It seems that I can rarely peruse the news in any fashion without reading about the 'epidemic' of opioid-related deaths. I know that we regularly see OD'd patients in ED.
Let's go ahead and say it: pain is *NOT* the fifth vital sign and this push to insist otherwise is a classic example of unintended consequences.
Rather than trying to confront the unfortunate truth that pain is something that we often need to learn to live with, we instead look to push the idea that every police officer should carry naloxone and a nasal atomizer. We're seeing Superbowl ads marketing medication to help treat another common narc side-effect that we see in the ED: severe constipation.
I'm sorry. Pain does suck (I speak as a chronc pain sufferer myself) and *limited* use of narcs can be helpful but let's put it in its place...
PAIN IS NOT A VITAL SIGN AND I REFUSE TO CONSIDER IT SUCH.
I apologize for posting on a thread I haven't fully read, and hopefully this has been said already- but I really hope you were just venting and did not mean to insinuate that police officers and first responders shouldn't push for the ability to carry and administer narcan. Narcan should be as widely available as humanly possible. I am all for vigorous conversation about addiction and how to best approach the problem, but while we are busy discussing it I want to make sure that no one dies for wont of a safe, easily administered medication like narcan.
I am sure I am speaking to the choir here. Addiction is a multifaceted disease, and much like diabetes and HTN, lifestyle factors are key in long term recovery. But I don't look down my nose at the diabetic who comes in with a BS of 500 and a donut in their hand, and neither should we look down at the addict who comes in strung out on heroin and septic.
I want AEDs as widely available as possible- this doesn't negate the need to address cardiovascular disease from a holistic, systems wide approach. Similarly, I want narcan in every police cruise and ambulance, and hell- I want it at the school nurses' office, I want it behind every pharmacy counter. I want anyone who has an opioid addict in their life to carry one.
I kind of think it should be over the counter. Having trouble thinking of an argument against it, except the tired old idea that providing harm reduction will just promote more risky behavior. The same tired idea that people use against PrEP, needle exchanges, and supervised injection sites.
I will bow out quietly now, since I did not read the thread and this has probably been rehashed ad nauseam already.
It's been my experience that a lot of people really don't understand the pain scale. I've had people that I don't believe were drug seeking tell me they had 8/10 pain but their body language and demeanor would say otherwise. It's possible that they have learned to live with chronic pain but in these particular cases, I think they truly did not understand. I can hardly blame them. There have been times when I've been in pain and have stopped to think about what number I'd give it, and it's hard to come up with a number. Perception depends on so many factors, including how stressed I am a the moment (making it worse) or how busy I am (distraction).
It wasn't all that long ago, I recall being told that there was no need for people to live in chronic pain and that they would not become addicted to opioids. Obviously, that was not true. I can only hope that the pendulum does not swing too far in the other direction, leaving people who have pain, either acute or chronic, with insufficient relief.
I 100% agree to this. I do not understand pain scales and how they apply to me. I've lived with arthritic pain for over 25 years. I've taken every anti-inflammatory on the market. I've been puttering alone on Celebrex and Tylenol Arthritis until 2 years ago, when my back finally went. I've been a geriatric RN since the old days, before mechanical lifts and easily raised beds. My SI joint is shot, and no matter what the pain clinic has done, I still have pain that stops me cold. What number do I give? I keep going, no matter what. Does that make 8-9 unbelievable?
i now take opioids, PRN, that help, kind of. A pain level of 8 is looked at askance when I've driven to my doctor, made small talk with his receptionist, laughed with his nurse, then grimaced and shifted my position repeatedly once the door closes and I'm alone. I DO think narcotics are over-prescribed, but I was YEARS before I agreed to take them. What's the answer?
i manage at work because I'm busy and don't have time. I get home, however, and collapse into a fetal position and cry until the meds take effect.
I 100% agree to this. I do not understand pain scales and how they apply to me. I've lived with arthritic pain for over 25 years. I've taken every anti-inflammatory on the market. I've been puttering alone on Celebrex and Tylenol Arthritis until 2 years ago, when my back finally went. I've been a geriatric RN since the old days, before mechanical lifts and easily raised beds. My SI joint is shot, and no matter what the pain clinic has done, I still have pain that stops me cold. What number do I give? I keep going, no matter what. Does that make 8-9 unbelievable?
i now take opioids, PRN, that help, kind of. A pain level of 8 is looked at askance when I've driven to my doctor, made small talk with his receptionist, laughed with his nurse, then grimaced and shifted my position repeatedly once the door closes and I'm alone. I DO think narcotics are over-prescribed, but I was YEARS before I agreed to take them. What's the answer?
i manage at work because I'm busy and don't have time. I get home, however, and collapse into a fetal position and cry until the meds take effect.
I just dont know.
I don't think there is an easy answer. But multi-modal analgesia and holistic pain management specific to the types of pain the patient may have (according to the WHO pain ladder and best practice guidelines) goes a long way. There's a huge difference between someone like yourself using PRN narcs as part of a supervised pain management plan and someone who just wants to get high and is faking/exaggerating their pain.
Addiction and adverse effects can be minimised by using adjunct medications for e.g. neuropathic pain, by using PCA's post-op, and by using slow-release narcotics for chronic and palliative pain. Also, holistic pain management should be a big part of pain management for any chronic pain patient (heat and ice therapy, acupuncture, TENS, massage, counselling, breathing exercises etc, depending on what is appropriate and safe for the individual)- this is NOT my advice, this is just what I believe is good pain management.
Lady K, I'm sorry you are in so much pain on a daily basis, I hope you have a good pain management clinic supporting you.
If iv narcs are not prescribed routinely there is much less of a problem. In the UK we rarely administer bolus doses of iv narcs outside of PACU/ED as patients having these require careful monitoring. Post-op it's generally PCA's, infusions via syringe driver, epipleurals, epidurals or oral meds. Obviously, we still have drug addicts but I think, as others have said, not jumping straight to solely opioids can be helpful.
Pain is not the 5th vital sign...just some thoughts.
I had had a screening colonoscopy a couple of weeks ago. As an NP in family practice, I haven't worked in the hospital in 20 years. I was stunned at the verbiage around pain as I was admitted by the RN. She asked about pain and I admitted (to my regret) to some intermittent knee pain, due to the fact that I am 62 and becoming somewhat arthritic. All of a sudden, everything was about my knee pain, and what level is it, how often, etc., etc. I finally told her this is not anything we need to talk about in this setting.
I retired from my NP practice in primary care 18 months ago. Among many things, the need to manage patients on opioids for chronic pain factored in my decision. I had many same day patients in my practice. I had many aggressive drug seekers I had never seen before who sucked time from my day arguing about their need for opioids even when confronted with the information I had unearthed from the state drug registry and the amount of pills they already received.
And, I am amazed at the amount of relief opioids (5 mg oxycodone) provide for my husband recently diagnosed with cancer. And I am frustrated by the fact that I have to bring my very weak and shaky husband in to the clinic for a new prescription because the hospitalist did not prescribe enough to last until his scheduled visit.
Here you go. Inside this lengthy writeup I discuss the physiology of pain and how sleep does mean the patient is not perceiving pain.
Some other things to note. I teach lectures on this stuff to my colleagues including understanding pharmacological interventions. I work directly beside Anesthesia daily, of which I have gone over things like this with them numerous times. The article I linked I typed up here at work with limited resources but I'll think you'll understand. I dont understand how perpetuation of a myth that you made up of a patient sleeping and pain equates into more opiate use? Enjoy!
I'm not sure if you meant to provide a different source, because neither of the two you've linked to support your claim, and actually the second source goes into depth about the effects of sleeping while in pain, which pretty clearly doesn't support your claim that sleeping equals no need for pain treatment. I also don't know of any evidence to support your claim in the linked post that there is no form of pain experience while asleep.
I'm not sure if you meant to provide a different source, because neither of the two you've linked to support your claim, and actually the second source goes into depth about the effects of sleeping while in pain, which pretty clearly doesn't support your claim that sleeping equals no need for pain treatment. I also don't know of any evidence to support your claim in the linked post that there is no form of pain experience while asleep.
Maybe you just didn't read my write-up. Pain is not objective, its subjective. You cannot express pain if you are asleep (you're unconscious). Since pain is a perception and how we treat pain is based on how a patient is expressing discomfort, how do you suggest they have a 10/10 pain if they are sleeping (its impossible). The second article was to show that people having pain do not experience sleep, it does not mention pharmacological intervention, it was used to help provide framework. Put it this way.. if you give opiates (or even multi modal approach) to a patient and they fall asleep, do you keep pushing narcotics on them? I dont because perceived pain is controlled and we risk running into airway issues. I can understand if this is a hard concept to grasp. You keep pulling at straws here.
I have read every reply on this thread and almost didn't reply, but I must! The beauty of free speech, right? I get where OP is coming from, which I think, is more from the stand point of the people who abuse narcotics. They suck the life out of you, they take up our time that I could be spending with my acutely ill patients, they make me question why the heck do I do this job! I get it, it makes our job hard. However, it doesn't mean that pain isn't real, which the OP has also stated they understand. There is an opiate epidemic in this country and its real. The problem can't be fixed by nurses and doctors deciding not to give narcotics. It is a problem that has to be addressed by so many disciplines in our field from PCP's, to the ER to Pain Management. And in every field, there are docs who know what they are doing and docs who throw a Percocet script at the patients with a sprained ankle. What makes me want to speak up is the fact that I deal with someone who is in chronic pain daily. If I could only tell you the three years of hell we went through and the ridiculous amount of physicians we went to before finding a doc who didn't just throw a narcotic prescription at him and tell him to come back in 6 months. We are beyond grateful we found an amazing Doctor. Would we have found that doctor if I wasn't a nurse and advocated for my husband? Probably not. Everyone isn't this lucky. His doctor controls his pain with multiple medications, not one of them being a narcotic, until recently. It was something I stood up and said "no way, my husband won't be addicted to narcotics!" Where did my thinking come from, not actual fact but my skewed biased of the percentage of people I see as a working nurse who abuse the system. My husband suffered for years because of me. Does my husband still suffer in pain? You betcha, but there is some more quality to his life. Does my husband also have other Pain Management modalities other than narcotics? You betcha. He takes gaba, NSRI's, PT and sees a shrink to accept the fact he will have a life of pain and needs to learn how to alter his lifestyle because of it. Because of my narrow mind, I truly believe I did more harm than help, and I am his advocate! However, this experience made me alter my nursing practice. Do I hand out narcotics like water to the seekers, no way. I talk to the providers and give them my assessment- they are laughing and joking with their visitors displaying not an ounce of pain then when I pull the curtain they roll back and forth and put on a show. Will I make them "see the way to sobriety" by withholding their narcotics? Not a chance. But I do advocate for patients I believe are in pain, despite their history of no chronic pain or having chronic pain. Just because someone has prescribed narcotics does not mean that they cannot exacerbate or have a different acute condition. And yes, they do require higher doses of narcotics for an acute issue. Shame on me for my years of judgement. At no time in school or practice did someone say, here is your nursing license, go forth and judge people. Do I get duped sometimes? Sure! Is pain always what the patient says it is? No way! But I learned that every patient is individual, and it is my responsibility as a healthcare provider to be nonjudgmental. Recently there was a patient in the ER that ended up with a ruptured appy. Was also an IV heroin abuser. They died. Would we have prevented their death by giving some IV narcotics? No! But would their death have been prevented if they weren't just flagged as an abuser? Who knows, maybe. My whole point is, as a few other commenters stated, this is not a black and white issue. There are MULTIPLE flaws in our healthcare system surrounding the subject of pain. Oh and one more thing and I will shut up! Someone stated yoga for chronic back pain. Yes, for some, can be an amazing form of therapy. But for others, not so much. Chronic back pain is not one condition, there are hundreds of underlying factors and conditions that cause chronic back pain. If I went to our neurologist and said "hey doc, I read online that my husband should do yoga for his 'chronic back pain,' I read it on the internet so it must be true" he would probably get up and smack me. In which he should! That would be the most detrimental thing for my husband. I am not on a soap box nor here to change anyone's mind. There is a difference between addiction, pain management, abuse, dependance and tolerance. I hope if I ever take my husband to the ER one day that he will not be judged. But I'm also aware that is not probable.
Is the relief of pain and suffering not the number 1 reason people present to the ED?
Perhaps the real problem is the lack off alternatives in treating pain.
When the only tool that you have is a hammer,everything looks like a nail."
With all the issues of staffing shortages and reimbursements, it is no wonder that the easiest choice is made in terms of Tx.
Let's get to the root cause, and that is the overuse/overprescription of pharmaceuticals. If you really want to look at pharmaceuticals that are overused/overprescribed, cholesterol and BP pharmaceuticals by far are the worst offenders.
Finally I would argue that REACTION to pain IS a vital sign (think neurological assessment).
I see multiple problems within this thread. Firstly, lots of judgment. If a patient is in pain, why does it matter to you if they "deserve" it or not? OK, so no one used that word but that's how it's coming across. Does it matter to you that the pain might be a 5, or a 7...or a 10? Does the medication come out of your paycheck? Or is it perhaps the social stigma that has formed your bias and you have somehow reflected that on to your patient? Your job as a nurse is to keep the patient safe, act as an advocate and provide them with care. If there is a legitimate (and notice I use the term legitimate) order, then there should not be an issue carrying out that order. If the patient becomes apneic or hypotensive, then of course we need to follow due process and report that and follow rapid response guidelines. Being disapproving and judgmental is not going to help your patient. I'm sure that many of those commenting are likely in their 20s and 30s and have yet to experience how chronic pain can run your physical and emotional state into the ground. I hope you never find out.
The other issue is the lack of available choices for chronic pain management. Being that in pharmacology, medications can only activate or prevent natural processes from happening, it is not possible to just invent a magic drug that will take everyone's pain away without any side effects unless the body has physiologic ability to process that drug. There's only so much you can do. In order to agonize the mu receptors the drug needs to be transported across the blood/brain barrier which is very hard to achieve due to it's hydrophobic barrier, and without other CNS effects like euphoria and CNS depression. NSAIDS act in a completely different way and there is a big chasm between the two types of receptors on which they act, plus they carry their won set of long term complication like heart disease. And, you have to take in to account the dosage curve that factors in potency vs efficacy. Some drugs cannot compete with others in their efficacy no matter how much you give because they are a different potency. Lastly, every human has a different intrinsic manner of metabolizing drugs, so you can give a whole bunch of one drug to person A and they may have a genetic variation that means they produce more enzymes than person B. Person B will have too many effects and person A will metabolize that drug right out of them and have no pain relief. Pain is completely subjective because of those factors. Similarly, a person has no control over the fact that frequent narcotics will lead to downgrading of mu receptors meaning they will build up a tolerance leading to a need for higher dosages to have the same effect because the receptors are just not there any longer to accept the agonist. This includes the euphoric CNS side effects that decrease with use.
My point: until there are other effective analgesic options, we are left with a very small pool of medications with which to treat patients, and attaching a social stigma is not helpful to anybody, least of all the people are are genuinely in chronic pain and are unable to get medicated because some "professionals" think they shouldn't have the med because...you know...they might get addicted! *gasp* How about we give people the meds they need, while educating at the same time about side effects and consequences, and offering options to our patients to choose for themselves and find some relief!
I worked in an ER and got a patient, a 72 year old male, who thought it was a good idea to climb a ladder and clean the eaves of his house. Needless to say, ladder fell with him on it. This man was in horrid pain. The doc refused to give him any pain meds because his pain was so bad nothing was gonna work anyway. What an ass. I had to dc the patient still hurting. Told him to go to the next town and get real treatment.
There is another problem that people with chronic pain must face and that is the look when they ask for pain meds in the hospital. It is a look and the manner that says you are drug seeking. I do not use any meds except those prescribed for me but almost every time I visit the pain doctor I have to give urine for a drug screen. Every year I must sign a contract that says I will only take what is prescribed and if another doctor orders something I will report it. The latest indignity was completing a survey that was part to see if I am depressed and part to see i I am misusing my meds the only narcotic I am currently taking is Vicodin for breakthrough pain but need to do these things to prove I a not drug seeking.
I feel that I am not believed although as a nurse I know that these things are required by law and my doctor does not doubt me because she feels that I need to take the Vicodin more often. Most of the conversation in this thread is about not believing the patient which has never been what I do but I will guess that most people do not know what has to be done as a patient in a pain clinic or practice here in New York. If people with long term pain were seen by "pain" specialists the overuse of narcotic would decrease and maybe I and patients like me would not have to feel like they are addics.
It's not all the time, but at least 3-4 times a week, and it's at least half of rapid response calls. Especially if the patient is having a COPD exacerbation and is already having trouble getting rid of CO2 when somebody slams in an opiate and drops his/her respiratory rate.
I don't know why people don't advocate for some Toradol or something when somebody teetering on the edge of buying himself a tube because of high CO2 complains of pain.
I have had chronic pain (back, neck) for DECADES. I know intellectually that over prescription of narcotics is a problem, but it's hard for me to really absorb because in the 30+ plus years of my disc problems (since I was 16), NOT ONCE have I ever been offered narcotics for my back/neck pain. I've been prescribed it after surgery and after I had shingles. Oh, and once when I had influenza, with 104 temp in the ER and absolutely excruciating sore throat pain and the worst body aches I've ever felt in my life (I imagined this is what bone cancer feels like), I got Lortab elixir. But for my chronic, horrible back and neck pain? Not once.
Of course, perhaps part of this is because I never asked for it. Maybe that's the thing, but my own vast (personal) experience has taught me that narcs are not given out like candy, at least in my neck of the woods.
I thought Bextra was my miracle drug. Relieved pain, no discernible side effects. Then they broke my heart and took it off the market. Second best is Toradol, truly a fantastic drug imo.
For chronic pain, I would not want to go down the narcotic pathway. But for terminal illnesses and acute pain situations, it's so appropriate, and I think it really gets short shrift from people who have seen so much abuse that they project those behaviors on almost everyone.
cayenne06, MSN, CNM
1,394 Posts
I apologize for posting on a thread I haven't fully read, and hopefully this has been said already- but I really hope you were just venting and did not mean to insinuate that police officers and first responders shouldn't push for the ability to carry and administer narcan. Narcan should be as widely available as humanly possible. I am all for vigorous conversation about addiction and how to best approach the problem, but while we are busy discussing it I want to make sure that no one dies for wont of a safe, easily administered medication like narcan.
I am sure I am speaking to the choir here. Addiction is a multifaceted disease, and much like diabetes and HTN, lifestyle factors are key in long term recovery. But I don't look down my nose at the diabetic who comes in with a BS of 500 and a donut in their hand, and neither should we look down at the addict who comes in strung out on heroin and septic.
I want AEDs as widely available as possible- this doesn't negate the need to address cardiovascular disease from a holistic, systems wide approach. Similarly, I want narcan in every police cruise and ambulance, and hell- I want it at the school nurses' office, I want it behind every pharmacy counter. I want anyone who has an opioid addict in their life to carry one.
I kind of think it should be over the counter. Having trouble thinking of an argument against it, except the tired old idea that providing harm reduction will just promote more risky behavior. The same tired idea that people use against PrEP, needle exchanges, and supervised injection sites.
I will bow out quietly now, since I did not read the thread and this has probably been rehashed ad nauseam already.