Pain relief without fostering addiction

Lev, MSN, RN, NP · Mar 12, 2015

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 · Mar 12, 2015

. 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.

Libby1987 · Mar 12, 2015

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 · Mar 12, 2015

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 · Mar 12, 2015

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.

allnurses Guide · Mar 12, 2015

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 · Mar 12, 2015

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".

allnurses Guide · Mar 12, 2015

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 Â» Prescription Drug Abuse Statistics

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

Home Health Columnist / Guide · Mar 12, 2015

Plenty of articles and FAQ in Pain Management Nursing addressing issue.

Anna Flaxis, BSN, RN · Mar 12, 2015

... 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 · Mar 12, 2015

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?