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.