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?

__________

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

**Drug-seeking individual.

, , , , , , , ,

  1. #1 by Jenn Jilks on Monday 07 November 2011 - 1743

    Isn’t it a sad state of affairs? With my hospice and palliative work our older doctors have so many false perceptions. ONe of my dear friends, spinal stenosis, a nurse, paraplegic, could get weed in B.C., but not here.

    I have written much on this one. Agitation or pain?
    I so agree. Getting pain relief for my dad was one of my failures as caregiver.

    All the best, woman. Take good care.
    Remember: Caregiver Show: White Coat Black Art, Nov. 19th!!!! :-)

  2. #2 by Dr Dean on Wednesday 09 November 2011 - 1652

    Crusty old….I’m sure you exaggerate…. It is easy to get cynical about all those who are allergic to Toradol and ibuprofen, and ask for their “favorite” analgesic.

    But I try not to.
    I’m using the pain scale and letting the chips fall where they may….

  3. #3 by thehipcrip on Wednesday 09 November 2011 - 1736

    I can’t thank you enough for posting about your experience, and hope that every nurse and doctor in the blogosphere sees this. I take narcotic pain meds that were prescribed by a pain management specialist for central pain from spinal cord damage that’s resulted in tetraplegia and reliance on a wheelchair for mobility..

    After I disclosed that info during triage after breaking my right tib/fib two years ago, the ER doc not only denied me pain medication, she accused me of deliberately breaking my leg in order to get IV pain meds.

    Most people in pain I know NEVER go to the ED, because suffering through it is better than going to ask for help at their local ED and being mocked, ridiculed, and/or openly scorned as a drug-seeker.

  4. #4 by Noni Mausa on Wednesday 09 November 2011 - 2027

    My last run-in with severe pain was in 2007 for an abscessed molar, for which I was provided antibiotics and Tylenol 3’s. A few days short of the root-canal appointment I could see my T3s would run out a couple of days early, so I toddled down to the Urgent Care clinic and they provided me with a scrip with no comment. I still have half that bottle, sealed and tucked away in the fridge for some future toothache (the 2007 molar struck on a Friday night, leaving me with 3 days untreated pain before I could get in to see my dentist. I don’t want to do THAT again. Ever. Clove oil doesn’t work.)

    Do dental patients get treated differently from other people in severe pain? Do DSIs ever try to tap that (presumably) legitimate excuse? How the heck do clinicians evaluate pain, anyway? Is there a standard test or scale or procedure?

    Noni

    • #5 by torontoemerg on Thursday 17 November 2011 - 1047

      Pain is evaluated by patient’s own report (usually using a pain scale) and by observation. The general consensus is that we have to accept what the patient tells us about pain, even if we don’t believe it. Dental patients are sometimes as DSIs and unfortunately (in my experience, anyway) physicians tend to underestimate dental pain.

  5. #6 by The Nerdy Nurse on Saturday 12 November 2011 - 1019

    I really don’t think that a whole we are trying to ‘stick it to the drug-seekers’. I have to believe that most of us as trying to do what we think is right.
    If as a nurse you do think someone is drug-seeking, then what is the right thing to do? Treat their pain as they report it, of course, but you are really only feeding into their addiction. It’s a difficult path to walk when within the first 30 seconds of meeting a patient they tell you “I need something for pain. It’s a 10 out of 10. The only thing that works is Dilaudid” as they are smile, eat cheetos and drink their Coca Cola, and talk on their cell phone… It’s really hard to believe that they are in enough pain to require a heavy and potentially deadly narcotic with all those contradictory signs.
    I think instances like the one listed above are what jades healthcare providers into being stingy with the drugs.
    I’ve experienced the other side as well. An entitled nurse was just so sure I had only sprained my ankle and let me sit in agony for over 2 hours in the waiting room with a broke leg. In the ER of my own hospital, when they knew I worked there, knew I was a nurse, and were not terribly busy. I begged for something for pain and she decided to tell me her sprained ankle story in there.

    Sometimes I think as healthcare providers we get clouded in our own opinions and forget that it’s not about us at all. It’s about the patient.

    • #7 by torontoemerg on Thursday 17 November 2011 - 1043

      Sometimes I think as healthcare providers we get clouded in our own opinions and forget that it’s not about us at all. It’s about the patient.

      Agreed.

  6. #8 by CC on Sunday 13 November 2011 - 1936

    It’s not only pain medications that are judged, but if you happen to be a nurse and you accompany a relative into ED or make legit suggestions or ask questions about a relative on a hospital unit – you are judged and sniffed at and looked down on……..from what I read in a LOT of ED nurses’ blogs…..there is a LOT of judgment re: nurses. Recently, I was reluctant to go to ED with chest pain….and probably in the future will tend to treat myself just to stay out of ED or the hospital. It’s sad really.

  7. #9 by good chinese stuff on Monday 23 June 2014 - 1416

    Unquestionably believe that which you stated. Your favorite justification seemed to be on the net the
    simplest thing to be aware of. I say to you, I certainly get irked
    while people consider worries that they plainly do not know about.

    You managed to hit the nail upon the top and defined out the
    whole thing without having side effect , people can take a signal.
    Will likely be back to get more. Thanks

  1. Best In Nurse Blogs: Curmudgeon Edition! | The Millionaire Nurse Blog
  2. Non Pharmacological Pain Management|Non Pharmacological Interventions for Pain|Natural Pain Management

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 1,257 other followers

%d bloggers like this: