery and rehab by discouraging pain relief. But, there's definitely a lack of forthright communication in the medical field regarding the real dangers of narcotics.

Since I'm wrestling with this subject myself, recovering from a painful surgery and rehab, I've been giving it a lot of thought. I'm having a hard time finding a balance, and probably too paranoid. Yet, I've seen the horrors of narcotic dependence too.

Lev, BSN, RN

Specializes in Emergency - CEN. Has 7 years experience.

I think the best rule is to take as prescribed. In the first couple days after surgery, research has shown that scheduled pain medications work best to manage post-op pain. You can also alternate the narcotics with extra strength tylenol and NSAIDS (if allowed). Then, try to keep on a schedule with non-opioid pain medications and take the opioids only when needed.

ArtClassRN, ADN, RN

Specializes in Med Surg. Has 8 years experience.

. But, there's definitely a lack of forthright communication in the medical field regarding the real dangers of narcotics.

This isn't true. There is a wealth of information on this topic. That is not to say it isn't an issue, but geez.

I don't see addiction as a result of post op meds but I do see a lot of concern and reluctance to utilize their narcotics to adequately manage their pain. I know it is a jumping off point for some but just don't see it in my work. Any patients who are narcotic dependent came that way and for most they have real pain issues.

Gooselady, BSN, RN

Has 23 years experience.

Narcotics affect individuals differently. I 'discovered' this when I was the nurse supervisor at a chemical dependency hospital.

I've taken Lortab or Vicodin, got a terrible stomach cramp, got not-unpleasantly woozy and then was constipated for a week. It wasn't worth it, but I had a corneal abrasion and they wouldn't send me home with those WONDERFUL anesthetic eye drops! The doctor said "Go ahead and fill the Vicodin script, you are gonna need them." So I had that experience of my own and then bore witness to the alternate experiences from people who had become addicted to them.

Almost to the person, Vicodin (or other narcotic tablets) gave a burst of 'energy', like caffeine only more joyous. Several women told me they'd pop extra Vicodins and get to house cleaning. Or before a long, boring task, pop a Vicodin and instantly there was plenty of 'energy' and the boring, dull task was even more pleasant.

I had patients admit they could be in the WORST possible mood, depressed and hopeless, and after taking a narcotic it's as if the entire world changed, from a place of despair to a place of hope.

I heard similar stuff about alcohol -- the shy person who became extroverted and social, the life o' the party.

I wonder if certain individuals have slightly 'different' mechanisms of uptake of opioids in their brain, that may predispose them to addiction?

Another 'difference', obviously, is taking narcotics to alter a mood or 'give pleasant energy' as opposed to taking them as prescribed for pain. There was one gal who had dental surgery, and 'really liked' the Percocets. She started stealing scripts from the doctor's office she worked for about a year later, after she'd 'faked' a couple of injuries or persistent 'headaches' in order to get Percocets prescribed. She was a mother, wife, a medical assistant with no job problems and a supportive (but clueless and confused) husband. She denied depression, but did have childhood abuse issues and traumatic memories. She'd actually been very depressed without realizing it. Her life was good, but she felt 'bad' and the Percocets became her best friends because they made her FEEL happy, which she didn't feel and didn't know why.

I think as nurses we can't prevent people from misusing or becoming addicted. It may not be a matter of education. I think certain individuals have metabolic differences that predispose them, and all we can do is provide teaching (and encourage colace lol), and emphasize how important it is to use narcotics for brief periods of time. I'm not including those who need to take them regularly, that is a different story.

If anything, this is an educational matter for NURSES as much as for patients. But I don't think nurses can do very much harm, if it turns out that narcotic addiction is a metabolic issue. We ought to be ready to identify possible misuse versus 'tolerance' and legitimate 'dependence' when a person suffers chronic pain.

TakeTwoAspirin, MSN, RN, APRN

Specializes in Peri-op/Sub-Acute ANP.

I think we are bundling addiction into one nasty catchall that everyone is vulnerable to. I don't believe this to be the case at all. For a start, there is physical and psychological dependency. In order to be a drug seeking addict, I believe both elements need to be in place.

The majority of people who have never had problems before with addiction or dependence will have their surgery, get adequate pain relief, and then move on with their lives. They may have some physical symptoms of withdrawal, although this should be avoidable with tapering responsibly. I see all too often that patients are reluctant to take prescribed medications for pain because they are afraid to become addicts. I've even seen elderly, and palliative patients, refuse pain meds because of this fear.

The best way we can help people avoid addiction is to dispel some of the myths that surround pain relief. Don't get me wrong, I also see the other end of the spectrum with pain seekers who are in deep, but the majority of patients who seek pain relief do so responsibly. I know it may feel like everyone gets hooked, this is simply not the case.

Nurse SMS, MSN, RN

Specializes in Critical Care; Cardiac; Professional Development. Has 9 years experience.

I talk to my patients about taking narcotics in response to pain (around a level 3-4) and to beware of taking it in anticipation of/fear of/prevention of pain. We discuss that pain is a normal, expected part of postsurgical recovery and if they take the medication as directed, evaluate their pain level, take it when the level is relatively controllable and not wait until it gets out of hand, they can avoid the anxiety that can then lead to taking more than they should or more than they need. We also discuss taking ibuprofen or other OTC medications that their doctor has approved while pain is very low (around a level 2-3) to see if they can start weaning off the narcotics.

This seems to strike a good balance between encouraging them to treat their pain and cautioning them against inappropriate use. It also helps them to know that pain is not an abnormal response to surgical intervention and that it will get better, but that they should not expect to be pain free in the immediate postop period. Most of the behavior I see that has the potential to turn from use to abuse circles around unrealistic expectations for pain control and extreme fear of pain/postop anxiety.

If the pain is above the levels mentioned above, then the patient should not be discharging yet, as we have not yet established what they need for their pain to be adequately controlled. I truly believe we have a responsibility to address this before sending a patient home.

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

I think we need to stop discussing pain relief solely in terms of preventing or enabling addiction. Two different problems with vastly different solutions.

It's time that people in pain stop getting punished for other peoples' "sins".

Nurse SMS, MSN, RN

Specializes in Critical Care; Cardiac; Professional Development. Has 9 years experience.

While I understand where you are coming from, heron, I disagree about discussing it. Part of patient teaching is educating on the danger of these medications and to not do so because some people are having addiction problems and therefore to suggest this person could as well....the idea that talking about that is somehow harming them...I just....that is like saying there has been a tornado here and therefore we don't talk about tornadoes because it might make us less likely to treat their personal disaster adequately. It makes no sense. They are at risk of tornadoes too and need to know about that.

Nobody is being punished when we discuss the potential for abuse, tolerance and/or addiction when sending people home on narcotic medications. Deaths from OD have more than doubled in the last 15 years. ER visits for prescription drug abuse problems are up 123%. The United States has 5% of the world's population but uses 75% of the world's prescription drugs. This IS a conversation that needs to happen. People are being put on these medications more than ever before. Talking about the propensity for abuse is far from wrong. It is imperative.

Popping Pills: Prescription Drug Abuse in America | National Institute on Drug Abuse (NIDA)

CLAAD.org » Prescription Drug Abuse Statistics

CDC - Facts - Drug Overdose - Home and Recreational Safety - Injury Center

... I had a corneal abrasion and they wouldn't send me home with those WONDERFUL anesthetic eye drops! The doctor said "Go ahead and fill the Vicodin script, you are gonna need them."

Chronic or repeated use of proparacaine can cause scarring of the cornea and vision loss. There is a story at my workplace about a guy who pocketed the bottle that had been left at the bedside, and ended up going blind in his affected eye.

Anyway, yes, I think it's important to distinguish between tolerance, dependence, and addiction. Most people are not going to become physically dependent upon narcotics having used them for postoperative pain. It takes much longer, chronic use for that to happen. Addiction is another ball of wax, and as far as I know, we haven't figured out why it happens in some people and not others. Oh, of course there are many thoughts on this, such as psycho-social-emotional-environmental factors and differences in genetic predispositions, etc etc.

I think it's true that as nurses, we cannot prevent misuse or addiction. We can provide accurate information and moral support, but the rest is up to the individual.

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

Chronic or repeated use of proparacaine can cause scarring of the cornea and vision loss. There is a story at my workplace about a guy who pocketed the bottle that had been left at the bedside, and ended up going blind in his affected eye.

Anyway, yes, I think it's important to distinguish between tolerance, dependence, and addiction. Most people are not going to become physically dependent upon narcotics having used them for postoperative pain. It takes much longer, chronic use for that to happen. Addiction is another ball of wax, and as far as I know, we haven't figured out why it happens in some people and not others. Oh, of course there are many thoughts on this, such as psycho-social-emotional-environmental factors and differences in genetic predispositions, etc etc.

I think it's true that as nurses, we cannot prevent misuse or addiction. We can provide accurate information and moral support, but the rest is up to the individual.

Furthermore, by prioritizing the dangers of addiction over the dangers of unrelieved pain, we are letting addicts determine our treatment objectives for everyone who needs pain relief. I don't think that's right.

There's a value judgement to be made here: which is more important, pain relief or winning a power struggle with a presumed addict?

Mavrick, BSN, RN

Specializes in 15 years in ICU, 22 years in PACU. Has 30 years experience.

While I understand where you are coming from, heron, I disagree about discussing it. Part of patient teaching is educating on the danger of these medications and to not do so because some people are having addiction problems and therefore to suggest this person could as well....the idea that talking about that is somehow harming them...I just....that is like saying there has been a tornado here and therefore we don't talk about tornadoes because it might make us less likely to treat their personal disaster adequately. It makes no sense. They are at risk of tornadoes too and need to know about that.

Nobody is being punished when we discuss the potential for abuse, tolerance and/or addiction when sending people home on narcotic medications. Deaths from OD have more than doubled in the last 15 years. ER visits for prescription drug abuse problems are up 123%. The United States has 5% of the world's population but uses 75% of the world's prescription drugs. This IS a conversation that needs to happen. People are being put on these medications more than ever before. Talking about the propensity for abuse is far from wrong. It is imperative.

Popping Pills: Prescription Drug Abuse in America | National Institute on Drug Abuse (NIDA)

CLAAD.org » Prescription Drug Abuse Statistics

CDC - Facts - Drug Overdose - Home and Recreational Safety - Injury Center

I think you may have missed the word solely.

Both pain relief and addiction are potential outcomes of taking narcotics.

I really fight that battle in my PACU practice. Addicts can have acute pain and I'm not about to deny them adequate pain relief in any kind of attempt to educate them on the hazards of addiction. I had no problem giving my post op patient 63 mg of Dilaudid IV in 1 1/2 hours. They left my unit discussing what they were going to order off the dinner menu.

I really appreciate the comment about people being addicted prior to entering the healthcare system. (came that way) Pain relief sometime requires the enabling of the addiction in the short term. Yep, I'm gonna let the "addict" win.

Edited by Mavrick

Emergent, RN

Has 27 years experience.

I feel encouraged to be a little easier on myself. I've been denying myself needed pain relief, paranoid that I'll run out, stressing from my painful, hourly PT exercises. I have most of my pills left.

It's hard to find the right balance in life, everyone is so individual.

Straight No Chaser, ASN, LPN

Specializes in Sub-Acute & Long-Term Care Nursing. Has 4 years experience.

Narcotics affect individuals differently. I 'discovered' this when I was the nurse supervisor at a chemical dependency hospital.

I've taken Lortab or Vicodin, got a terrible stomach cramp, got not-unpleasantly woozy and then was constipated for a week. It wasn't worth it, but I had a corneal abrasion and they wouldn't send me home with those WONDERFUL anesthetic eye drops! The doctor said "Go ahead and fill the Vicodin script, you are gonna need them." So I had that experience of my own and then bore witness to the alternate experiences from people who had become addicted to them.

Almost to the person, Vicodin (or other narcotic tablets) gave a burst of 'energy', like caffeine only more joyous. Several women told me they'd pop extra Vicodins and get to house cleaning. Or before a long, boring task, pop a Vicodin and instantly there was plenty of 'energy' and the boring, dull task was even more pleasant.

I had patients admit they could be in the WORST possible mood, depressed and hopeless, and after taking a narcotic it's as if the entire world changed, from a place of despair to a place of hope.

I heard similar stuff about alcohol -- the shy person who became extroverted and social, the life o' the party.

I wonder if certain individuals have slightly 'different' mechanisms of uptake of opioids in their brain, that may predispose them to addiction?

Another 'difference', obviously, is taking narcotics to alter a mood or 'give pleasant energy' as opposed to taking them as prescribed for pain. There was one gal who had dental surgery, and 'really liked' the Percocets. She started stealing scripts from the doctor's office she worked for about a year later, after she'd 'faked' a couple of injuries or persistent 'headaches' in order to get Percocets prescribed. She was a mother, wife, a medical assistant with no job problems and a supportive (but clueless and confused) husband. She denied depression, but did have childhood abuse issues and traumatic memories. She'd actually been very depressed without realizing it. Her life was good, but she felt 'bad' and the Percocets became her best friends because they made her FEEL happy, which she didn't feel and didn't know why.

I think as nurses we can't prevent people from misusing or becoming addicted. It may not be a matter of education. I think certain individuals have metabolic differences that predispose them, and all we can do is provide teaching (and encourage colace lol), and emphasize how important it is to use narcotics for brief periods of time. I'm not including those who need to take them regularly, that is a different story.

If anything, this is an educational matter for NURSES as much as for patients. But I don't think nurses can do very much harm, if it turns out that narcotic addiction is a metabolic issue. We ought to be ready to identify possible misuse versus 'tolerance' and legitimate 'dependence' when a person suffers chronic pain.

This is exactly why we need to treat addiction, even before it becomes addiction. (How, I don't know....) The fact is that addicts have a different chemical makeup and become addicts because they are self medicating a problem that could have been addressed long ago, had it been discovered.

heron, ASN, RN

Specializes in Hospice. Has 40 years experience.

Emergent, it's inappropriate - and against TOS - to give medical advice, but if you're denying yourself pain relief out of worries over addiction, please talk to your provider. If you're like me and know yourself to be vulnerable to addiction - that is using the med for the buzz instead of for pain relief - it's really important to have a plan and adequate support.

If you're just worried on general principles, be aware that using an opioid to prevent pain, rather than suppress pain that is already severe, usually results in using less medication over time. It's a learnable skill.

Unrelieved pain can cause problems of its own: depression, delayed healing, sleep disorders, as well as slow your progress in PT. Don't be a hero.

Edited by heron

Emergent, RN

Has 27 years experience.

No, not prone to addiction actually. This has been such a stressful time, lots of anxiety happening. I've always viewed myself as such a strong person. Really causing me to reexamine my world...

I'm going to be ok.

mmc51264, ADN, BSN, MSN, RN

Specializes in orthopedic; Informatics, diabetes. Has 8 years experience.

I am one of those that get more focused on pain medication. It is like the anti-Ritalin. It has been shown that tramadol can have a serotonigenic (bad spelling-sorry!) effects. I recently was in the hospital and had IV dilaudid for the first time. It was awful!!!! I cannot understand why people like it so much. gave me the worst cotton mouth EVER. Not for me. Even oxycodone, that I have taken for post-op pain makes me nauseous. So far vicodin works the best for me without the nasty side effects.

I work in ortho and obviously pain is an issue, we have two types: those that want all the meds they can get and the ones that are afraid of becoming addicted. We constantly are educating that taking pain meds for a short time as prescribed should not be an issue.

The ones that kill me are the ones that come in, they have legitimate chronic pain, but the pain clinics might have them on 90 mg of oxycontin Q8H. That is insane. And they are not sedated or anything. We use ketamine occasionally (research says that it is supposed to "reset" pain receptors) but that doesn't seem to fix the tolerance issue.

Very rarely do we see "addicts" and if they are admitted to acute care, that is not really the place to detox them.

I went to a conference and there was a presenter that was there form the state version of the CDC and he was showing us data where they were cracking down on some of the pain clinics. The prescription narcotic use was going down, but guess what is going up? Heroin use. I guess users are going to use.