Two Big Questions For Pain Experts

LadyFree28, BSN, LPN, RN · Nov 26, 2013

Accepting that pain is what the patient reports doesn't mean that you think that a patient never lies. It does however mean that there is a better chance for the patient experiencing pain to receive adequate treatment as opposed to a scenario where the patient isn't listened to and the judgement to medicate/treat is solely based on another person's interpretation. To me that approach is paternalistic and I do believe that many patients in the past and probably in the present have suffered because of it.

^THIS...well said! :yes:

One of the issues I have absolved about the pain scale is from this statement; I have seen far too many people-including personally-approach it in a paternalistic manner; I've had to "chase the pain" from a "drug seeker" (or, what the reporting nurse said to me) and after further evaluation, the patient was sent out with a valid complication; the pain was acute.

On a personal note, I had EXTREME post operative pain-I had a major medical trauma-I almost bit my PACU nurse's head off because in her mind I "had a PCA" and thought that it was enough for me...I made enough of a ruckus-I pulled the "nurse" card and said I need something for break through pain, preferably Toradol...and it WORKED. I repeated this several times; once I told them I was a nurse, it was a different story.

I've had other experiences, but these two are the ones that stuck with me- the "drug seeker" angst vs. the "hesitant to be a drug dealer" attitude; it doesn't help the patient AT ALL.

A thorough pain assessment, which includes a review of pain history helps with future pain assessment; that's including a review of pain history in the pre-op setting, and then during the post-op process, the information is relayed through the post-op process; this occurred as post anesthesia monitoring on the floor was routine where I worked; so all that information was readily available and helped guide the process of pain assessment and management, because of a good, thorough pain history assessment pre-op AND post-op. :yes:

SocratesJohnson · Nov 27, 2013

I've had other experiences, but these two are the ones that stuck with me- the "drug seeker" angst vs. the "hesitant to be a drug dealer" attitude; it doesn't help the patient AT ALL.

Just to be clear.....That's not what I'm talking about. I agree with you that I'd rather be a drug dealer than not treat post-op pain.

What I'm talking about are the patients who under no circumstances admit to a pain less than 10 because their goal is to receive as much pain medicine as possible.

There have been many occasions in my career when I take over a patient and take the pain far more seriously than the previous Nurse did.

We have, by all accounts, an epidemic of overprescription of opioids. My point is that this combined with an extremely unrealistic model for pain control causes problems in acute pain (and other) settings.

High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States. And over the last decade, the number ofprescriptions for the strongest opioids has increased nearly fourfold, with only limited evidence of their long-term effectiveness or risks, federal data shows.
“Doctors are prescribing like crazy,” said Dr. C. Richard Chapman, the director of the Pain Research Center at the University of Utah. http://www.nytimes.com/2012/04/09/health/opioid-painkiller-prescriptions-pose-danger-without-oversight.html?pagewanted=all&_r=0

martymoose, BSN, RN · Nov 27, 2013

What I'm talking about are the patients who under no circumstances admit to a pain less than 10 because their goal is to receive as much pain medicine as possible.

And many of those pts willl not accept Toradol, Tylenol, Nsaids, etc.They tell you "these don't work"

LadyFree28, BSN, LPN, RN · Nov 27, 2013

We have, by all accounts, an epidemic of overprescription of opioids. My point is that this combined with an extremely unrealistic model for pain control causes problems in acute pain (and other) settings.

How is it unrealistic if you are the patient's advocate??? If you are collaborating with a physician, and assessing the patient, and a good pain assessment, what are YOU missing???

If anything your article posting provides an example that it affects the physicians, positively; the new changes are forcing physician to do what nurses do-MONITOR their patients; not just look at them and send them on their way with a script; that has NOTHING to do with what we as NURSES have ALWAYS done; monitor the patient with pain by thoroughly assessing a patients pain history, collaborating a patient on what is an acceptable level of pain; in addition to the non pharmacological methods as well as medication management that has been effective, again, with the use of a good holistic nursing assessment and management.

A good nursing assessment will get the most shocking and the most prudent issues that a patient has going for them; including a referral to pain management if needed; perhaps evaluation through counseling and mental health; case management if a patient is actively in crisis; depends on hospital policy and protocol as well.

I find that if a nurse goes beyond the numerical scale and use the mild moderate severe descriptive model and the most pressing question:

*****"what is your acceptable pain level"*****

That can really assist in determining what needs to be done for the patient. It tells me whether or not the patient has an realistic pain goal; there may be underlying issues related to coping vs uncontrolled chronic pain issues vs acute pain vs underlying chronic syndromes that may have better use w/o the use of narcotics; there are plenty issues that can develop post operatively that can produce chronic pain; or the full exacerbation of an autoimmune disorder brought on because of surgery, prompting the body's response. There are many non-narcotic medications that provide or minimize symptoms of the underlying response. Even in the post-operative setting, the onus is on the team to have the patient follow-up with the surgeon or PCP where there is a higher probability for further testing and referral; the most we can do within reason is to advocate for the pt to get the appropriate testing through follow-up with the surgeon or PCP; it will be up to the pt.

SocratesJohnson · Nov 27, 2013

How is it unrealistic if you are the patient's advocate??? If you are collaborating with a physician, and assessing the patient, and a good pain assessment, what are YOU missing???

If you're assuming that the patient's pain is ALWAYS what they say it is you are missing a whole lot in some cases......Reality is what you're missing.

If anything your article posting provides an example that it affects the physicians, positively;

Patients are being greatly harmed by overprescription of opioids....People are dying from it.

monitor the patient with pain by thoroughly assessing a patients pain history,

I don't practice in an ideal setting (PACU that deals mostly with outpatients) so it's unrealistic to think that we're going to get a thorough pain history in many cases and even if we did we're unlikely to do anything differently in many cases.....Post-op pain is much different than chronic pain usually.

Anyhow the point is that some patients will say anything to get their hands on as much pain medicine as they can and careful assessment won't change their strategy at all.

Even in the post-operative setting, the onus is on the team to have the patient follow-up with the surgeon or PCP where there is a higher probability for further testing and referral;

Surgeons aren't inclined to go in for that sort of thing especially with outpatient surgery......They don't want to follow up on anything besides surgery.

Outpatient surgery isn't at all a good medium for helping the patient with anything besides issues pertaining to the surgery.......In a perfect world we would fix all sorts of things but the reality is we usually only deal with surgical implications.

LadyFree28, BSN, LPN, RN · Nov 27, 2013

If you're assuming that the patient's pain is ALWAYS what they say it is you are missing a whole lot in some cases......Reality is what you're missing.

Seems to me you are making the assumption that I assume the patients pain; I assess and go from there; my assessments are based in reality and pretty meticulous. :yes:

Patients are being greatly harmed by overprescription of opioids....People are dying from it.

As opposed to the ones who need it???

I would like to see actual statistics that have documentation of strictly opioid deaths, with no co-morbidities; not NYT, NIH data for example.

I don't practice in an ideal setting (PACU that deals mostly with outpatients) so it's unrealistic to think that we're going to get a thorough pain history in many cases and even if we did we're unlikely to do anything differently in many cases.....Post-op pain is much different than chronic pain usually.

Obviously. So your setting may be self-limiting; but your nursing practice doesn't have to be self limiting; what strategies are you willing to put in place???

Anyhow the point is that some patients will say anything to get their hands on as much pain medicine as they can and careful assessment won't change their strategy at all.

Pretty blanket statement...I respectfully disagree; I believe in quality vs quantity time in assessments; I have worked in FAR limiting settings; a focused assessment can elicit the pertinent information that one needs; that includes measuring acceptable pain levels according to the pt and a definitive assessment on pain.

Surgeons aren't inclined to go in for that sort of thing especially with outpatient surgery......They don't want to follow up on anything besides surgery. Outpatient surgery isn't at all a good medium for helping the patient with anything besides issues pertaining to the surgery.......In a perfect world we would fix all sorts of things but the reality is we usually only deal with surgical implications.

I disagree about this as well; most surgeons follow up with pts after surgery; whether outpatient or inpatient; I've worked with surgeons on an outpatient basis where they did inpatient as well as outpatient procedures; pain was a HUGE follow up issue, as well as consultation of referral to pain management if they had an issue; if there were underlying issues, they collaborated with other physicians, primary clinician, or otherwise whoever they needed for the underlying issue; your experience may be self limiting in what you believe is possible; what you see may be only a small piece of the picture; especially if your focus and priority is strictly PACU, then you position in your OP will appear without having the adequate knowledge at hand, leading you to your current position.

In the years (8 year total) that I have been a licensed nurse, I have never felt self limiting in assessing or managing pain; if anything, because of the population that served as my sea legs into nursing-SCI patients, trauma patients-I've had a better understanding of pain, assessment of pain, and management of pain, including underlying causes of pain. Our pain assessments were in depth because of the types of pain that we may encounter due to idiopathic illnesses vs post OP pain, vs acute vs chronic pain due to trauma.

Where I work now (LTC) where dose reduction of poly pharmacy and opioid misuse (which occurs in the elderly) is a HUGE issue and goal, I conduct pain assessments on a weekly basis; our assessment is not solely based on numerics; each place I have worked in the past 8 years have expanded their pain assessment to meet the patient's needs; like I stated before; I DON'T use the numeric scale for adults. I ask the patient I describe their pain, as well as the goal of "acceptable pain"; that take less than two minutes; if they are ready to raise the issue that their pain is NEVER acceptable, THEN, there's a candidate that NEEDS patient teaching. :yes: If they do not have readiness to learn, then I have to respect that; I can count on one hand when someone wasn't receptive to pain management-and not on referral, but for managing their pain post operatively or acute or chronic based on proper medication use; alternatives offered; working with a dosing schedule until the follow up appointment.

There are far too many interventions and teaching that we can do as nurses to provide the tools for our patients, regardless of setting.

While you present a viewpoint of opioid misuse or overuse; that should not overshadow that again, the points raised by other posters; WE cannot make assumptions based on the two patients that you presented; unless you have stats to back it up EBP, etc, or you are a twinkle in the eye of every pt that smiles and says 10 with a wink and a nod to get "the good stuff" there are people who need adequate pain management.

You state you don't make assumptions yet your continue to do in your own posts about one's nursing practice, yet yours seems to be self limiting based in the information that you provided in your OP to the point it seems that you are content to have your theories yet not take any initiative to provide EBP or even think about putting some EBP to practice; or even raising concerns enough to see if there is a way to provide other pain relievers via IV that can provide adequate pain relief; if you are deeply concerned about opioid misuse and your concerns about a more stepped approach to pain relief in the PACU, what solutions do you have for YOUR place of employment? In nursing practice? How about find those nurses who are undertaking the EBP for the past 20 years related to pain management? Reach out to pain management nursing orgs??? These are my valid questions for YOU.

My position is based on presentation of facts, determination and discernment of facts presented and then moving to a place of solutions.

Many have presented their nursing practice and their solutions; what are YOURS?

CP2013 · Nov 27, 2013

I started reading through some of these and just stopped after a while.

OP you said you needed this job and that's why you were there. If you ended up without a few seekers now and then and a few hypochondriacs for exploratory surgery....you might end up without a job.

I'm not saying to blindly treat pain, but as MANY others have said, the FULL ASSESSMENT would be important to note.

If 10mg of dilaudid isn't helping except to depress CNS, make a call to MD for a change of meds for better pain management. If patient is sleeping, I document "patient resting on bed with eyes closed, HR xx, BP xxx/xx, respirations xx/min, no acute distress noted at this time"...I don't wake someone to reassess pain. I don't. That's my nursing judgement. I think it's a better idea than waking up a patient for a sleeping pill like the nurse who cared for my mother.

Pain IS what the patient says it is, because they are feeling it, even if we aren't seeing it. Take a look at people who get tattoos - some tolerate well, others end up with what looks like a butchered mess because they writhe in pain. Just because someone is stoic does not mean they don't experience pain. Some of it is cultural.

In your first scenario, I would ASSESS the patients rationale for more pain medicine and delaying their discharge. I would inquire regarding how they intend to manage their pain without pain medicine.

In your second scenario, I would ASSESS the type of surgery, health history (as discussed, bone or nerve pain is difficult to manage) and then utilize my critical thinking skills to determine what may be causing 10/10 pain.

Their pain is perceived as a 10/10. Pain IS what they say it is. However my *intervention* is not to blindly give meds without using my CRITICAL THINKING and ASSESSMENT skills to determine if medication administration is indicated or necessary. I think that as a nurse if 30+ years OP, you should know better, as do most of the nurses on this forum have discussed.

Nurses don't just hand out medication without thinking about it. (At least not GOOD nurses) We deserve more credit than that. Just because a doctor writes an order doesn't mean we don't double and triple check before it gets to the patient.

If the MD orders 10mg dilaudid, obviously they are aware of the patients high tolerance level. I would have advised the MD that pain is still 10/10 but I had to arouse the patient via sternal rub and I'm concerned about excessive CNS depression and maybe we could try "insert drug here after ASSESSING patient allergies".

Also, you work in PACU...let me just tell you that PACU nurses can be some of the bigger jerks when it comes to pain. I am EXTREMELY sensitive to anesthesia and am always difficult to arouse after surgery. I literally feel trapped in my body wanting to scream in pain but I am physically unable to form the words. When I wake up and say I have 10/10 pain, I assure you I am not a drug seeker with addiction problems, but that I have been suffering for a while and I am just now able to form the words. Never once has a nurse offered to further assess my pain to determine where or why, I never get additional pain medicine, I don't have an advocate asking the doctor for something more or something different.

ONE time the physician's wife who took a special interest in me came to visit me in PACU and I managed to tell her I was hurting, so she went to her husband and asked for something. The nurse huffed when having to give it and said "do you want me to push it fast too?"

I realize that not all nurses are like this however. Jut like you should realize that even though pain IS what the patient says it is, we look at the big picture and assess further. Pain (and even vital signs like BP and HR/rhythm) requires more assessment and determination before intervention - it's just not all black and white.

SocratesJohnson · Nov 27, 2013

As opposed to the ones who need it???
I would like to see actual statistics that have documentation of strictly opioid deaths, with no co-morbidities; not NYT, NIH data for example.

"More people in the U.S. die from a drug overdose than they do from motor vehicle accidents and more of those deaths are caused by prescription opioids than those attributable to cocaine and heroin combined," said Alexander, associate professor of Epidemiology at the Bloomberg School and co-director of the new Johns Hopkins Center for Drug Safety and Effectiveness. Overprescribing of opioids impacts patient safety and public health

The fact is that there are patients who go in for extensive lying in order to receive pain medications and this includes lying about their pain level. There are, in fact, patients who never report pain less than a 10 as a strategy to receive more pain medication.......It's silly to ignore reality here.

Of course surgeons have follow up appointments but they aren't big on referrals on outpatient surgery and they generally don't participate in long term pain prescriptions unless they are treating conditions over long periods of time.

If a patient has a hernia or gallbladder surgery, for example, surgeons prescribe pain medicine for the recovery phase (a few days or a weeks worth) and then they are done......They don't generally get involved in long term pain management.

Many have presented their nursing practice and their solutions; what are YOURS?

Realistic criteria for assessing and treating pain.

SocratesJohnson · Nov 27, 2013

Pain IS what the patient says it is, because they are feeling it, even if we aren't seeing it.

It isn't ALWAYS what the patient says it is. We know that with certainty. It's absurd to pretend that it's ALWAYS what the patient says it is.........If we assume that then we have to treat people who have had 10 mg of Dilaudid and are in a Dilaudid stupor as pain emergencies and virtually nobody does that.

I'm not saying to blindly treat pain,

If you're saying that the patients report of pain is always accurate you are saying to blindly treat pain.

In your second scenario, I would ASSESS the type of surgery, health history (as discussed, bone or nerve pain is difficult to manage) and then utilize my critical thinking skills to determine what may be causing 10/10 pain.

One important factor to consider is that some people always report a pain of 10 in order to receive as much medicine as they can get.......That is reality and it is important to be aware of in some situations.

Their pain is perceived as a 10/10.

Once again....We know, with absolute certainty, that some patients will lie about their pain in order to receive pain medication.

it's just not all black and white.

That's my point.

There are other examples of patients reports of pain being wildly inaccurate by the way.

There are many patients who say that there pain is MUCH less after receiving significant amounts of pain medication but they still rate their pain as 10.

Some patients just don't do well with a 1-10 rating scale......You can explain it until you're blue in the face and they still won't use the scale properly.

Some patients aren't capable of nuanced self assessment......Either they hurt and their pain is 10 or they don't hurt at all and their pain is 0.........0 isn't always realistic after surgery.

As you said....."It's not all black and white."

ComeTogether, LPN · Nov 27, 2013

One thing i've noticed as a bystander about the pain scale is some nurses say "rate your pain on a scale of 1-10" Some say "Rate your pain on a scale of 1-10, with ten being the worst" and some say "Rate your pain on a scale of 1-10. 1 being a hangnail 10 being you're on fire".

I think often times when the patents understand the number scale a bit better and how it relates to pain they give a more accurate number.

As I said, bystander. I don't know what's allowed and what isn't in terms of explaining the number scale, but I like the last one the best.

ComeTogether, LPN · Nov 27, 2013

OP- I don't understand why you've chosen nursing. You seem to only want to prove your patients wrong and find ways to avoid controlling their pain. Isn't it better to medicate 9 people who's pain isn't "what they say it is" and 1 person who truly needs the relief than to potentially hold a med that would get that one patient over the hump to get some much needed rest?

martymoose, BSN, RN · Nov 27, 2013

Well ,it is the drug seekers who have ruined it for everyone else.

I guess if I was OP, I would try to get out of direct patient care. This is a battle that will not be won.

OP- have you tried to look for something non clinical in nursing for a job, so you don't have to directly be a legal drug dispenser? You have enought time/seniority. I wonder if some other type of nursing job could be had.