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Pain Drugs: When Nurses Get Caught in the Middle

Pain Drugs: When Nurses Get Caught in the Middle

Brady Pregerson, MD & Rebekah Child, RN | Scrubs Magazine

May 18, 2010

On a scale of zero to ten, how often do you wish you could somehow wave a magic wand and know how much pain your patient is in—zero being never and ten being every day? Four? Ten? Twenty?

ER Doc Brady Pregerson and Nurse Rebekah are ready to “go there” in the first of a four-part series on pain management.

Dr. Brady: The can of worms I’d like to open up is one that I think raises more hackles than almost any other patient care issue in medicine: the use of narcotics to treat pain.

We’re all well aware of the fact that mixed in with our usual patients is a smattering of those who are addicted to narcotics or, even worse, fill their prescriptions and then sell the drugs on the street.

Prescription drug abuse is becoming a bigger and bigger problem. But oligoanalgesia—the under-use or sometimes non-use of opiates to treat legitimate pain—is also a problem. And we doctors and nurses are caught in the middle of this dilemma.

As a physician, I read in a quarterly newsletter from the Medical Board of California about all of the physicians whose licenses have been revoked or placed on probation. This litany of doctors and their bad deeds is there in black and white as a warning to the rest of us not to stray from the path of Hippocrates.

Each month, a good part of those whose licenses are under restriction have ended up where they are through the inappropriate prescribing of narcotics. Inappropriate narcotic prescription can do more than feed an addiction; it can get you in trouble.

On the other hand, if I don’t treat a patient’s pain appropriately, not only does the patient suffer, but she’ll probably write a letter to my boss. If I mess up either way, there’s trouble.

This wouldn’t be such a big deal if I could accurately gauge pain all of the time, but I can’t. I rely mostly on what my patients say. That’s accurate if they’re telling the truth, but what if they’re lying? You can’t fake hypoxia, you can’t fake hypotension, you can’t fake hyperkalemia or rales or vomiting up blood, but it’s not that hard to fake pain. And as the Bard said, “There’s the rub.”

Nurse Rebekah: I love this hot topic. There is a continuum of people in real pain, people in fake pain, people in pain who refuse to acknowledge the pain, people in pain who acknowledge it too much…the list goes on and on. From my perspective, scaling the pain can prove to be the biggest obstacle.

I love when I’m asking a patient for his pain scale and the following scenario occurs:

Me: “On a scale of zero to ten, ten being the worst pain you’ve ever had in your life and zero being no pain, what would you rate your pain?”

Patient: “Twenty.”

This kills me! I gave you ten integers, eleven if you include zero, and you still go off the scale! You don’t get more pain points if you make up your own pain scale…you probably won’t even get a higher degree out of this faux original research because there are, like, a MILLION pain scales out there.

Or this one:

Me: “On a scale of zero to ten, ten being the worst pain you’ve ever had in your life and zero being no pain, what would you rate your pain?”

Patient: “Uh, I don’t really know…[pause]…lemme think…

[Insert “Jeopardy!” theme here.]

[Ten minutes go by.]

…uh, maybe a five and a half.”

Well, I’ve fallen asleep waiting for the patient to scale his abdominal pain, and his appendix has probably burst by now. I’m so glad he put that much thought into it.

Okay, there’s really no right or wrong answer here. Your pain can be whatever you want it to be (as long as you stay within the 0–10 range; otherwise I get irritated). I won’t yell at you if you lowball or highball your pain. IT IS YOUR PAIN. Embrace it, own it, rate it.

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    PamelaSnook

    over 2 years ago

    4 comments

    I'm not convinced the pain scale 1-10 works. I use it because we are required to, and it's the tool we have. That said, I also know people who say 15 to anyone who asks, then turn around and try to sell the meds or go to different providers to get multiple scripts. These people are folks I wouldn't know did it, unless I hadn't seen it happen. They tend to talk the talk and walk the walk to get by socially, and are sometimes respected members of their community. I really don't know how doctors are supposed to know that pain control is being abused. Not everyone doing it is obvious. One case I know of, they move out of state every time the law begins to figure it out. But, their record doesn't follow them, and when people first meet this individual they think she is normal and charming. I'm not sure what the answer is, but present methods still leave a lot of room for error.

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    holebaby69

    over 2 years ago

    2 comments

    I don't really like the numeric pain scale, as someone's 6 could be severe compared to someone else's 6. I really think we need to come up with a better pain assessment tool. I am on the pain committee at my hospital currently, and I try to include the Wong/Baker scale, however, I really think most people have completely different ideas on what those numbers really mean to us.

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    choritz

    almost 3 years ago

    2 comments

    This show how hard nursing can be sometimes. I fully understand it.
    nursing programs

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    nurseus

    almost 3 years ago

    2 comments

    There are times that patient should gift baskets not use pain medication because they can start relying on it.

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    mandal

    about 3 years ago

    32 comments

    Is really hard to see how people suffer.My sister was in a center for treatments for heroin addiction.Before she checked in we tried to help her,but she always return to the drugs because she said she couldn't face the pain.The facility was the best solution and I'm glad she finally understood that.I'm telling you,I'm her sister but I couldn't do that again.

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    NeilKirchoff

    over 3 years ago

    10 comments

    "Pain management" is not really a good answer to this thing. You either block it or let it destroy you. Of course some years will pass until you will start to feel nothing at work but if you let the pain eat you up then you are not meant for being a nurse. I have a friend that works at a drug rehab treatment facility and after a few years she started to feel nothing. On the other hand it is kind of sad because if you block your feelings in your professional life too much you could end up blocking them in your social life too. Not everyone is meant for nursing!

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    OldSun

    over 3 years ago

    16 comments

    I was just browsing on drug rehab for women when I found your page.I guess every nurse would like to know how much pain their patiens are suffering so they can know what kind of pain killers they have to give them.

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