Treating pain/anxiety in patients with drug history

NurseLoveJoy88, ASN, RN · Aug 13, 2011

From my experience patients with a hx of drug abuse are often undertreated for their pain. I have heard doctors and nurses say things like" I'm not giving or prescribing any more pain medication because he/she is drug seeking" I have also witnessed judgmental behavior from the many healthcare professionals in response to those who appear to be "drug seeking"

My point of view: pain is whatever the patient says it is and it is NOT my place to judge or withhold prescribed pain medication. If it is safe to give and all 5 rights have been checked and I can safely give it then I will. I have taken care of patients who clearly was "drug seeking" , one patient had a davis drug book at the bedside, once again its not my place to withhold prescribed meds.

I honestly don't see why nurses get upset over this. Yes their are other priorities which is why I offer the PRNs as soon as they are do so that I won't get interrupted later in the shift.

This is just my 2 cents.

Whispera, MSN, RN · Aug 13, 2011

It's all part of the stigma of mental illness and addiction. Many people, including doctors and nurses believe a person with a mental illness or addiction could either snap out of it or has a personal weakness and should be able to be well just because he or she wants it.

I've seen very caring doctors and nurses who do their best to care for their patients with medical problems who also have psych/CD disorders. I've seen others that have no empathy in them at all for such patients. I'll never forget one nurse I was sitting next to, who had a patient in the early stages of withdrawal from alcohol. The patient was very anxious and nauseous. The nurse called the doctor and said, "you don't want to order anything for this patient do you?" with a sneer on her face. That's a worst case scenario though, even though I'll never forget it.

Many medical doctors don't know what to do about mentally ill/addicted patients. They just don't have the experience, just like cardiac specialists may not have the experience with pediatric oncology. They do the best they can.

Weaning a patient off benzos and narcs in 4 days is cruel beyond words. 4 days is when the true misery begins!

leslie :-D · Aug 13, 2011

i've always thought that having an on-call pain AND addictions specialist as part of hospital staff, would be beneficial to staff.

i definitely believe in treating pain/anxiety.

perhaps a psyche eval would be helpful in ascertaining whether pt is being manipulative, may help...or not.

it's a frustrating call to make.

some people are master manipulators.

leslie

Elvish, BSN, DNP, RN, NP · Aug 13, 2011

Some drug (meaning, prescription or otherwise) addictions make pain harder to treat too, as the pt has built up such a tolerance or their receptors are already occupied. A dose that works for them would probably be more than enough to knock most of us into next week. And I've met many many docs (and nurses, for that matter) who are afraid of overdosing them.

If they're baseline taking x amt of oxycodone just to function, it's going to take a bit more to control their pain.

Double-Helix, BSN, RN · Aug 13, 2011

This might be a great question to ask one of the psychiatrists on your unit. There can be a number of different reasons, and I'm sure it's not the same for each patient.

For example, a patient admitted with depression/suicidal ideation who is also taking narcotics for long standing pain. The patient needs to be evaluated and treated for the depression. Narcotic pain relivers, as CNS depressants, might make it more difficult to assess the patient's actual affect and psychiatric status.

Are the patients being weaned off prescription benzos? Or illicit use? If the patient is in a locked unit, their current medications obviously aren't being take regularly or aren't working for the patient. Therefore it might be necessary to wean them off to get a better idea of their actual mental status and prevent any drug interactions in future therapy.

Unfortunately, even if the patient is anxious or in pain, it's difficult to tell whether they are seeking, withdrawing, or have a legitimate reason. Depending on why they are weaned in the first place, it might not be a good option to reintroduce the medication.

If you encounter this situation, though, I would consult the doctor or phsychiatrist in charge of the patient. Actually, first do a physical exam and see if you can find any physical cause for the pain. Try non-pharmacological methods such as distraction, relaxation, music, ice/heat, etc. If that's unsuccessful, then notify the doc of the complaint and ask if it's possible to give the patient something. If the patient is complaining of pain, there are non-narcotic options that should be offered first. Someone who is legitimately in pain should be willing to try to non-narcotic methods. For anxiety, try to help the patient identify the root of the anxiety and work with them to resolve it.

Gently.me · Aug 13, 2011

This is such a tough subject, because the abusers tend to ruin it for everyone.

I have worked at a primary care doctor office for awhile, and we had quite the variety of pain patients. We had the abusers who only wanted the quick fix and had no responsibility whatsoever when it came to taking medications as prescribed. We had the patients who had legitimate problems with pain, and don't want to try anything else other than pain meds. Then there are the patients who have tried everything and nothing works except the meds.

Currently I am working at an Urgent Care facility and a Neurosurgery Center where we also have a pain doctor come in to treat his patients. I feel in both of these environments, it is appropriate to acutely treat pain as much as possible.

Doctors have to protect their licenses, and that in itself is no excuse for ignorance, BUT on the other hand look what happened with Michael Jackson.... They went after the doctors and not the person who was irresponsible.

Simply Complicated · Aug 13, 2011

It's all part of the stigma of mental illness and addiction. Many people, including doctors and nurses believe a person with a mental illness or addiction could either snap out of it or has a personal weakness and should be able to be well just because he or she wants it.
I've seen very caring doctors and nurses who do their best to care for their patients with medical problems who also have psych/CD disorders. I've seen others that have no empathy in them at all for such patients. I'll never forget one nurse I was sitting next to, who had a patient in the early stages of withdrawal from alcohol. The patient was very anxious and nauseous. The nurse called the doctor and said, "you don't want to order anything for this patient do you?" with a sneer on her face. That's a worst case scenario though, even though I'll never forget it.
Many medical doctors don't know what to do about mentally ill/addicted patients. They just don't have the experience, just like cardiac specialists may not have the experience with pediatric oncology. They do the best they can.
Weaning a patient off benzos and narcs in 4 days is cruel beyond words. 4 days is when the true misery begins!

Keep in mind Whispera, I am speaking from a psych point of view. So I'm talking about the psychiatrists.

Simply Complicated · Aug 13, 2011

i've always thought that having an on-call pain AND addictions specialist as part of hospital staff, would be beneficial to staff.
i definitely believe in treating pain/anxiety.
perhaps a psyche eval would be helpful in ascertaining whether pt is being manipulative, may help...or not.
it's a frustrating call to make.
some people are master manipulators.
leslie

This is in an inpatient psych center, no psych eval needed:lol2:

Simply Complicated · Aug 13, 2011

Some drug (meaning, prescription or otherwise) addictions make pain harder to treat too, as the pt has built up such a tolerance. A dose that works for them would probably be more than enough to knock most of us into next week. And I've met many many docs (and nurses, for that matter) who are afraid of overdosing them.
If they're baseline taking x amt of oxycodone just to function, it's going to take a bit more to control their pain.

Oh yes, absolutely. What I find so frusturating are the ones that want to order NO medication. Basically they have a drug history, they get no narcotics, benzo's, etc.

Whispera, MSN, RN · Aug 13, 2011

SimplyComplicated, I missed the part about the docs being psychiatrists. So, with that in mind...

1. Someone graduates at the bottom of the doctor/psychiatrist class

2. Some psychiatrists get pretty hardened from dealing with pain and anxiety day in and day out, and lose their empathy

3. Some psychiatrists, just like some people, in general, just don't understand and don't care to understand

4. Some psychiatrists don't understand addictions (to benzos, narcs, or any other addictive substance)

This brings me back to the weaning in 4 days...people can die from that or at least feel like they're dying...

If someone has been using prescribed medications, even at a high rate, and comes into the hospital (psychiatric or otherwise), the few days there (most psych hospitalizations are short-term) aren't the time to wean off the drugs. It will be cruel, and won't work. What in the world is the point? To show them a thing or two?

Can you tell I have feelings about this?

xtxrn, ASN, RN · Aug 13, 2011

When I worked drug/alcohol rehab, the docs were great- and addiction certified MDs.... they would treat the symptoms of the acute issue with a dosage that took into consideration the length and extent of their addiction- and during that time, do 'talk' therapy to help them with whatever was causing most of the anxiety (usually a fear of being taken off stuff cold-turkey, like they had in other places- we didn't' do that)... of if pain (like getting teeth pulled while in tx since they hadn't seen a dentist in 10 years d/t spending $ on drugs), treat them with narcs for 2-3 days, then NSAIDs..... there was NEVER a situation where the acute situation was not dealt with in whatever way necessary. But, they were also temporary w/additional meds.

When patients had to be transferred to the acute care hospital (and where I later worked and saw this), they were essentially ignored. It was horrendous.

One LTAC I worked at had a paraplegic (still had pain sensation- no mobility), and hip disarticulation, w/a dinner plate sized decub in his sacrum - to the spine. He HURT. And he was on methadone maintenance- and not a very high dose. The admitting doc refused to give him pain meds for the decub. I'd go into the room (him not expecting me- so no time to work up a tear stained face) and be sobbing. I'd call the on-call docs (worked weekends) and tell them about the hx of addiction and decub pain, and get IV morphine for the weekend. Finally I had to refuse to take him when the doc got mad about it. I would not participate in torturing the guy. He may have been an addict (and dealing with it by methadone maintenance- which I don't like- BUT it is an effort to not use the street/contaminated/illegal stuff) but the guy was also a human being, and deserved humane care...