REAL Pain or ADDICTION?

Mandee · Jun 28, 2007

There is no way to know for sure if he is addicted to lortab or not...Patient's with chronic pain don't look the same as someone with acute pain..so it's possible for pain to be severe and him to be joking etc...As far as the methadone goes, I would say he was not on it long enough to titrate and evaluate the effect..jmo.

leslie :-D · Jun 28, 2007

to me, the pt's comfort level is more important than any possibiity of addiction.

leslie

doodlemom · Jun 28, 2007

How much methadone was he started on? 2 days on the methadone is really not enough time to do anything with methadone. You really need several days to titrate the med. We usually start low and titrate every 5 days. You could try letting him have his lortab during the transition and slowly decreasing the MS Contin. If his pain is not well controlled, he may appear to be "drug seeking" which is understandable behavior.

aimeee, BSN, RN · Jun 28, 2007

Does this patient have a history of substance abuse? They frequently require very high doses to relieve their pain. I think this is partly because use of these substances has changed the way their body reacts to them, partly because they may have accumulated damage to the body systems that process them. Another component is that these people manifest their mental/spiritual pain as physical pain. That doesn't make it any less real to them, but it means that in order to achieve "relief" they are needing a measure of escape.

Allow Mystery · Jun 28, 2007

The primary goal is pain control, whatever the method. I would keep titrating the morphine ER dose upward, and try morphine IR and Roxanol for BTP. Good luck!

vamedic4, EMT-P · Jun 28, 2007

to me, the pt's comfort level is more important than any possibiity of addiction.
leslie

EXACTLY.

This patient has a history of CA PAIN, hence the need for the multitude of pain medicine. Patients in chronic pain are much different from acute pain patients- their pain is usually ALWAYS there to one degree or another.

And as we all should know - some pain meds work great for some people, some don't. Some work best in combination with others for many people, other people require more and/or different med "recipes" in order to control their pain. If this patient is getting relief from his current regimen - then why not keep him on it? What you have listed is a TON of strong medicine, but if it works for the patient's pain??

Another thing - has the patient had any success with fentanyl? Just wondering, because the Actiq lozenge is available for pain such as this...and now Fentora (similar to the Actiq but in a dissolvable tablet form). These are available at different dosages from 100 to 1600 mcg. Just a thought.

Keep in mind, too, that since your patient is on so many of these as "scheduled" or "regular" meds (meds he takes every day), this will cause his BTP to require higher dosages of breakthru meds. The body becomes accustomed to having so much med in the system that the normal doses are less effective.

Just my $.02

vamedic4;)

a21chdchic · Jun 29, 2007

You need to fully assess pain, what kind of pain is he having? Somatic, Visceral, or Neuropatic - or a combination of 2 or 3?

Lortab and Fiorcet both have acetaminophen, and you can OD on too much.

Lortab and Fiorcet are not the best choices for chronic pain. The methadone, roxanol, and decadron is a good combination of meds for some cancer pain, but you still need to know where, severity, what kind of pain it is, when is it worse, when is it better (what time of day),

precipitating factors, etc., in order to make suggestions for further changes. Doodlemom is right, Methadone can be titrated up Q 5-7 days and you do not even get the full effect of the drug until the 4-5 day. As far as the 'blotches' and mental status changes go, What was your assessment? Did you observe anything that would indicate an allergy or adverse reaction? Or did you see a patient expressing a personal preference for Lortab? You and the MD are the professionals, and sometimes we have the unpleasant job of letting the patient/family know that although they may prefer something comfortable that they have used for a long time, it is not always the best choice for them, and explain to them why another drug/combination should be given a fair trial period, and why their current drug regimen is no longer appropriate. (It is no longer effective, can OD on acetaminophen.)

If he truly is having an adverse reaction/allergy, obviously the med responsible should not be given, but that doesn't mean patient chould go back to an ineffective regime. Another effective opiod is Oxycodone and can be given as tab or liquid. (oxyfast) I'm not a big fan of Fentanyl, most cancer patients do not have the subcutaneous fat required for proper absorption of the med.

Your best bet is to assess for the different types of pain, and get meds ordered that will effectively treat each type of pain that the patient is experiencing.

Ana

KarenGeorgeBSRN · Feb 19, 2008

My recent reply on another TOPIC and this is truth!

Re: Drug seeking or real pain? How do you tell?

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Good Morning!

One of the most difficult concepts for a nursing professional who is brainwashed into thinking of "drug seeking" as a medical term is the differentiation between "tolerance" and "addiction." The physical symptoms are the same for either person; yes they are both viable clients with overtly different diagnoses and outcomes!!

Over and over I read posts on this topic in the year 2008 where modern research has shown that "tolerance" and "addiction" appear the same physically, when indeed the only similarity is the symptoms physically that occur between a person who is legally prescribed medication for pain, and someone with a serious disorder which is entirely differen; this disorder ist termed "addiction."

Physical withdrawal can occur between the "pain patient" and "the addict" with the same result; an uneducated physician or nurse can infer by value system (not by the subjective verbal report of the client) that a person is in fact "drug seeking" and one of the top pain specialists in the United States told me "at some point a patient not treated for his or her pain will be RIGHTFULLY drug-seeking at some point if not treated, for he or she cannot tolerate the suicidal level of pain they experience."

Nursing professionals are in the role of advocate by the nature of our profession; with or without a value system in place; putting ourselves as "God" does nothing for the client in need, makes us look like idiots, and furthermore negates the value of our very comprehensive education. I do not care whether you are a LVN, two year or diploma RN, or four year RN--you know through clinical experience if not through text book knowledge the truth.

Reply after reply show nurses who have years "in the trenches" learning from their own misconceptions about the term "drug seeking." When I tell you that stating such in an ER with a client in true need is malpractive for a physician and the nurse involved I mean this. If any of you who use this term freely or believe somehow that you know better than the client experiencing pain "his experience" then you are wrong. Lack of objectivity will keep you miserable in your role as a potential advocate, and then when someone you know and love, even yourself falls through the cracks, and is attacked or mistreated in thousands of ER's (in particular) throughout the United States you might change.

We have an obligation to continue the learning process throughout our lifetime. I know of no other profession where it is encouraged, applauded, and complimented. Our profession can make a difference in the lives of many; this particular concept of "drug seeking" needs to be trashed along with foul language, abuse, and a thousand other crimes of a medical nature that occur with frequency today.

I ask all of you in disbelief to further educate yourself; get your nurse managers or DON's (such as myself) to arrange inservices, really make yourself an open book when you approach any new client, and "stop the violence." One day it might be you so labeled and suffering, please do this for your client's and for yourself.

There is no "seeker" this is a disgusting judgement. An addict is also suffering a serious disease process; one that is incurable, but a psychiatrist is in the role to truly determine if a person fits into that diagnostic criteria; not a one shot five minute analysis rendered by a value statement.

Thank you,

Karen G.

crb613, BSN, RN · Feb 19, 2008

to me, the pt's comfort level is more important than any possibiity of addiction.
leslie

:yeah: :yeah: :yeah: My thoughts exactly!

ray2512 · Feb 19, 2008

You didn't say where the pain was. But if it is in his shoulder its probably brachial plexus. Nuerontin would be the med for that nerve pain. 300 mg tid to start can go up from there.

sharona97, BSN, RN · Feb 20, 2008

KarenGeorgeBSNRN:

Not only a well thought out truthful post and advocate for the patient, your post furthers insite into a very deep individual type of comprehention and treatment that we as caregivers need to hear. Loud and clear IMO, lest we forget that we ourselves are not infallible to what might happen to our own loved and cherished family members, including ourselves.

Margo McCafferty gave a lecture on chronic pain while I was in nursing school in the early 1980's. Her summation and definition of chronic pain vs any pain I feel is parallel to your post.

For me, discussions and conferences and knowledgable input from learning brings me back to what is what and how to proceed, subjectively as well as objectively.

Thank you for your valuable input on treating pain and listening (key word) to your patients.

Sharona:nurse: