Treating pain/anxiety in patients with drug history

[Simply Complicated]

I originally posted this under psych, since thats where I work, but haven't gotten any answers. Thought I would try the main nursing forum.

I'm just wondering the experience others have with their doctors, and the treatment of patients with a history of drug abuse? I work as a float in an acute locked unit. We have 4 units in our department, with 6 doctors total, although one is the director and rarely has patients. Obviously we get a lot of patients who have dual diagnoses. It seems frequently they will wean these patients off all benzos and narcs over a 4 day period, and then offer them next to nothing. They frequently act out, and then it's just said Oh they are drug seeking.

I was taught in nursing school that even if a person has an addiction, it does not mean their pain is not real. Does the same not go for psych patients? Doesn't mean their anxiety/agitation is not real and deserves to be treated. I feel like they are frequently blown off when they report the Vistaril ordered is not working. A few of our doctors also frequently will D/C the pain meds they have been on for years, because they have a hx of polysub.

I am sure some of them are drug seeking, and it is obvious at times that the behaviors are intended to get them meds. But then others seem they truly need something.

Just wondering others views, experiences??

[leslie :-D]

Someone who is legitimately in pain should be willing to try to non-narcotic methods.

this statement couldn't be truer.

when i was hospitalizd (1 night) for a diagnostic procedure, it necessitated me needing a chest tube.

and boy, that hurt.

i got iv fentanyl, dilaudid, and morphine.

those did little to nothing for my pain...they only changed my perception of it, i.e., making me loopy/high.

nurse gave me iv toradol...my pain went from an 8 to 0.

i'm telling you, no pain whatsoever.

that's the only med i wanted after that.

so yes, if someone is legitimately in physical pain, they'll take whatever works....and they're not always narcs.

leslie

[xtxrn, ASN, RN]

this statement couldn't be truer.

when i was hospitalizd (1 night) for a diagnostic procedure, it necessitated me needing a chest tube.

and boy, that hurt.

i got iv fentanyl, dilaudid, and morphine.

those did little to nothing for my pain...they only changed my perception of it, i.e., making me loopy/high.

nurse gave me iv toradol...my pain went from an 8 to 0.

i'm telling you, no pain whatsoever.

that's the only med i wanted after that.

so yes, if someone is legitimately in physical pain, they'll take whatever works....and they're not always narcs.

leslie

I agree w/you for the most part (toradol used to be THE primary pain med, was given as a scheduled med, for post ORIF of the hip and THRs and was wonderful :)).

My only disagreement is when the patient has had pain for ages, and knows what will and won't work (and hopefully has the info documented somewhere).... the NSAIDs (or whatever) can prolong getting pain relief.... JMHO (this being for someone who is not necessarily an addict....just pain in general). :)

[brandy1017, ASN, RN]

I also think its wrong to take patients off pain meds and anti-anxiety meds because they have a history of so-called drug abuse. They are taking these meds for a reason and they usually have chronic pain and anxiety.

They are basically punishing them for taking meds to relieve their pain and anxiety! I'm always surprised how honest patients are admitting they take street drugs or they borrowed a friend's pain med; and then they are written off as drug seekers.

Many of them need pain relief and help with anxiety and depression. Even heroin addicts are given methadone. Isn't methadone just another narcotic to trade one addiction for another.

There has to be a fair alternative to lower their pain and psyche drugs, while also offering other help such as medical hypnosis, therapy, and pain relief thru an epidural or TENS unit. Not just you've been bad, now we're going to take everything away from you so you can suffer in pain and fear!

[xtxrn, ASN, RN]

I also think its wrong to take patients off pain meds and anti-anxiety meds because they have a history of so-called drug abuse. They are taking these meds for a reason and they usually have chronic pain and anxiety.

It is like they are basically punishing them for taking meds to relieve their pain and anxiety! I'm always surprised how honest patients are admitted they take street drugs or they borrowed a friends pain med and then they are written off as drug seekers.

Many of them need pain relief and help with anxiety and depression. Even herion addicts are given methadone. Isn't methadone just another narcotic to trade one addiction for another.

There has to be a fair alternative to lower their pain and psyche drugs while also offering other help such as medical hypnosis, therapy, and pain relief thru an epidural or TENS unit. Not just you've been bad now we're going to take everything away from you so you can suffer in pain and fear!

If they take them as directed, they shouldn't have issues with getting orders for meds from the doc who does the prescribing and knows they need it..... I think a lot of the trouble comes with docs who don't know them. And many of those docs have been burned by the true addicts who take increasing doses more often, and have had negative consequences of their addiction and can't stop, and won't get help..... big mess for everyone

Patients who need pain meds are generally viewed as suspect, even with no previous history of abuse or addiction. Nurses often interchange dependence and tolerance... and that doesn't help either. Docs don't want their licenses dinged for DEA infractions, yet most don't want people in pain either.

Methadone is a great pain med in its own right- Methadone maintenance is cruel IF the patient hopes to eventually get off of it - the detox from methadone is horrendous, and makes heroin detox look like a birthday party

[AndiSN]

I have personal experience in this area. My mom had problems with addiction and alcoholism. It took me many many many years to get her to admit she had a problem. Even when I was able to get her to admit it she was terrified of getting help. She was a nurse and had worked in addictions and knew that if she went in they would take her off most of what she was on. Although I know that in many instances addicts make excuses not to seek treatment but she really did know what it was like. She knew it would create a label for her and that she may never be able to control her pain again due to this. She died from heart failure. The autopsy was inconclusive because she had already been embalmed and so they had to do tissue toxicology which isn't as accurate. However, they did say that it was probably due to misuse of her medications because her disease hadn't progressed enough to have killed her. Very sad and it is awful to know that she could have been helped. It had a lot to do with her own choices but it also had to do with a bit of a broken system as well.

[Hospice Nurse LPN, BSN, RN]

one of my biggest pet peaves uncontrolled pain. so many docs just don't understand pain mgmt. of course the addict is going to need much larger doses of pain meds than granny does. it's tolerance. addicts are bad people, they just have a problem.

eta: i mean addicts aren't bad people.

[linearthinker, DNP, RN]

Well I think it depends on what kind of pain they have. There are probably much better choices for them than Sched IIs, such as OTC, heat/cold, accupuncture, PT, etc. If they have ca w/ mets, that obviously isn't going to help, but for ordinary aches/pains, Vicodin, et al, is probably unnecessary and unwise. Ditto the benzos. I think all the nonpharm interventions should be tried (and given a fair chance to work) before reverting back to controlled substances for an addict.

[SweettartRN]

I strongly disagree with much of what I see.

I have found that most drug addicts and alcoholics are struggling from severe EMOTIONAL pain, and use drugs and alcohol to self medicate this pain. It helps numb them and not deal with the emotional needs that they have so that they can "function." As much as they want to try, they can not treat emotional pain with drugs; it's not going to help the underlying problem. And any doctor who realizes this, and encourages therapy and treatment rather than giving pain and anxiety meds has my vote. I understand that we are to treat pain as subjective, but I simply can not do that in those who have a history of drug abuse.

(We do not allow any narcotics, benzos and others of any kind, and we strongly discourage the use of muscle relaxers and other drugs. Some will abuse their Seroquel and Wellbutrin, but we usually get them out of the program for doing that sooner rather than later. )

[SweettartRN]

one of my biggest pet peaves uncontrolled pain. so many docs just don't understand pain mgmt. of course the addict is going to need much larger doses of pain meds than granny does. it's tolerance. addicts are bad people, they just have a problem.

yes, and usually their problem is emotional, and no amount of drugs is ever going to treat their "uncontrolled pain."

[xtxrn, ASN, RN]

Yes, and usually their problem is emotional, and no amount of drugs is ever going to treat their "uncontrolled pain."

So an addict w/acute post op pain isn't in pain "enough" to be medicated? What about an addict that tears an ACL....???? An addict that is an orthopedic puzzle after an MVA doesn't have physical pain? Their bilateral compound fractures are causing emotional pain ?? What about the alcoholic with acute pancreatitis... just toss him an ibuprofen, and tell him to buck up???

Doesn't your facility deal with acute pain in addicts ???

Yes, the root cause of addiction is a combination of emotional pain and genetic predisposition. But they also can get hurt with real injuries, and not treating them is cruel. Appropriate medicating by an addiction specialist who understands physical pain treatment with whatever meds needed for the ACUTE period is not feeding the addict. If anything, it will help with compliance to keep him/her from getting the illegal stuff along with what is given in the hospital (risking interactions and ODs)- or bailing out altogether due to UNCONTROLLED pain..... I've seen many addicts/alcoholics who have acute pain, that got limited narcs for a few days, then transitioned to NSAIDs, and continue with treatment....

Why do they have to be "punished" for getting help??? JME, and IMHO....

[SweettartRN]

So an addict w/acute post op pain isn't in pain "enough" to be medicated? What about an addict that tears an ACL....???? An addict that is an orthopedic puzzle after an MVA doesn't have physical pain? Their bilateral compound fractures are causing emotional pain ?? What about the alcoholic with acute pancreatitis... just toss him an ibuprofen, and tell him to buck up???

Doesn't your facility deal with acute pain in addicts ???

Yes, the root cause of addiction is a combination of emotional pain and genetic predisposition. But they also can get hurt with real injuries, and not treating them is cruel. Appropriate medicating by an addiction specialist who understands physical pain treatment with whatever meds needed for the ACUTE period is not feeding the addict. If anything, it will help with compliance to keep him/her from getting the illegal stuff along with what is given in the hospital (risking interactions and ODs)- or bailing out altogether due to UNCONTROLLED pain..... I've seen many addicts/alcoholics who have acute pain, that got limited narcs for a few days, then transitioned to NSAIDs, and continue with treatment....

Why do they have to be "punished" for getting help??? JME, and IMHO....

I work in drug and alcohol rehab. If they are there, they do not get pain meds, (with the exception of Tylenol/Ibuprofen) and if they do hurt themselves to the point that they need narcotic pain meds they are not allowed to continue in the program.

Two completely different scenarios. Are we talking of drug seekers here who continually go the hospital to get drugs, or are we talking about someone who gets in an MVA has trauma and needs medication to help deal with the exruciating pain? I am all for reliving the pain of someone, but I am not all for treating addicts with narcotics to try to alleviate their emotional pain. My assumption is that we were discussing anxiety and "pain" in addicts.

I don't ever feel that people who aren't in true physical pain shouldn't receive pain meds. However, those who are seeking, and are looking to cover emotional pain with narcotics should never be given the drugs for that reason.

[xtxrn, ASN, RN]

I work in drug and alcohol rehab. If they are there, they do not get pain meds, (with the exception of Tylenol/Ibuprofen) and if they do hurt themselves to the point that they need narcotic pain meds they are not allowed to continue in the program.

Two completely different scenarios. Are we talking of drug seekers here who continually go the hospital to get drugs, or are we talking about someone who gets in an MVA has trauma and needs medication to help deal with the exruciating pain? I am all for reliving the pain of someone, but I am not all for treating addicts with narcotics to try to alleviate their emotional pain. My assumption is that we were discussing anxiety and "pain" in addicts.

I don't ever feel that people who aren't in true physical pain shouldn't receive pain meds. However, those who are seeking, and are looking to cover emotional pain with narcotics should never be given the drugs for that reason.

I have worked in drug and alcohol rehab as well. The drug seekers were not indulged. The ones who came back from the dentist with root canals, the fractures, etc were medicated. Addicts can still have physical pain- that's my only point. They shouldn't receive lousy pain control for objectively substantiated problems......and of course, emotional pain should not be medicated ( a few would get antidepressants, Depakote, etc- non-scheduled meds).

ED jockeys shouldn't be indulged w/o objective medical diagnosis of injury/disease (pancreatitis is painful and legit; fractures from falls, etc- I believe they should get very monitored adequate pain meds- Our patients used to get a few days of hydrocodone for actual medical procedures initiated by the rehab facility. The ones who were jonesing were escorted to a CADAC or LCDC to talk. :)

This is what worked where I was a nurse.