Pain Seekers

[missswiss44]

I am just wondering if other hospitals have the same colossal amount of pain seekers? I feel like every single day I work I have a patient who only wants IV dilaudid mixed with IV phenergan mixed with IV benadryl mixed with IV ativan with a roxycodone to top it off. I just recently cared for this woman who I was giving pain medication every 2 hours and her pain never got any better; mind you I gave her 8 mg of IV dilaudid in about 10 hours as well as 3 doses of Percocet. I am just so tired of being a legal drug dealer, just to give these people their fix. No, I don't believe that their pain maintains a constant 10/10 when they are given this amount of pain medication and when they look high as a kite. And we just support this behavior! Because controlling patient's pain is so important and pain is subjective so we must believe them. This is not why I became a nurse and I am just wondering if this daily occurrence is just at my hospital or if its all over the country.

[klone, MSN, RN]

LadyFree28, you just sounded very aggressive and defensive and I did think you took it personally. This is the last time I will respond to you.

Okay, now you're just acting kind of weird. Is this your first time at a message board?

[canigraduate]

i got it that someone wants pain meds. What I dont understand is the need for phenergan, benadryl, etc to make sure the person is snowed into oblivion. Does phenergan, benadryl, ativan, etc potentiate the actual narcotic? Or is it that the "seeker" wants to be unaware of their surroundings, as opposed to getting pain relief?

I've had "seekers" get angry that I woke them up ( to see that they havent crossed that line past moderate sedation) because now I ruined their "relief" of 19/10 from 20/10.( What I am usually told)

Firstly, phenergan is a known adjunct for narcotics. It potentiates the opioids and increases their effects. Secondly, benadryl is also a CNS depressant and can have a further potentiating effect. Thirdly, ativan makes everybody feel better. You may hurt just as much, but you care less about it, which often reduces your perception of pain.

Finally, if I am your patient and I have finally gotten comfortable enough to fall asleep and you come and wake me up to make sure you can, I do not know that you are trying to make sure I am not dying. I just think you are an a-hole.

Frankly, if a patient is sleeping and has adequate respirations with a normal pulse ox, I let 'em sleep and get a continuous pulse ox ordered. Part of the benefit of sedating a patient is the sedation. If you don't want them to be sedated, fine. Just be prepared because the patient is more than likely going to be angry that now they have to experience the pain instead of just sleep through it.

[canigraduate]

Yes, I believe all the other IV medications potentiate the narcotic as they can (benadryl, phenergan, and ativan) cause a sedated effect. What is funny to me is when people ask me to give them together and then push the dilaudid fast. I have had patients get mad at me because I won't give them IV pain medication when they are falling asleep talking to me and their blood pressure is in the toilet.

When patients ask you to give them together and push them fast, that is your addict. This is your opportunity for education.

I tell the patient that what they are asking for is against the administration instructions and that it could kill them. This is when they say the other nurses do it all the time. I tell the patient that I am not responsible for another nurse's practice, just my own, and I will follow all the safety rules for their benefit.

If they continue to be argumentative, I hand them an AMA form (I can usually see this kind of patient coming and have it already filled out) and tell them that if they are having withdrawals and not telling me, then they are more than welcome to go home and get relief however they normally do and start to take their IV out.

It usually shuts them up when you threaten to cut off their IV access. Once you have established that boundary, addicts are usually more respectful. Unless you have a psych patient. Then all bets are off.

[Tenebrae, BSN, RN]

And how do you know it is safe to give the pain medication?

Are they conscious?

What are their vital signs?

When did they last have it?

How often can they have it?

What are they rating their pain as?

What non verbal indicators of pain are they showing? Eg grimacing, tense, hunched, agitated, restless etc

Do they have abnormal liver or kidney function?

[Nonyvole, BSN, RN]

I have chronic pain. I've since moved from OTC pain relievers to prescription-strength NSAIDs, supplemented with more OTC pain meds. I have been through countless tests to try to figure the source of this pain over the past decade (more, actually), and all that the doctors can say is "well, maybe it's this. Have some muscle relaxants, painkillers, and...yeah. You're already doing everything else that I'd tell you to do so keep on doing it." The next round of tests starts in a few days, actually...they think that they've figured out one cause - no real fix - and they're concerned about something else being in the mix.

Looking at me you wouldn't know that what I consider my baseline pain level is usually around a 3. I'm very, very rarely pain-free.

Hook me up to a monitor, and my BP will be around 110/70. My heart rate will be in the 70s, my respiratory rate will be 12-14, and my SpO2 will be in the high 90s. Does that mean that I'm not in pain? No. It just means that I, like other people who have had some sort of medical issue that causes pain for years, have become accustomed to a certain level of pain. And looking at me you wouldn't be able to tell that I'm in the situation I am, because I can laugh and joke around with the best of them. Be crafty...although that's getting harder since the repetitive movements of knitting, crotcheting, needlepoint all hurt.

Several times a week the pain will spike. Some days, when I'm at work, it truly is all that I can do to keep on moving. It's worsened my depression, so I'm also on anti-depressants. I'm grouchy, so my relationship with my husband has been affected. There are some days that I have to get extra assistance at work to move patients or reach things on the high shelves. I sleep a lot, but it's poor sleep - I don't wake up feeling rested.

I refuse to take opioids at this point in time. I used to, and they did help, but I can't work while I'm taking them. But it's been over a decade since all this has started and I'm getting tired of it. There are days that all I want to do is cut off the parts of my body that are hurting. Get some real sleep. Be able to get out of bed in the morning without assessing "okay, how does this part of me feel? This part?"

Or, I, like darn near everybody else out there with chronic pain, want to be normal again.

(I feel like I've written this, or something similar to it, before)

So if I end up in the hospital because of my pain, I do want to know that my nurse will manage it and not tell me that "it's been two hours, you don't look like you're in pain. You can wait another two." I want to know that my nurse understands that while pain is subjective, yes, just because I need a higher dose doesn't mean that I'm a drug seeker. It means that I'm hurting and would like to not be hurting, thank you very much.

From the nursing side, I do have many drug seekers come through my ER. How do I know? History. Observing them come limping in and as soon as they get their prescription for opioids they're suddenly pain-free and walking normally, almost running. Even without me giving them anything but that piece of paper. People that when we ask "did you follow up with the specialist that we referred you to last week?" Say no (and it isn't because of insurance). Doctor shopping - we can look up their controlled substance history and what they've had filled and when. So a list a mile long with ten different doctors from four different ERs? Raises red flags. And yes, it's tiring, it's a waste of resources (especially when they call 911), and it just annoys us, but what can we do? We call them on it and they'll just try again with a different nurse, a different doctor.

But when somebody comes in, complaining of pain, and they aren't one of our usual drug seekers? Darn straight I'm going to manage their pain to the best of my ability and to their ability to maintain their respiratory drive and O2 saturation. Obviously not without orders, but if it has been ordered, then I'll give it unless there's a darn good reason not to.

So. Something to think over.

[RNperdiem, RN]

Emotional topic. I see a lot of projecting onto the OP things she never said.

[LadyFree28, BSN, LPN, RN]

A few thoughts:

If you feel that way because you don't know how to treat someone with a long-standing history of drug use (note: I did not say ABUSE) for his pain, then you are the one taking advantage of your position and control of his pain.

Someone who uses pain medications for chronic pain and needs a lot more than opioid-naive people is not an addict. Furthermore, addicts are also habituated, but can also have pain and need pain meds on top of whatever they need to prevent withdrawal.

You need to understand the concepts of habituation and tolerance. Many folks on methadone or other opioids take regular doses that would make us opioid-naive folks stop breathing, so why is it that they are still alert and well-ventilated?

It's because their bodies are habituated (used) to that level of the drug and so they tolerate it.

If you can take a prn tramadol or oxycodone dose on top of your baseline opioid level (presumably zero) without risk of hypopnea, so can they, and for the same reason. There is no justification whatsoever for making them wait some arbitrary period to prevent a complication that will not occur, and for the same reason that no one should make you wait for prn pain relief if you ask for it when you need it. To do so is punitive and unethical.

Unethical, I tell you. You need to back off this attitude and do some serious studying on this. There are a number of threads on AN that could assist you. Your patients depend on you for safe practice, and your current attitude is unsafe.

I understand, now having read the entire thread, that you were mostly just venting and you think you do give adequate pain relief as prescribed. But seriously, I think your attitude is not helpful either in managing these patients or in caring for them. Do recalibrate.

Thank you for saying MUCH better than what I was trying to say!

Well said, as always.

[rnmaybe]

how do you know if they have abnormal liver and kidney function? What if they have abnormal kidney function?

Are they conscious?

What are their vital signs?

When did they last have it?

How often can they have it?

What are they rating their pain as?

What non verbal indicators of pain are they showing? Eg grimacing, tense, hunched, agitated, restless etc

Do they have abnormal liver or kidney function?

[FineAgain]

My life became much easier when i dumped the judgement. I can't save everyone, I can't change them. I give them whatever they have ordered, whenever they want it, as long as in my clinical judgement it is safe to do so. Their pain is what they say it is, that's all. Some people just like to get high, that's true. But as a previous poster stated, I would rather not under medicate someone who is truly in pain.

[canigraduate]

how do you know if they have abnormal liver and kidney function? What if they have abnormal kidney function?

1) See the pee. Make sure you have an adequate amount and the right color.

2) Check your BUN and creatinine (kidney)

3) Check your LFT's (liver function tests)

If the kidneys or liver are compromised, it takes longer to metabolize the meds, which leaves them in the body longer and increases their effect. This can lead to seriously poor outcomes.

Also, one of the main adjuncts to narcotic treatment is tylenol, mostly in the form of combination drugs such as Norco and Percocet. Tylenol can kill your liver quickly. If you already have poor liver function, you shouldn't be getting NSAIDS.

[JWG223]

JWG223, You make it sound so simple. Do you have patients like this that you must deal with?

Plenty. I'm just a nurse. I let the doctor be the doctor. They decided the patient should have said drugs available. Who and am I to worry about it beyond patient safety? Get it done.

[klone, MSN, RN]

Also, one of the main adjuncts to narcotic treatment is tylenol, mostly in the form of combination drugs such as Norco and Percocet. Tylenol can kill your liver quickly. If you already have poor liver function, you shouldn't be getting NSAIDS.

Tylenol is not an NSAID. Kidney function is what is important with an NSAID.