Asking for Drugs

In the Emergency Department, part of a nurse’s job in discharging patients is to figure out if they are good to go home, because in part it’s good nursing practice, but mostly you don’t want to have them bouncing back in a few hours because they didn’t understand something, or have a question. So you eyeball them, do some health teaching, review their prescriptions and follow-up, tell them when and if to come back —  and assess their pain. This past week I’ve had five patients — all male, incidentally — who needed scripts for stronger analgesia than what is sold over-the-counter. The doc had overlooked this aspect of their care of them were reluctant to ask for good analgesia directly from the physician. They didn’t want to be seen as being unable to handle the pain. They all ended up with scripts after I advocated for them.

A few days ago, I had a very minor, but enormously painful procedure performed for a notoriously uncomfortable condition in my local (but not my) ED. I got handed a script, and when I was leaving when I noticed the physician neglected to prescribe any analgesia. Percocets or even Tylenol 3 would have been appropriate.

I pondered, briefly, whether I should ask for painkillers. I decided no. I was embarrassed to ask. I didn’t want to be labelled as drug-seeking. The sequel is now I am taking far too many 222s (ASA, codeine and caffeine) and Tylenol 1 than is really good for me (both of which can be gotten over-the-counter in Canada) and also Advil than is really good for me, and I still don’t have good pain control. Though I am feeling pretty spinny from all the caffeine in the 222s and T1s.

Barrier to care, anyone?

Sad to say, nurses and physicians in the Emergency Department still tend to manage pain like every patient is drug-seeking, or will become addicted or else is exaggerating their pain to so they get the “good stuff”; we eschew measurements like self-reported pain scales, instead relying on our highly subjective and unreliable judgment about whether the patient is actually in pain or about the patient’s relative worth. (I have witnessed physicians withholding narcotics from drug-addicts with large bone fractures. Ha ha, take that, you addict! I have also seen orders for morphine 1-2mg q4h for sickle-cell crisis — which, to my mind, manages to be racist, bad practice and plain awful, all at the same time. ) We disbelieve reports of chronic pain. We laugh when a patient presents with back pain and is taking Lyrica. We believe deeply as a culture that suffering somehow ennobles, but in reality only thing suffering does is make people suffer.*

It strikes me that even after years decades of education about pain management, we still don’t really get it about pain control. If a crusty old emergency nurse like me worries about being labelled as DSI* for asking for ten Percs, do you think there might be something seriously wrong with our approach to pain management?

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*I have yet to meet the patient whom overwhelming pain has made into a better person.3.

**Drug-seeking individual.