Two Big Questions For Pain Experts

[SocratesJohnson]

If it's assumed that the patient's pain is ALWAYS what they say it there are two major questions that arise. The questions arise because they are real-life situations.

1. A patient has had surgery that isn't expected to be painful. The patient has had 4mg of Dilaudid for pain that is reported as 10. The patient has a goofy grin and says: "I'm going to say that my pain is a 10 because I like pain medicine." (This actually happened)

Do you continue to administer Dilaudid in this situation? Do you take his report of pain at face value? I was advised by my co-workers to send the fellow home and I did so.....He left smiling......Did we do the wrong thing?

2. A patient is close to being in a Dilaudid coma after receiving 10mg of Dilaudid. The patient appears very comfortable and, when awakened, rates his pain at 10. (This actually happened)

Do we have a pain emergency here? (I've seen many situations that are clearly pain emergencies but this one doesn't seem to be a pain emergency.) Can you in good conscience send the patient to the floor with a pain of 10 under these circumstances?

O.k.....I asked more than two questions but the other questions are tied to the main ones.

[SocratesJohnson]

I believe that telling you that it depends on the patient and on an individual basis..

I've been reading Nursing Magazines for years and years. They frequently get questions on how to manage different situations with patients.

It's not as if I'm the only person who has ever written a question on how to manage a situation with a patient.

Obviously pain is treated on an individual basis.

[macawake, MSN]

My purpose is to find out what the experts say to do. In the examples I mentioned do you treat pain ratings of 10 with more medication(s) or not?

The examples aren't, or weren't, vague......Decisions had to be made about what to do with the patients.

I'm very interested in knowing what a pain expert would do in those situations.

In one of your previous posts you called (at least some) pain management "experts" extremely ignorant. Now your asking what a pain "expert" would do in your two examples.

I'm confused. What is your definition of an "expert"? Do the people posting here meet the required criteria?

Like others have pointed out it's difficult to give exact answers based on a subjective report over the internet.

As far as pain goes, I view the patient's self-report as the most reliable indicator but it does not always stand alone. It needs to be combined with other factors. Vital signs and behavioral signs among other things. I think that it is important to remember that the absence of an elevated heart rate or blood pressure does not automatically mean the absence of pain.

I'm sorry but I can't answer how I would have managed your patients. I wasn't there to assess them.

I'm curious, how did you manage them? Did you administer more pain medication?

[Pudnluv, ASN, RN]

I think what the OP is trying to ask, is what do the pain experts say when dealing with these situations. As we are not physicians, we cannot answer whether to give more meds or not. All we can do is assess the patient and report our findings. Whether we give the meds that are ordered would take a secondary assessment. I think, as nurses, it is entirely appropriate to withhold narcotics in situations where the patient is barely arousable , the BP is soft and respirations are under 12/min. But this is a finding that should be reported to the physician managing the patient and the physician should also be called to make an assessment.

In the type of case described in scenario number 1, the patient is clearly on the path to discharge. If the physician decides to write for more dilaudid, again a secondary assessment should be done prior to administration and if there are no contraindications, the med should be given. The nurse can offer alternative methods to pain relief in accordance with our scope of practice, but ultimately, we report our findings to the physician who then makes the determination whether to prescribe more pain meds or not. I would think that if the patient is getting ready for discharge, oral meds would be tried, as we don't send patients home with scripts for IV dilaudid.

The discussion regarding pain management and over use of narcotics, is a philosophical debate. The actual, real world treatment of pain is grounded in our nursing practice. We assess, collect data and report our findings. We can try nursing interventions for the relief of pain, but ultimately, these findings need to be reported to the MD. The MD makes the determination for or against the need for more pain meds. You may disagree with the physician and if you have compelling physical evidence, might get him to change his mind. But you cannot withhold pain meds because you think someone is an addict.

[macawake, MSN]

No....Nobody has told me how to manage the patients. Should they have received more medication(s) or not?

In the case of #2 administration of more opioids would likely have necessitated reversal with Narcan. Given that is it O.K. to discharge him despite a pain rating of 10?

I didn't see this post earlier.

Is patient number 2 is the one that you described as "semicomatose"? What was the respiratory rate and other vitals?

If this is indeed the patient described as semicomatose my main concern would be sending this patient to the floor too soon. It seems like this patient would benefit from the lower patient:nurse ratio in a PACU as opposed to what I'm guessing is a higher ratio on the floor.

Again, it's hard to be definitive when you don't have all the pieces of the puzzle. But "almost in a coma" sounds like a red flag that should delay transfer.

[heron, ASN, RN]

I'm not understanding the reflexive, vitriolic response to the OP's questioning of ... not whether or not an individual patient requires opioid pain control ... but whether or not the system is broken, setting us all up for failure.

Since the only posts that come anywhere near being "vitriolic" are mine, I'd like to address this.

For one thing, the question of whether the patients in the OP require further opioid dosing was presented with no background information at all. We know that there are types of pain that do not respond well to opioids - cutaneous, bone and nerve pain come immediately to mind. Thus, it's entirely possible for the patient in scenario 2 to be in severe pain in spite of heavy sedation from dilaudid. What was the underlying condition requiring the surgery? What surgery was performed and what kind of accidental trauma could it have caused? Any question of bone mets or other damage? Neuropathy from a comorbidity?

While PACU staff really doesn't have a lot of information about their patients' lives, it seems he could at least have this much information, which is what many posters were trying to elicit. Why would he refuse to give it? Hence my conclusion that these questions were more manipulative than an innocent quest for advice.

The OP seems to be looking for a simple one-size-fits-all prescription that is exactly what has caused the severe over-use of opioids to begin with.

One size does NOT fit all - THAT is what experts say and what OP refuses to hear. A patient with bone mets, for instance will be practically comatose on opioids and still be in severe pain - instead of staff labelling the patient as an addict, they might try IV Toradol, for instance.

I agree, actually, that the pendulum has swung way too far towards overuse of opioids.

Part of the problem is that professionals are not bothering to learn what we already know about pain.

For instance, we know there is a significant difference in responses to chronic and acute pain. Acute pain triggers a fight-or-flight response reflected with behavioral changes and elevated vital signs. The body can't sustain this response over time, so when pain becomes chronic - the patient adapts to it. So, yes, Virginia, it's perfectly possible for someone to "look comfortable" and still be in severe pain. No cognitive dissonance here.

Yet, I continue to see professional nurses cite this as a reason to label someone a "seeker" and blow them off.

True seekers exist and haunt our ERs. Addicts abuse the system and everyone trying to help them. They pursue their high in spite of any adverse consequences to themselves or others (this, btw, is the definition of an addict). Dealing with them is infuriating and it's practically impossible to avoid a power struggle with major ego-involvement on the part of providers.

However, someone who "spends all their waking hours worrying about how to get more pills" could certainly be an addict ... or they could be undertreated (google pseudoaddiction - a controversial subject but interesting to think about).

So, you see, it isn't as easy as "sedated, looks comfortable + complains of pain = addict seeking drugs" with the misguided expert enabling the addiction every step of the way.

I agree that we need to look closely at how we enable addictive behavior and think about what should be done. In my opinion, invalidating all complaints of pain that do not match our idea of what pain looks like is not a useful approach. This non-critical thinking is just as wrong as an automatic opioid prescription for every report of pain.

Neither is conflating the problem of addiction and the problem of pain. Related though they may be in some populations, they are still different problems. In our zeal to make sure that no addict gets high at our expense, we are likely to enable significant suffering for those whose pain does not match what we think it should be.

[nurseprnRN, BSN, RN]

OK, you're the same JonJacobs who was trolling around here the other day ranting about addiction and pain management. Hint: Using the same picture and the same profile (less the hometown in Maryland) isn't much of a disguise. Not to mention the same writing style.

I'm starting to think you're not all you say you are (would a real PACU nurse not know how to spell Dilaudid?) , even though the MD Board of Nursing says you have a diploma and a current license. What's your beef, anyway?

[Rose_Queen, BSN, MSN, RN]

OK, you're the same JonJacobs who was trolling around here the other day ranting about addiction and pain management. Hint: Using the same picture and the same profile (less the hometown in Maryland) isn't much of a disguise. Not to mention the same writing style.

I'm starting to think you're not all you say you are (would a real PACU nurse not know how to spell Dilaudid?) , even though the MD Board of Nursing says you have a diploma and a current license. What's your beef, anyway?

Actually, it's the same account. Looks like he took someone's advice not to use his real name and changed his user name.

OP, there is no black and white in pain management, which it appears you are seeking. There are so many shades of grey in this issue with no defining line between.

[SocratesJohnson]

One size does NOT fit all - THAT is what experts say and what OP refuses to hear.

I don't refuse to hear that. I have said that several times.

The ones who go in for the one size fits all are the pain experts with their: "The patient's pain is ALWAYS what they say it is" nonsense.

Instead of posting that sort of nonsense about me you should acknowledge the problem I posed.

[SocratesJohnson]

OK, you're the same JonJacobs who was trolling around here the other day ranting about addiction and pain management.

I'm the same person and I'm being obvious about it. I went with a pseudonym at your suggestion.

I don't troll and I can't understand why you're lying about the matter.

If you can show that I'm wrong about anything I said I strongly encourage you to do so.

Posting unsupported nonsense about me isn't necessary.

[SocratesJohnson]

OP, there is no black and white in pain management, which it appears you are seeking.

I'm seeking guidelines from pain experts in how to manage difficult pain control problems that I've experienced.

In response I've recieved personal attacks which is odd......

I thought I might get discussion from experts but instead I got condescinding attacks on my knowledge and my character.

Oh well...

[heron, ASN, RN]

I don't refuse to hear that. I have said that several times.

The ones who go in for the one size fits all are the pain experts with their: "The patient's pain is ALWAYS what they say it is" nonsense.

Instead of posting that sort of nonsense about me you should acknowledge the problem I posed.

I already have. Perhaps you can name the "experts" that have gotten you so angry. Maybe then we can address their misconceptions without all the pseudo-socratic games.

I'm the same person and I'm being obvious about it. I went with a pseudonym at your suggestion.

I don't troll and I can't understand why you're lying about the matter.

If you can show that I'm wrong about anything I said I strongly encourage you to do so.

Posting unsupported nonsense about me isn't necessary.

More like you didn't realize that all your posts would show the new username, not just the ones posted after you changed it.

You're just trying to re-ignite the argument that was shut down when the mods locked the other thread.

Enough.

[SocratesJohnson]

Yet, I continue to see professional nurses cite this as a reason to label someone a "seeker" and blow them off.

I'm not suggesting anything of the sort.

The example of the patient who was smiling after 4 mg of Dilaudid and boldly stating: "I'm going to say my pain is a 10 because I like pain medicine" seems to me to be different than someone who is screaming in obvious pain.........Do you see any difference?