REAL Pain or ADDICTION?

sharona97, BSN, RN · Feb 20, 2008

I've been trying to locate on the web an article co-written by Barb St. Marie and Marfgo McCafferty from I think around 204 or 2005. Barb St. Marie was working at the Fairview Hospital Pain Clinic at the time. Has any one read this article or know where to find it?

I've googled everything I can think of.

Thanks.

KarenGeorgeBSRN · Feb 21, 2008

Hi Ray,

Neurontin was never FDA approved for nerve pain; in fact the side effects are so severe for those with NIP we do not recommend it for regular use; these include suicidal ideation, irreversible weight gain and memory loss.

Thanks!

Karen G.

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.

wannabeenurse1 · Feb 21, 2008

To all of you hospice pain gurus: I have a pt that has been taking Lortab 6xday with MS Contin (100mg) bid and Roxanol (20mg:1ml) 1ml q1-3 hrs prn breakthrough pain, and Fiorcet prn for headache (he takes at least 3 per day). Every time I ask him what his pain is - it's always at least a 7 and usually 10+ (Dx: lung CA). Meanwhile, he is conversing with me and his spouse without any apparent distress, joking around and such. Spoke with his MD and his meds got changed to Methadone, Decadron and Roxanol for breakthrough. He lasted 2 days and requested to be switched back to the Lortab regimen. He had a change of mental status (per spouse), and broke out in blotches - although he did not complain of a rash or itch. I'm just astonished that the methadone did not work - I've heard such good things about it. It makes me wonder whether this pt just loves his Lortab??? What do you think???

The PT is dying of cancer, why are you so concern with him becoming addicted to drugs. At this point in his life he just needs to be comfortable.

KarenGeorgeBSRN · Mar 2, 2008

Dear "Professionals,"

The patient is.... "in pain" and is suffering. Pain can and does kill. Even with properly utilized opioids the organ systems within the body react as if in fight or flight response; wearing away over time the entire person's ability to do simple ADLs, have restorative healing, and to intentionally live.

Those not in pain just do what others in pain must think to do. (Please reread that sentence and think it out several times before continuing.) A person afflicted with pain who has been functional is no longer able to react physically as their mind and body are overtaxed with negative reinforcers. If they bend their knees, pain tells the brain "stop" and when they force it pain spreads and or has a "referred response." It causes such exhaustion and overload that over time there is depression further depleting the brain of endorphins (natural substances endogenically produced to soothe pain), and a cycle of negative consequence occurs.

Many in chronic pain look great; if they are again reinforced by support list(s) such as mine; they do not lay in bed, they get up and out of the house (fight isolation) and do to their best capacity what they can to realign their inability to do what is normal. For those with catastrophic pain who have lost everything; job, family, and friends an entire reorganization of life must occur starting with "who am I now" (new role), and the constant reminder that the "pain" has a persona so powerful it is as if "satan" is there sabotaging their every move.

Whatever pain it is; terminal or nonmalignant it must be relieved, and to chase acute pain in a chronic, means large doses of IV push medications in a humane environment; this post shows me that many here this or chase the physician for he or she to do this. Prevention of those rapid cycles is the true way to treat the pain; hopefully with a good LA or two good LA's and a BT medication for short acting results.

Put yourself in their shoes; recall that time when you had a sudden event; a renal stone; bad appendicts, MI...Remember that pain, and when a patient states he or she has pain, gives it a number on a scale of 1 to 10 (0 being none and 10 the worst imagined pain) do something about it. Do not forgo your normal nursing assessment at all; for indeed there could be an acute cause in one with NIP; but do not degrade your client by doing less than he or she warrants.

Humane, professional treatment. Ladies and gentlemen you are not opening your own vault of "morphine" to allow a client relief for 2 to 3 hours here; this is a chemical used to treat pain; does not matter which medication is given, only that there is a response. We all know what works best; we also must assess tolerance in those who have NIP, and honestly share their normal medications et al. We want our client to be open and helpful so that we in turn, may provide interventions to relieve their pain, to help this plague on sanity (body and mind) that can truly take them to a point of such destruction that suicide (over time) is the only outcome!

Those with terminal pain are lucky on one level; the DEA truly does not care if they are medicated. What about those who live; who have families, and want to work and continue with heads held high? How may nurses do you know who are in NIP and working on PM? Not many perhaps but more than you are likely to know; it is far harder to convince a nurse that his or her NIP needs proper treatment for "we" tend to think we are above this nonsense but sadly we are not. Those who do work on PM, may be cautiously "silent" to avoid the very prejudicial statements we have all witnessed on this and other posts, bedside in the setting that those in "pain" unjustly receive.

If it makes a nurse in these days of high demand and high technology a functioning member of our profession; a good wife or husband, and an able member of society so be it. Remember, tolerance disallows getting high; that those in pain can suffer profound withdrawal IF they are suddenly removed from medications, but addiction is another serious deadly disease where the person suffering takes all he or she can get to the point of overdose and death. Such a difference needs to be pointed out early on in training. Many of us have not had the benefit of training, and should be throughout our careers and lives open and able to learn, to absorb new information, and also to pass it along to those in need. We must be advocates; there are family members to educate, physicians, CNA's all about us.

Let us put our energy to good use; not to negative and judgmental rage.

Thank you all!

Karen G.

The PT is dying of cancer, why are you so concern with him becoming addicted to drugs. At this point in his life he just needs to be comfortable.

leslie :-D · Mar 2, 2008

i appreciate your post, karen.

a lot of valid information.

yet, there remains a very gray area, for those with chronic pain.

pain causes loss of function, loss of work, loss of productivity.

to be put in a role of helplessness and dependence, creates a lot of mental pain:

depression, apathy, isolation, hopelessness.

compounding these mental stressors with physical ones, many DO become addicted.

opioids DO blunt physical and mental anguish.

to downplay this reality, only serves to fortify addictive behaviors.

and i don't know the answer.

we know that physical pain must be addressed.

but we also must recognize the very high risk of addiction, not tolerance....addiction.

to deny such occurrences, only serves to perpetuate the cycle further.

as for hospice patients, let them have a field day.

leslie

leslie :-D · Mar 2, 2008

as for hospice patients, let them have a field day.
leslie

this last statement warrants clarification.

terminally ill/hospice pts have many issues to deal with at end of life.

it is certainly not limited to the physical.

there are often many loose ends that need tidying up.

yet, many are incapable of dealing w/the mental stressors that go w/dying.

and, knowing the liberal amt of narcotics they are given, many choose to be medicated.

this helps with their physical and emotional pain.

if that is their choice, who am i to dictate their means of dying?

i will not knowingly let anyone kill themselves.

even if i have no moral issues with it, it remains illegal, and will not happen on my time.

and i only come to these conclusions, after working w/them, and then determining how far they're willing to go.

many choose to be alert and want to die, knowing they've said their "i love you's", and have attained closure in any outstanding issues in their life.

yet many others choose to be as blunted as possible.

i will not interfere with these choices.

so in that respect, yes, let them have a field day.

afterall, it is their death.

and i will not play judge.

addiction amongst the terminally ill, is the least of my concerns.

one learns to choose their battles wisely.

leslie

Em1995 · Mar 5, 2008

The word "addicted" doesn't ever enter into my vocabulary or thought process. Pain is pain and whatever the patient says it is. Our mission is to alleviate that pain.

coralynwoodson · Mar 12, 2008

According to Core Curriculum for the Generalist Hospice and Pallative Nurse 2nd ed. page 58, "persons with chronic pain often have no changes in vital signs or facial expression". We need to also be mindful of what pain means to the patient and what it means to his/her family. Is this pain affecting the quality of life for which he or she are accustomed? Could this patient or his or her family have increased fear, anxiety and the wonderment that death is imminent? We must always provide comfort by what ever legal means are necessary to the patient and the patient's family. Pain comes in many forms; spiritual, emotional, physical, and as nursing we must be careful that we are not party to enhancing the pain with stereotyping or other prejudices to the affects of disease on a person. I'm sure that hospice nurses who are new to the profession bring in allot of past practices with them such as monitor the patient for drug hunger. But in hospice, when the patient is in pain, and maintaining comfort is crucial, we must lay aside the weights we have about possible addiction. If pain is what the patient says it is, then we must know that the patient's pain may be "it hurts too bad to think about my dying", or "why is this happening to me" or " I took medicine but it isn't helping the pain". All of these are reasons for us as professional nurses to maintain the patient and his family's comfort.

Em1995 · Mar 12, 2008

I noticed you mentioned "legal", Carolyn. I chuckled. One of my 20 year old patients with stomach cancer experienced intractable nausea and vomiting. I had tried everything under the sun from diet change to meds: Zofran, compazine ativan...you name it, I tried it. One day, I met her mother out in the driveway and she was acting very nervous. She stammered that her daughter's friends had been over and that she had smoked some pot which totally alleviated ALL nausea and vomiting and allowed the patient the ability to visit with her friends and even enjoy some chocolate! I was thrilled! I told her mother that it is medically indicated and to go ahead and let her do this. I did try the pill form of Marinol with her....horrible stuff, doesn't work and it's about 90.00 PER pill! The pharmaceutical industry is really scamming the public by claiming this stuff works. To me, good ol' home-grown is effective.

Once her daughter was no longer able to do this, I resorted to haldol suppositories which were very effective as haldol is directed at the vomiting center in the brain.

Malanya · Mar 20, 2008

I saw this thread. I'm still a student, so my thoughts may be based on the merry glow of knowledge with no experience yet...

But if a patient is in hospice care, the goal is amelioration of suffering, improving quality of life, and comfort until the patient dies, right? I'm assuming the patient wouldn't be in hospice care unless they were terminal?

In that case... I would be less concerned about addiction and more concerned about quality of life. If the medications are causing them to have a WORSE quality of life, then I'd be concerned. But if they're keeping his pain level at the best it can be, allowing him to enjoy the time he has left as much as he can... then it would seem they were doing the job.

I don't know if I'd be able to work in hospice care. Then again it may be rewarding enough, being able to give comfort and being able to help the patient and his family through the dying process, that it might be worth it.... I just don't know if I'd have it in me.

Thanks to all of you who do what others cannot!

thevicarofblue · Jun 26, 2008

ooh, i really do NOT like Fentanyl. and i get a little nuts when doctors start prescribing three kinds of pain meds. i'm used to good ole MS in some long-acting form with a fast-acting (and flavored by our compounders) for break-through pain. why methadone? all the hospice stuff i've ever read says that MS (or Dilaudid) is far superior to heroin or methodone. of course if there's bone pain, one uses something like an NSAID and we usually use topical NSAID. and then just treat any other sx like terminal secretions or anxiety....

i canNOT imagine hospice without the genius of compounders

the vicar of blue

marachne · Jun 26, 2008

In general, I agree that having multiple kinds of opiods usually doesn't make sense -- it's often more confusing to the pt and just not necessary. BUT there are things to consider: poor kidney function? Best bets are Fentanyl and Methadone (least amount of metabolite accumulation) see Fast Fact 161. Liver failure? Again, Fentanyl seems to be the safest product (issues of clearance and first pass effect). A really good article on medications in liver failure is

Palliation and Liver Failure: Palliative Medications Dosage Guidelines (2007)

Rhee, C., & Braodbent, A.M.. Journal of Palliative Medicine, 10(3), 677-685.

I'm curious as to why you hate fentanyl. I've had good success with it, and when I have a confused patient who is not on an infusion, it makes dosing easier. Also, while I know they say you need SQ fat for absorption, I haven't noticed a major drop in efficacy w/cachextic pts.

I'm also curious why Karen George was so adamant about not using gabapentin -- again, for nerve pain it has done wonders -- pregabalin too when someone has limited time for titration. No experience with any of the side effects mentioned (suicidal ideation, memory loss).

I realize this is an old thread, but I also feel an urge to comment about the whole addition issue. I used to be totally "tx the pain of the person as they say it is." But I've also come to see the need for people with chronic pain to have a more biobehavioral approach. The reality is that pain medication can only do so much. In a non-(imminently) terminal person, the thing to focus on is function -- what will give the person the best possibility of having the highest level of function? What are the other tools that can be used (psychological as well as physical) that will give them the best QoL? To me, it's analagous to just throwing SSRIs at a person with MDD -- usually, pills alone are not going to solve the problems. I'm not saying we judge and not give meds, and not recognize the potential tolerance in someone w/a drug abuse background and punish them, but we (the health care system) are responsible for creating more addicts, and we have to be more responsible with how we prescribe.

Just my :twocents:

miriam