Two Big Questions For Pain Experts

Specialties Pain

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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.

Specializes in PACU.
why do you stay in nursing if this bothers you so much??????

I need the job. Thanks for your post by the way......You have a good understanding of what is going on.

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Specializes in PACU.
I would assess their resp. offer re positioning and ice or heat, then I would have the discussion about pain expectation and that they are being discharged

Those are very good ideas in most cases. In this case the patient's stated goal was to get a lot of pain medicine.

If the doctor doesn't want to address it I

Anesthesiologists won't order more medication for someone who is close to being in a Dilaudid induced coma.

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Specializes in PCCN.
I need the job

yes, I sympathize. Me too.....

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Specializes in Pediatrics, Emergency, Trauma.
The two patients had been taking pain pills for a long time. What would you have done?

Gave the medication; reason-long term pain therapy.

One thing I do with patients that have a long standing therapy is to not interfere in a way that causes breakthrough acute pain where my patient is in a position where they are "chasing the pain."

Unless one has experience with that storm; most people have the slant of "oh, this person is addicted" not fully understanding how suddenly removing medicine, possibly stimulating the pain center and causing pain.

Post-OP is NOT the time in changing a person with long time use of opioids IMHO; if it is of concern, a referral to a pain specialist would be out into place, if applicable; but that would only be after an assessment and a suggestion to the provider, along with a collaboration with the patient.

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Specializes in Pediatrics, Emergency, Trauma.
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.[/quote']

Agree. :yes:

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Specializes in Pediatrics, Emergency, Trauma.
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.

Well SAID. :yes:

I am in this camp.

I realized I didn't answer about the second scenario; however my response stands; I would medicate; but not with Dilaudid if they were experiencing symptoms of respiratory depression; again, through assessment and collaborating with the doctor, there are other medications that can be used besides Dilaudid; Toradol works wonders.... :yes:

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Specializes in PACU.
yes, I sympathize. Me too.....

Thanks.......Hospital work has gotten more brutal over the years and I'm getting older which doesn't help.

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Specializes in PACU.
Gave the medication; reason-long term pain therapy.

I don't remember and the histories we get, written and oral, aren't reliable enough to be the basis for an involved pain assessment....It's common for a patient to say that they almost never take pills and then come to find out later that they've been eating Percocet like candy for the last 10 years.

not fully understanding how suddenly removing medicine, possibly stimulating the pain center and causing pain.

I understand that phenomenon well. Chronic suppression of pain receptors results in the pain receptors becoming overactive.

I had mentioned on the other thread that, in many cases, chronic use of opioids can cause patients to have a lot more pain than if they weren't taking the pills.

Post-OP is NOT the time in changing a person with long time use of opioids

I agree......I do my best to alleviate pain in everyone whether they are addicted or not. Basing treatment on the pain scale is, in some cases, absurd in the PACU though as some, not most by any means, patients aren't at all reliable with the pain scale.

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Specializes in PACU.
Toradol works wonders...

It can work wonders. It doesn't always and it can't always be given.

There is evidence that it inhibits bone growth slightly so there is a case to be made that it shouldn't be used after major orthopedic surgery. (see below)

there are other medications that can be used besides Dilaudid

There are many other medications but most of them don't work well on those who have a huge tolerance for opioids after painful surgery. In the #2 example the patient had been given 10 mg of Dilaudid and still reported pain of 10......Anyone who can tolerate 10 of Dilaudid has a very high tolerance ("Tolerance in the technical sense rather than common parlance)

Large doses of Morphine tend not to work at all in patients with high tolerance and normal doses of Fentanyl (IV I mean.....the patch's work well) are a waste of time.....Fentanyl works for about 5 minutes in people with tolerance.....5 minutes after administration all the pain is back.

Effects of ketorolac on bone repair: A radiogra... [Pharmacology. 1998] - PubMed - NCBI

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Ok, only skimmed through the previous posts, but I have a couple thoughts:

First, OP, you are really, really playing with fire by having such an easy-to-ID profile and by being so specific about concerns about your patients' care. Tread cautiously.

Second, you really do seem to have an axe to grind re: patients taking opiod pain medication you feel they don't need. Even if you are raising valid points, your strident, almost obsessive tone makes it hard to take you seriously.

Third, "we would need to assess further" is a perfectly valid answer. Really, the only answer.

My thought has always been that if a patient has a valid order for a PRN med, and my nursing judgement tells me they can safely tolerate the med.... then just give it. Who cares if they have a big, goofy grin on their face?

If their LOC, respirations, BP, etc. are all within normal limits, what right do you have to withold an ordered medication? You need something more concrete than "they aren't really painful" or "they're just med seekers" to withold that PRN pain med.

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Specializes in PACU.
Second, you really do seem to have an axe to grind re: patients taking opiod pain medication you feel they don't need

My "axe" has to do with the extreme harm that the current epidemic of overprescription has caused. In the abstract I don't care if people are using medication to get high........If it's not doing anybody any harm they can 'have at it' as far as I'm concerned.....My concern has to do with the incredible harm that overprescription has caused.

Even if you are raising valid points, your strident, almost obsessive tone makes it hard to take you seriously.

Unlike some of my detractors I don't go in for personal attacks. It's true that I'm hard on ideas that I think are bad ideas......There is a lot not to like about the pain scale as a basis for treating pain. (It works quite well on many patients but it works very badly on some)

My thought has always been that if a patient has a valid order for a PRN med, and my nursing judgement tells me they can safely tolerate the med.... then just give it. Who cares if they have a big, goofy grin on their face?

That's not what I was up to. I don't care about the goofy grin. The patient in question had received 4 mg of Dilaudid for a procedure that isn't normally very painful....Many patients wouldn't need any medication after the procedure.

My concerns with the patient in question are practical.......Keeping the patient around all day in a busy PACU causes logistical problems so the decision must be made about whether a given problem is worth aggressive treatment. My co-workers agreed that it was time for the patient to go home.

Don't think I'm being punitive here......I have no desire to punish people for their drug habits. Their habits cause them serious problems in many cases though and I'm charged with dealing with some of those problems in many cases.

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Specializes in PACU.
If their LOC, respirations, BP, etc. are all within normal limits, what right do you have to withold an ordered medication?

It not a question of withholding ordered pain medicine.....It's a question of going to an Anesthesiologist and asking them to increase a dose limit of Dilaudid that is already very high.

I'm not interested in withholding pain medicine. I'm talking about serious problems involving the treatment of Post-Op pain in patients who take a lot of pills.

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