Pain control in narcotic addicted pt

Hello all:

In my practice I have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. May I make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. They will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds.

My question/comment is this: After all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain?

Perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?
"Confessed"?I'd rather err on the side of the patient's statement. I don't want us to go back to the "bad old days" where you practically had to do a polygraph before a pt. proved he was in pain.

Quote from dankimalHello all:In my practice I have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. May I make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. They will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds. My question/comment is this: After all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain? Perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?

We have many people on "care plans". They are not supposed to receive narcotics unless their PCP ok's it (or unless they really have something going on). These are the people that show up sometimes up to 3 times a week for generalized body pain with unknown etiology (multiple CT scans negative, entire work ups negative).It takes one a long time to get a care plan and some of the doctors do not honor them, so they get the narcotics anyway. Yes, for these people I know we are contributing to addiction - but there is nothing we can really do about it. For these people, every time I pull the same combo of narcs out of the pyxis, I feel guilty.... but if the doctors keep ordering it, we have to give it. We are not a detox unit.That being said, sometimes there are things going on with the pt that every test may be negative and we just haven't tested for the right thing to pinpoint the problem.

As an ER nurse I can tell you that whomever came up with the adage, "a patients pain is, whatever they say it is" never worked in an ER. Rule #1--- Pts lie. The 1-10 pain scale is so ridiculously misused that many patients arrive in triage and immediately explain to me how their pain is a 10/10, (with normal vitals and while they laugh along with the friends they brought with them, text, sneak outside to smoke, eat, drink, and otherwise be merry!!!!) What about using the FLACC scale? Implement something that takes into account a patients demeanor and what would be considered innate human physical responses to pain. FLACC has been used in infants and patients who lack the ability to communicate (i.e. trach&vented, MR, brain injury etc). I chart against patient demeanor, and behavior when I am in triage. Our frequent fliers and narc seekers can tell me their pain is a 10/10 and I will chart that, right along with..."pt observed laughing with friends while in waiting area" "pt reports continued abdominal pain and rates 10/10, with increasing nausea and vomiting. Pt eating Taco Bell Beefy Cheesy burrito, hard shell taco supreme, and Mexican Pizza at this time. No vomiting observed" "Pt observed smoking multiple times and advised by security there is a No Smoking policy within 100 feet of hospital entrance. Reports increase in cough at this time."

On one hand, I agree that too many narcotics are given out to some people. Working in the ER, some of the same people show up again and again with the same pain complaints, and it is very frustrating.On the other hand, those addicted to narcotics develope conditions that are truly painful, and they will require high doses of narcotics if we are going to effectively treat them. Pain is so subjective we have to take a person's word for it. Consider the opposite...I was taking care of a young man (late teens) who had dislocated his shoulder playing sports. He said it did not really hurt and refused conscious sedation when the MD reduced his shoulder. I would have thought that of anyone, he could have claimed 10 out of 10 pain. Point being, you could also have a pt who rates his/her pain as being way higher that what you would think considering his/her condition.

One word: Buprenorphine. It's a magical magical drug...turns our crabby, opiate-hookde patients whose pain is NEVER in control to pleasant, relieved, non-doped up humans.

Quote from Hearticulture RNOne word: Buprenorphine. It's a magical magical drug...turns our crabby, opiate-hookde patients whose pain is NEVER in control to pleasant, relieved, non-doped up humans.

Quote from dankimalHello all:In my practice I have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. May I make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. They will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds. My question/comment is this: After all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain? Perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?

Quote from leslie :-Dand what about those "crabby, opiate-hookde" pts, who have legit pain?some do, you know.leslie

Quote from psu_213On one hand, I agree that too many narcotics are given out to some people. Working in the ER, some of the same people show up again and again with the same pain complaints, and it is very frustrating.On the other hand, those addicted to narcotics develope conditions that are truly painful, and they will require high doses of narcotics if we are going to effectively treat them. Pain is so subjective we have to take a person's word for it. Consider the opposite...I was taking care of a young man (late teens) who had dislocated his shoulder playing sports. He said it did not really hurt and refused conscious sedation when the MD reduced his shoulder. I would have thought that of anyone, he could have claimed 10 out of 10 pain. Point being, you could also have a pt who rates his/her pain as being way higher that what you would think considering his/her condition.

Quote from dankimalhello all:in my practice i have encountered several instances of objectively addicted pts being prescribed massive amounts of narcotic medications. may i make it clear that these are not pts with low pain tolerances, these are confessed addicts with telltale signs and symptoms of narcotic addiction. they will manipulate, exaggerate symptoms, fabricate symptoms, and will go to great lengths to have more meds. [color="sandybrown"]my question/comment is this: after all physical causes of pain are ruled out, isn't it simply enabling to allow this population to remain admitted with increasing amounts of pain meds to satisfy ever increasing self reports of pain? perhaps our mantra of "pain is whatever the pt says it is" should be modified to "pain is whatever the pt says it is until objective signs prove pt reports of pain to be unreasonable."?

Quote from OCNRN63You make them suffer. Then you can feel self-righteous when you deny them pain meds.