The following post Successful Pain Management for the Recovering Addicted Patient will hopefully shed light on evaluating and treating patients with histories of substance abuse. The article was written in 2002 but was a great find and still accurate today - don't miss reading the tables! Please read the second article The Ethics of Pain Management to help you align your own opinions and prejudices when working with cancer patients who have a history of substance abuse.
Questions
- Discuss how addiction differs from dependence or tolerance. Also tie in the concept of how someone might develop a pseudo- addiction once they have been diagnosed with cancer.
- When treating cancer pain, why is it important to distinguish between acute, chronic, and end of life pain?
Discussion Question - Many prescribing physicians are fearful of legal ramifications when prescribing opioids to a patient with a substance abuse history. How can you be an advocate for these patients? What type of proactive management strategies and education can be provided to patients when there is a history of substance abuse?
Send your answers to melissa.luebbe@ctca-hope.com. Remember to use composition style writing with a minimum of two to three sentences per topic. You need to blog your discussion answer and respond to at least one other blogger's response for full credit.
There will be no posting for credit during the month of December. But, if you have a short story or poem about nursing or being a nurse, here is your chance to publish! It is also okay to share someone else's work you enjoy as long as you give credit to that individual. Please forward no later than Thanksgiving.
I think we can be a great advocate for these patients by doing a complete assessment/history and helping other staff realize that all patients deserve proper pain management regardless of their history. Some strategies include education about the medication with clear directions for use, having the caregiver dispence the med when possible, encouraging the patient to express fears and feel comfortable discussing issues with the staff, and only having one doctor refilling the med. I also want to add that addition should not even be considered with end of life. The only thing that should be considered is pain management and quality of life.
ReplyDeleteI agree with you Victoria, we are first and foremost the patient's advocate and can influence the medical provider to see that all patient's deserve adequate pain management regardless of their history. The different strategies you listed from the articles support the patient and help providers to be aware of signs of relapse as well.
DeleteI agree with you as well Victoria. Background, assessment, and listneing to the patient fears can be tools we use to "build a case" if you will, to become an advocate for our patient. Another aspect we have to remember is culture. Some cultures deal with pain completely differently than either of us can understand, but it still impacts how we are going to properly advocate for our patients.
DeleteGood point, Samantha. Cultural differences wasn't mentioned. Another reminder to keep in check our personal feelings about pain management.
DeleteI agreed with providing all the support at end of life. Having a caregiver be part of the patients medication plan is a wonderful idea
DeleteIn order to become an excellent advocate, I myself need to reflect upon my biases and attitudes toward the patient, especially a patient that has a history of substance abuse. I also need to educate myself to the different ways to support individual patients' and their situations both proactively and also during active pain management treatment. With this knowledge, I can approach the prescribing health care provider in a situation where a patient needs pain management and has a history of substance abuse. I can discuss openly and frankly on behalf of the patient. I can allow the prescribing health care provider time to answer and discuss the plan. If I feel that the patient is not being properly cared for, I can discuss refering to a pain management MD/team with the provider. If there is still resistance from the prescribing provider, I would escalate the situation to my manager. I would make sure and document clearly what happened with the provider and the patient, make sure that the prescription medication list is clear, accurate and up to date including medication name, dose, timing, etc. I would also discuss with the patient their fears about pain not being controlled and/or relapsing, when appropriate, and dispell any fears about both medication and non-medication ways to manage their pain. I would ensure that the patient has a proper follow up schedule, once a plan has been made with the prescribing provider. I would reach out to the team's care manager for follow-up calls to verify that the patient's pain is managed and to screen for relapse. I would also be aware to monitor for any changes in the patient's life such as divorce, loss of job, etc along with new or increased pain symptoms that could be related to emotional, psychological and/or physical distress. If these occur, pt would benefit from returning to the office for a full evaluation and possible referals for mind-body, pain management team, massage/PT/OT, social services, nutrition, etc. (Thankfully, these support groups are available here!!).
ReplyDeleteTo be an excellent advocate for our patients, we need to be sure to be aware of our patient's history. We need to be sure that the patient is aware that they should not be taking pain medication without having pain. That is the key. If one is in pain and they take medication, they should not have an issue.
ReplyDeleteAll patients deserve proper pain control regardless of their history. Patients will most likely develop a pain medication tolerance, and that should be considered when prescribing higher doses of medication to the patient as well. This is a subjective measure regardless of a history.
That is a very good point Kari. I know in the past, a lot of patients I have dealt with had concerns about becoming addicted to pain medications all the while they were laying in a hospital bed with 8-9/10 pain. We have to advocate for the patient and make them aware that like yoy said "if one is in pain and they take medication, they should not have an issue."
DeleteHi Kari and Lauren, great posts. Patient advocacy as well as patient education have helped me to help patients with both addiction issues as well dealing with patients fears of becoming addicted.
DeleteChristi Ables, IR x1517
We need to remain advocates for the patient and remind the physicians that these patients need to be treated for their pain related to cancer regardless of their history of abuse. We can continue to educate the patient on proper pain management and the at the same time have an understanding that patients can build tolerance and may legitametly need increase in pain medication.
ReplyDeleteI agree with you Jolie sometimes the doctors just don't want to deal with the pain medications and want to push them off on someone else to do it
DeleteI agree that there are many factors that should be considered when taking care of a patient and properly managing their pain. In some settings the risk associated with addiction out weighs the relief needed by the patient; but luckily the better understanding of pain related to certain disease processes help others see pain both subjectively and objectively. The best advocacy begins with education on all levels; which starts with the prescriber, the patient/family/caregivers and ends with the general public. Addiction is a disease like cancer and many others that need proper medical attention and continued support from those around the patient.
DeleteAnother way to be an advocate for our patients is to be aware of the resources available to our patients. I think it is a tremendous asset for staff and patients to have a pain management team on site. Another alternative for pain management which at times can be overlooked is the utilization of pain blocks. By working with the pain management staff, we can hopefully provide pain relief to our patients in other ways.
ReplyDeleteI also feel it is crucial to continually educate our patients on the proper administration of pain meds, many times when patients return to the clinic they have not been taking the long acting pain meds correctly and do not truly understand the pain medication regimen.
Good point Chris! I forgot about monitary resources. I have been told by some patients that it is cheaper and more affordable for them to use illicit street drugs than to pay for prescription medications.
DeleteThank you for mentioning the option of a pain block. I believe physicians overlook that simple procedure because they don't specialize in pain management. We are very fortunate to have a dedicated pain management team for our patients. I also agree that patients present to MRMC with pain medications that they aren't taking as they were prescribed which can lead to uncontrolled pain.
DeleteYou can be an advocate for these patients by ensuring the doctor is really aware of the pain that they are feeling and also making them aware that the pain is real. Proactive management strategies can be things like teaching the patient other ways of dealing with their pain such as guided imagery or ice/heat therapy. By educating the patient on other ways to deal with pain, and by becoming proactive with the pain, they may be less likely to need actual opioids or less opioids to achieve adequate pain control.
ReplyDeleteI agree with Lauren's statement regarding providing alternatives or adjuncts to opioids such as imagery or ice/heat. We have so many resources at CTCA such as Mind&Body, massage therapy, music therapy. I agree that we need to validate the patient's pain perception, then education for the patient/caregiver on why pain is occuring, what to do for the pain, and knowledge related to prescriptions. Prioritizing pain management in the cancer patient with addiction history is the first step.
DeleteTo be an advocate for these patients we must first be self aware and recognize our own biases. Regardless of the patient's history, they all deserve aduquate pain management. As nurses, it is our duty to advocate for them.
ReplyDeleteNursing assessment skills become crucial. Getting to know our patients will enable us to pick up on the subtle changes. Emotional/behavioral/ and/or physical changes could mean they have developed a tolerance and previous pain regimen no longer provides relief OR it could possibly suggest addiction/relapse.
Jessica,
DeleteI agree with your views on recognizing our own biases. As nurses, we have all learned that we must take in subjective information regarding pain and we have to treat that pain accordingly. These physicians must use their best judgement when dealing with these types of patients instead of assuming their situation with pain meds.
Everyone of us can be advocates for these patients. Education is the key as well as listening and trying to understand out patients. Pain is subjective and should not be judged or dismissed by caregivers. Providing a less amount of pain medication to be effective for the pain but maintain function level is the foundation of pain control. It is important to understand our patient's fears and concerns of using narcotics for pain control and then provide detailed education.
ReplyDeleteI agree with your comments on understanding out patient's fears and concerns of using narcotics for pain control.
DeleteI agree that our patients often have a fear of using narcotics and may under estimate the level of pain to avoid pain meds. As nurses we really need to be intuitive to verbal and nonverbal indicators of pain and the emotional challenges the patient is struggling to manage the pain. Good education is essential.
DeleteSharing this article with physicians is one step towards improved pain management, especially for the patient with addictive history. I agree with the preceding comments, we need to appropriately assess pain, validate the pain experienced by our patients, educate the patient/caregiver on pain treatment but also educating the physicians on what we have just learned. Identification of the type of pain (acute, chronic, end of life) and the subcategories of the pain type applying designated interventions/medications as key strategies. Also addressing the fear of addiction in patients is critical to successful pain management as this impacts compliance.
ReplyDeleteI agree Donna, the doctors should read articles and have ongoing education concerning this matter. Also assessing the pt's concerns regarding their pain, it's management, and any possible sequela should be ongoing.
DeleteDonna I agree with you that sharing the articles with prescribing physicians would be helpful. They just as anyone of us can become a bit jaded as it relates to labeling of patients as seekers or addicts. When we don't ignore our preconceived opinions the patient suffers.
DeleteAfter learning about pseudo-addiction, I understand that I can simply advocate for my patient by understanding their history/background, listening to their concerns, believing what they are explaining to me and relay that informatino clearly to the caring physician. Culture can also play a large role in pain control and their hesitancy to use medication. So having a clear view of your patient as a whole physically, emotionally, spiritually and culturally make a large difference in your advocacy as well.
ReplyDeleteSamantha, I had not even thought about culture, until I read your post. You're right: this has a lot to do with it, as well! Gender may play a role, too, as men may be inclined to "suck it up," and be less vocal. You remind me of a technique I used, when in direct-patient care. When I wanted to know pain, I first addressed just the patient, by name, and looked only at him or her, for a response. (I wanted to avoid the "peanut gallery!") I then offered space for outside commentary, as sometimes caregivers would tell me something totally different...
DeleteThere are so many things to consider when our patients are taking long term pain meds. To advocate well, the health history is important, but as others have pointed out, cultural beliefs, financial issues, family dynamics, mental health issues, and history of addiction are important to be aware of. Having a good working relationship with the prescribing physician is critical. We, as nurses spend the most time with our patients and pick up on so many things the physician may miss. We are our patients biggest advocate.
ReplyDeleteI think that Tina's comment about having a good working relationship with the prescribing physician is critical, so that we can provide all the necessary information to help create a pain treatment plan.
DeleteTo be an advocate for patients, it begins with a thorough history, including any psycho-social issues(including any history of substance use/abuse), previous experience with health issues concerning pain, support and networks in place, and current concerns regarding their care/pain management. This information should of course be shared/discussed with the MD caring for the pt so that everyone has the same information. I agree that the number of prescribing MD's should be minimal, although not limiting referrals to appropriate disciplines when needed(neurology, psychology, pain specialists etc.). Ideally these MD's should all be collaborating and sharing information regarding the treatment plan. If the pt has a history of substance abuse, early identification and initiation of appropriate disciplines is imperative. The pt's support system, if possible, needs to be an integral part of the care as well. Thankfully, pt's have various disciplines and modalities they might need all here at CTCA as they journey through treatment.
ReplyDeleteYes! How important it is to obtain a history and treat any underlying problems that cause the abuse! great points!
DeleteI think that in creating a pain regimen that best advocates for our patients we must use our knowledge and create a plan that delivers medications according to the appropriatse guidelines first and foremost, and at the same time consider all the various circumstances surrounding a patients wellbeing. We really need to attend to their psycosocial issues and provide support for them from alternate care givers from all the various support channels at our disposal ie Pastoral Care, Mind Body, Psychiatry etc
ReplyDeleteThe nurse should remember that the goals for pain management in a patient with a history of substance abuse are the same as those for a patient without a history, namely to control pain and to maximize function. As with all patients, care should be holistic. Multiple disciplines (pastoral care, mind/body medicine, naturopathy) should be utilized if available. The nurse should give whatever comfort measures are within her scope of practice to give and educate the patient on pain relief techniques that can be done at home. Nurses should remember that, as the article aptly stated, ineffective pain management can even contribute to a relapse in substance abuse, as patients may seek pain relief elsewhere or from non-medical sources. Even patients without a substance abuse history can develop a pseudo-addiction if pain is poorly treated for any amount of time. If a patient reports poorly managed pain, it is the nurse's duty to the patient to report this to the provider and ensure adequate pain medication/support is given.
ReplyDeleteYes, I love how you mentioned the holistic approach when helping patient's manage their pain. We do this so well at CTCA with the help of our PEC teams and other services in the hospital. You're right, the goals for drug abuse pt's and pt's without a drug abuse history are the same.
DeleteI can understand why it is difficult to manage these patients. I would be reminded that the definition of pain is whatever the patient says it is when they say it is. As a nurse it is important to establish a trusting relationship with the patient and continuity of care with these patients is vital. It's important that the nurses are educated to "drug seeking" behaviors. It's important to be proactive with these patients and have them keep a diary and have them try nonpharmacological strategies as well such as acupuncture, mind and body, psychological therapy.
ReplyDeleteI agree, having a thorough history of the patient and offering other "modalities" for pain control before offering narcotics as theyre only option would be beneficial to all patients and prevent "drug seeking" behaviors.
DeleteTo be a good advocate to a patient with pain and a substance abuse history is to do a thorough assessment re: the type of pain, frequency or pain med refills, and other drug seeking behaviors and needs of pain management. Assure pt that pain needs will be addressed to provide adequate pain control without withdrawal symptoms as necessary and establish good communication for collaborative care. Proactive management strategies and education that can be provided to patients with a hx of substance abuse include assessing all the physical pain as well as psychosocial and spiritual needs a patient may have. Once identified appropriate referral s for a Psych consult could be suggested or other departments such as Mind Body or Pastoral Care can be called to assist pt. At CTCA patient can be followed by the Pain team for greater accountability to one physician for pain needs.
ReplyDeleteI like your response in regards to having a thorough assessment done and providing proactive strategies,educaton, and communication which is important.
DeleteI wholeheartedly agree that a psychiatric consultation really needs to go hand in hand with pain management. For example, an anxious, sleep deprived patient with a history of substance abuse will have improved pain control with less opiods if all of their needs are being managed appropriately.
DeleteBy providing a complete assessment and providing proper education, we can be great advocates to these patients. I think advising our patients to use the resources available at CTCA ie: therapists, pain management, mind and body, etc...that can help them with their quality of life.
ReplyDeleteAccupuncture and guided imagery can be good adjuncts for pain relief
DeleteI agree with Rebecca that a complete assessment and providing proper education to the patients is needed ,so we can be a great advocate for them.
DeleteNot to mention all the proper and available resources that they can use at CTCA .This will assure them that they came to the right place , and help them feel assured that they are not alone in their fight against this disease.
In some pain clinics, patients and doctors will sign an agreement that discusses what is expected of the patient and the doctor / office. It provides information to all parties about what is expected while they are receiving treatment in the pain clinic. If a patient does not follow the rules of this contract the doctor / office is allowed to taper down the pain medications and the patient is release from the service. This is a very good idea if patients have an addiction issue. I really like the idea of a contract with both parties because both will know their antipated results. Healthcare providers should ask open ended questions when evaluating/assessing a patient for future pain medications. Patients should feel able to share their prior history without any judgement.
ReplyDeletePatients come to us at CTCA/MRMC with different backgrounds. I have learned many things from patients - good and bad. Most of the recovering addicts /patients I have seen NEVER want to be in that dark place again,and some addicts/patients will never admit they have an issue. All patients deserve to have good pain control. That can be from pain medications, massage, acupuncture, distraction, and faith.
I also like the idea of signing a contract. I feel that it clarifies what is expected from the patient and lets them know that they are working with the doctor to manage their pain. I also feel as nurses that we can help them understand that we are not judging them for their past or current substance abuse issues but that we are here to help them manage their pain. It is a good idea to refer them to the supportive therapies and encourage them to try them.
DeleteI agree with Meg-adequate pain management is equally important for patient with a history of substance abuse as for the patient without a history.It is our duty as nurses to advocate for those patients and be the bridge between patient and the provider.Also educating patient on nonpharmacological strategies to help with pain control is very important and for some patients those techniques may be very helpful.
ReplyDeletePhysicians should want to provide benerficence for their all patients. Do good. Patients should be taught to rate their pain on the 0-10 pain scale to give the physician an accurate picture. The patient should be taught to talk to their physician if they feel the physician is not prescribing adequate pain relief. Nurses should remind the physicians to treat all patients with justice, equally.
ReplyDeleteI agree Mary. Beneficence and Sympathy/Empathy are important things to make sure are incorporated in our practice and that physicians are reminded of this as well.
DeleteUnderstanding that a patient has a history of drug abuse is definatley something that should be discussed when the discussion of pain management is brought up at a visit. Bringing up the abuse in conversation and having an open honest conversation about which medications where abused can help develop trust between the provider and the patient. Patient's may also verbalize which medications they don't trust themselves to receive again based on their history. That being said, pain should never be ignored. The treatment plan should be individually based on the pt's pain description, not whether they are a past drug abuser.
ReplyDeleteLike the ideal of working with the patient on developing a treatment plan. This will establish a good rapport between physician and patient right off the bat.
DeleteFirst step would be being aware of a pt's history, is this drug seeking behavior or is it pain tolerance. Being an advocate for a pt that is addicted to pain meds would include having resources for help with substance abuse or recommending other pain control options such as naturopathic meds, massage or physical therapy.
ReplyDeleteOf course there is going to be physicians that are fearful of writing scripts to patients that are addicted to pain meds but how can one be so certain that any given patient is or isn't? I think it's best to set aside the stereotypes and just use your best judgment and this may need to be re-enforced with the physicians as well. The patients should also receive some education on the drugs along with some other non-pharmaceutical ways that can be used to distract or ease pain. Also I have seen instances where pharmacies have red flags when it comes to patients that have too many pain medications and/or refill too quickly.
ReplyDeleteI agree with Lindsey! Education is key and it should also include physicians and other disciplines. Not only patients.
DeleteMaking sure that we all know the patient and their history will also help us identify those @ risk and be more vigilent when assessing during follow up visits.
It is understandable that a physician may be fearful of prescribing opioids to a patient with a history of substance abuse. However, the adage still stands: "a patient's pain is what he or she says it is." If a patient has diagnosed cancer, as he/she will have, if at CTCA, then a nurse can advocate for the patient by gently reminding a hesistant prescriber that despite the history, the present situation is a reality that needs to be addressed. I actually think a more appropriate question to us would be "how to handle a NURSE being hesitant to give a PRN, given a substance abuse history." I have been there, and I am sure others have as well. It is not easy, sometimes! We have to look at what pain level is reasonably expected, given the specific diagnosis and the particular medication prescribed to alleviate it (long-acting versus short-acting, dose, etc). We also have to advocate for non-phamaceutical interventions, as many have typed...acupuncture, imagery, Tori the dog, etc. --Theresa Minniear, Clinical Research
ReplyDeleteTheresa, I agree with your points on advocating for the patient and understanding and treating their pain needs. I also like that you mentioned other modalities to help relieve pain in cases of the patient not wanting to use pain meds or a doctor who is hesitant to provide these medications. Your other great point is our own bias's in relating to patients with a history of drug addiction. However in the face of cancer and what type it is pain needs to be managed to provide good quality of life for the patients. Great post!
DeleteMany doctors are afraid to prescribe to patients with a history of substance abuse. I feel in order to be an advocate for these patients we can have them log their pain in a journal and present this to the doctor to determine what increases their pain, how long does it take for their pain to be at a tolerable level, what helps with pain, meditation, massage, warmth, cold...ect., and determine if the patient needs are being met. I feel that if we educate the patients with the importance of them providing us with detailed information with a thorough description of the pain, location, when it occurs and what makes it better or worse the doctors will be more willing to prescribe to them. If the doctors still are not open to prescribing, we as nurses need to push for a referral to pain management to meet the patient's pain management needs.
ReplyDeleteTrish, I agree that the use of a pain log could be very helpful for a patient in explaining their pain experience. Knowing what helps or what exacerbates the pain can sometimes be found through these types of pain logs.
DeleteAs a nurse we can be the best advocate for patients suffering with pain by trusting what the patient is telling us. It falls back to the standard definition of pain as being “whatever the experiencing person says it is.” It is not for us to judge the character of the patient, level of the pain or amount of pain medication necessary to provide adequate pain relief.
ReplyDeleteIt is important to advocate for a patient because we have to believe our patients when they say they are having pain and what level they rate their pain, regardless of any other factors. This being said, we can't deny our patients of pain medication. Also, it is a small percentage of patients who abuse narcotics or become addicted. The most important thing is education about pain management with our patients to help provide the best outcomes.
ReplyDeleteIf i was a doctor i would be a little leary of giving opiods to somone who in the past has abused them. I would also not want them to suffer in pain. With good assesments and knowledge of your patient you and the nurse should be able to determine if this is the right route to go. I also think that they should be monitored closley. Perhaps a counsling sessions to reinstill in them the importance of correct taking of medications,risks.
ReplyDeleteI think that having a physician such as Dr. Rahman to manage patients and their pain with or without a substance abuse history is very beneficial for the patients and the oncologists. However with that said physicians have to look at the patient’s history and determine their current situation and manage that situation. Nurses can advocate for patients by working with the doctor or recommending a pain clinic where one provider is managing these patients. While the histories are prevalent the act of respect and dignity for these patients’ rights to be free of pain need to be considered in any decisions.
ReplyDeleteI agree Pam. I do think that Dr. Rahman and team should be utilized to manage pain. This way, only one doctor is managing the patients pain.
DeleteI agree with Pam that Dr. Rahman and pain team should manage the pain needs for patient when needed.
DeleteI agree with Pam that Dr. Rahman should and the pain team should be the ones managing all pain medications. If only one Doctor is prescribing pain meds it will be easier to keep track.
DeleteDr. Rahman and his pain team are awesome in managing our patients pain. We, at CTCA are fortunate to have them. I agree with Pam that nurses can be advocates by working with one doctor is managing the patient.
DeleteOur patients at CTCA is very blessed to have a pain team that is always there for our patients and not only that as a nurse I am so glad that we have a dependable team that we can count on all the time for our patients and to me that is the truest sense of advocacy.
DeleteI agree the pain team is a great resource at CTCA! As a nurse, I have always felt comfortable relaying patient's concern and status of current situation with unrelieved pain.
DeleteAdvocating for patients is an expectation of a nurse. It is part of our job. So, advocating for the patient when it comes to pain control is huge. If one is in pain there quality of life is null. We as nurses, must believe that the patient's pain is truly whatever they say it to be. I do feel that a referral to pain management is the best thing for our patients. A pain specialist is the most knowledgeable about all of the details of pain management. They know how to treat someone that is in acute pain vs chronic pain. They also know the legalities of prescribing pain medications. They are aware of the need for a "contract" with a patient that has a history of abuse. Our facility is fortunate to have a Pain Team. I do feel like they should be the sole people to manage pain. So, if that means that we hire more of them to make it practical then that is what needs to be done.
ReplyDeleteAgree. It is so helpful having a pain team on staff. It is a necessary resource it believe in the oncology field. Having pain managed brings quality of life for our patients.
DeleteI agree. Our pain team is wonderful, and the nurses are great about collaborating with the floor nurse and the patient together to come up with the best plan for the patient's pain control. They are always available whenever we have questions or suggestions and that is always so helpful especially when a patient is struggling with pain relief when admitted.
DeletePatient education is important in when and how to take medication. Also encouraging other pain relieve options as reiki, accupuncture or massage theraphy. But ultimately trying to keep patient pain under control can also help prevent substance abuse.
ReplyDeletePatient needs to be educated about taking the pain medications and when to take the medication for pain. If the patient is afraid of taking the pain medication because of their history to addiction then other options could be discussed. The patient could try pain blocks, accupuncture, and messages. If this does not help the patient then pain medication could be discussed again with further education and support. Then a consult to pain team for pain control should be scheduled for the patient. Pain medication should be prescribed by one Doctor to control the pain medication given to the patient.
ReplyDeleteI think we are all part of the pain management team and I know compassion goes a long ways when it comes to pain management. From reading all the posts it feels to me that nurses here have a great understanding when it comes to managing pain with or without an addiction. Legally, it was good to be made aware of the 1978 amendment to the Controlled Substance Act, that specifically prohibits restrictions on opioid prescription for pain relief.
ReplyDeleteI agree about the nurses here as a group being possibly more compadsionate regarding pain management, and I think that is due to the population we serve and the kind of pain issues they deal with. Cancer pain can be so horrible and long term. I think oncology nurses have a good view on this and can become great pain management advocates due to this sensitivity
DeleteBase on the patients history, if they are trully has an addiction to pain medicine, that will stop our doctor from prescribing. Or maybe make some changes. We the nurses it's our job to do complete assessment. Certain kind of diagnosis, some patient are not allowed to take tylenol or ibuprofen. Oxydocone is the drug of choice. Especially stem cell patients.
ReplyDeleteI can be an advocate for the patient by addressing the ethical principles with the physician. Autonomy, beneficence,nonmaleficence and justice. I can also reinforce the basic principles of pain management with the physician. First we need to provide effective pain relief and management for the patient regardless of his history of sustance abuse. Remebering ther are mutiple medications and delivery routes available. Setting our sights on the bottom line relieving the patient's pain adequately. We need to have early identification of pain and initiate the appropriate disciplines. Patient may not need medicine all the time. We are lucky to have many pain relieving modalities here at CTCA. Looking at Reiki, massage, mind and body,guided imagery and even pastoral intervention. So if a patient has a history of substance abuse they can be taught to deal with their pain in different ways.
ReplyDeleteI agree, the patients pain does need to be addressed. The patient and their quality of life is a major concern. There are many drugs to prescribe and many routes. Also, great point about the different modalities we offer here! I did not even take those into consideration which are wonderful.Great perspective.
DeleteI agree that pain is what the patient states and there are many avenues to treatment but the bottom line is always to improve the patient's quality of life. Adding the adjuvant therapies are very effective for many of our patients
DeleteI would advocate for these patients by trusting their pain level as what they say it is for pain is subjective. A pain scale of 0-10 would be helpful to use to reassess the pain to be able to better treat the pain. Pain should be controlled according to the pain and using a form of pain medication to alleviate pain. This could prevent a patient from seeking other forms of medications not prescribed for them to control the pain.
ReplyDeleteTo help patients with a history of drug abuse the can be taught to slowly reduce the amount pain medication they are taking. This would allow them to slowly get the drug out of their system. In some cases a detox program may be needed. They could also agree to do random drug screens after pain medication is stopped to hold them accountable.
I agree, we need to remember the standard is that pain is what the patient says it is, not what we think it is as healthcare providers. While there may be people who abuse this system, not trusting our patients at their word will destroy the trust relationship when we later may need to deal with weaning issues
DeleteIn order to advocate effectively, I would first do a thorough pain assessment. A pain rating, is it radiating, when does it get worse or better. Have the patient keep a journal on what they are currently taking. That way the physician has solid information for increasing dosages. Continuing contact with that patient as they try their new medications and dosages, and encouraging them to continue keeping a journal so I can effectively advocate with the physician would be very important. Those with a history of adddiction can also agee prior to treatment to getting counseling and drug screening when the medication is discontinued. Basically, it is not acceptable as healthcare providers to leave people in pain over future concerns which can be dealt with in a variety of ways
ReplyDeleteI think our method of handling our pain patients at CTCA is an very good model. It is beneficial as an outpatient clinic nurse to be able to direct our physicians to using the pain team rather than having multiple members prescribing pain medication. Many times the history of substance abuse may cause a physician to avoid dealing with pain issues, and having a pain team offers the patient with the opportunity to have his needs met. Pain is what the patient states it is, and as nurses, we need to advocate for him and get him to the best practice available
ReplyDeleteJudy, I agree with what you are saying. I think it is wonderful that we have the pain team to count on for our patients. It's like having our own expert team to handle the individual patient needs.
DeleteI agree that our model here is very effective and comprehensive. We have a wonderful Pain Team that provides exceptional support to our patients and is very accommodating for acute needs as well as chronic.
DeleteJudy,
DeleteI agree with you concerning our pain team but addictive behavior can be very easily hidden by the patient until you are in the depths of his care. How do we as nurses advocate when a patient disconnect lines/tubes.., leave them open to the environment, go outside without permission or knowledge to the nurse, to partake in their recreational drugs? I have had pt's free basing in their room and have asked me to "wait" until they finished as I stood there with their pain shot. I do wonder if in our future there will be a blood test/sweat test... similar to an accucheck that will assist us in monitoring the patients pain level and what drugs are in their systems.
Listening to our patients and reading bodily cues is the first step in advocating pain management for them. You can't judge someone solely by whether they have had a history of abuse or not. Everyone deserves to have their pain managed well and steps can be taken to provide their needed pain relief without fear of addiction.
ReplyDeletePateints who have had a past history of addiction will need to have set guidelines and protocols. I believe if everything is open and spoke about prior to a script being processed, it will allow both parties to be active in pain control. Few ways of staying in partnership with the addictive patient would be by setting the limits, such as I am the only provider, periodic check in with compliance, monitoring to soon to refill, speaking with family members and using alternative methods to pain control. We as nurses can be a part of this active plan of care.
ReplyDeleteIn addition to referring our patients to the Pain Team here at CTCA, I am a huge advocate for utilizing Dr. Sunn and the Mind-Body department too. Utilizing every resource we have in a proactive approach and informing the patient of the management stategies that we can provide will not only benefit pain management techniques, it will also reassure the patient that they will be treated in a professional and caring team approach.
ReplyDeleteGreat ideas, Debbie. We have a great team at MRMC which can help the patient to manage their pain and some even with non-pharmacologic means. Treating the whole patient will help to ensure that their pain is managed in the best, most effective way.
DeleteI believe it is very important to advocate for patients by letting patients know you "are there for them", consulting with Pain team members to overcome any barriers, and informing the patient/family of right to pain care. I feel that MRMC does a wonderful job of coordinating a multi- disciplinary approach that works well for most patients.
ReplyDeleteI agree. It is very important for patients to feel trust and support from us to let them know we are doing all we can to help them. Our Pain team is very supportive and pro- active in managing our patients.
DeleteYes, MRMC does a great job at pain control. We can encourage patients to keep following up with the pain team but also to try acupuncture, massage, etc., if their physician approves of course.
DeleteThe earlier these pain management patients are identified, the earlier they can be effectively treated. Our well- qualified Pain team, along with all of our complementary disciplines, do a wonderful job of optimizing our patients quality of life.
ReplyDeleteA patient with the past history of addiction should have a set and limited pain medications prescribed by the physician, monitoring and communication will be a big factor . We can be an advocate for these patients by referring them to our excellent pain team here at CTCA , and always be there for them whenever they needed our assistance . Care for them like we are taking care of our own family .
ReplyDeleteNurses can offer objective/subjective data such as what the patient states his current behaviors are including pain level and recent analgesic intake and current clinical assessment to the prescribing physician to ease the fear of inappropriate refills when the patient is in need of better withdrawal management. Ensuring patient safety and advocacy is to provide medical supervision when tapering dosages and following up with the patient closely to monitor relapse behavior with a recovering addict. An important component a nurse can do to help an addict is to offer multiple resources including psychotherapy and addiction programs. If the caregivers are present, education is imperative for them to recognize signs/symptoms of relapse and withdrawal. Implementing the caregivers support can impact the addict’s decision making and increase chances for a full recovery.
ReplyDeletePat Dillow
ReplyDelete1. Addiction: if you review the ASAM definition of addiction it takes you further from the usually definitions to their short version definition : “ Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response”. But when you delve further into their website it takes you to the genetic factors that influence 50% of the addictive patients. http://www.asam.org/for-the-public/definition-of-addiction
So taking this one step further – how to determine if a patient has the fear of not having enough pain meds and are we looking at “pseudo-addiction” or true addiction. Our patients have an even greater challenge as they cannot just call, go to the office, pick up the prescription and go to the pharmacy. Our patients have to call, wait for an overnight letter with a hard copy and then continue on this journey. If they live remotely it can take 2-3 days to receive and “overnight” package. This fear compounded with the cancer/surgical pain is unimaginable.
2. It might be difficult for the cancer patients themselves to distinguish between these pains dependent upon their course of care . A perfect example is a patient that takes tincture of opium for his diarrhea and absence of a colon for absorption. We had a patient here with this same scenario a few weeks back and the amount of pain meds that he had to be given for pain relief post-op stunned the team. If you did not know this patient and do a thorough history you would have thought he was drug seeking or addicted. His chronic pain it is taken care of by the T/ O, his acute/end of life pain is/will be hard to distinguish and treat without fear of depressing his systems. He was given an astronomical amount of pain meds that depressed his resp. system, but his BP remained high and he was in severe pain. This is why a well-educated pain team is key in the cancer patients care.
True, Pat, about the "hidden" genetic component of addiction. It brings a new understanding of addicts to clinicians and hopefully will help the general public and providers have more compassion for addicts.
DeleteRe BP being high, it is NOT well known that vital signs are not good indicators of chronic pain, though they can be indicators of acute pain.
Pat,
DeleteYou bring up some very good points, and I agree that Cancer pain, and the pain from all of the surgeries and procedures that go with it really fit into their own category "cancer pain". Our patients do need to be assessed differently, and the pain management team and/or doctors need to know the patients full history when managing pain. It is difficult when these patients go back home sometimes and need a refill on their meds when their home E.R, or family physician doesn't understand cancer pain. I think our patients are trained to call here and speak to their care manager first, which I think most of them do, but it is very important for nurses to advocate for all patients, but for cancer patients especially.
We as nurses are absolutely responsible for for advocating for patients at all possible times. We must always be proactive when caring for these patients. Being proactive can encompass utilizing our pain team, and keeping the physician up to date on the patient's pain and how well it is or is not controlled. We need to make certain that we are listening to the patient and not doubt that they are in pain. We can also refer them to the mind body department, provide them with imagery, reiki therapy, accupuncture and massage. We must provide the proper education on how to use these alternative pain control modalities to assist in the control of pain in addition to using opiod pain medications. We also do a great job here of following up with patients that have pain management issues when they return home so that we can assist in reducing the amount of re-admissions a patient has. Education is key in successful pain control, and keeping the physician and pain team all on the same page, so that the patient feels an overall trusting relationship.
ReplyDeleteRe Fearful Prescribers, we can remind them that these patients may require higher doses of opioids to manage their pain. We still consider pain level to be whatever a patient says it is. It is a patient’s right to have their pain managed. We can be proactive by using pain contracts, letting patients know that they are not to take pain medications unless they have pain, they should never take more pain meds than prescribed (they can call pain management for adjustments in dosage), and refills will not be given sooner than every 30 days. Patients must be advised that they need to carefully guard their pain medications so as not to drop them down the sink or toilet, or leave them in their luggage or on the train, or give them to any other person. Prescriptions must be safeguarded also, as no replacement scripts will be given without a police report.
ReplyDeleteShirley, I agree that patient's need to have strict guidelines regarding be responsibly for properly taking their pain medication. They also need to be responsible for making sure to guard their medications, to prevent loss of them. I think there needs to be a clear cut agreement and understanding between the prescriber and the patient. We need to of course make sure we are providing them with adequate pain control consistently, as of course this can lead to other problems or issues.
DeleteOne statement I hear often is "pain is whatever the patient says it is," and this statement really sticks with me. I am sure it is not uncommon for a physician to doubt a former substance abuser in fear that the patient is nothing more than a drug seeker. When a patient rates their pain, they have the right to adequate pain control, regardless of their past abuse. This may require higher doses than typical in order to acheive theraputic relief. This also requires extensive education and this is where nursing plays a huge role. Nurses must be the biggest advocate for their patients and generally provide the patient with the most education. A former abuser will require extensive education on their responsibilites with the pain medications and will probably require more time than a patient who does not have a past of addiction or abuse. Education is key! Another huge part of being an advocate for the patient is communication! When a patient feels like their pain is not well controlled, they may fear discussing it with their doctor, thinking they may be looked at as a drug seeker. The nursing staff can be an advocate for the patient by communicating with the doctor or other provider to help this patient have the best pain control achievable!
ReplyDeleteI agree with you, Kristen. Education is most definitely the key in helping patient tackle their addictions. Those that have a history of substance abuse might need more education then those that don't.
DeleteIn reading these articles, I became more self-aware of my biases and attitudes toward the patients with a history of substance abuse. Knowing a patient's past history is important, and it is a vital part of their overall care. To speak professionally with the prescribing doctor as an advocate for a patient, an RN must be well educated with the patient's condition and past history. To help a physician understand ways he/she may better serve the patient's pain needs is a vital role we can play as nurses in helping our patients receive better care.
ReplyDeleteOne of the first things that is taught in nursing school about pain, is that pain is whatever the patient says it is. Everyone experiences pain differently, and every one’s number on the pain scale is not going to match up because of the difference in levels of pain tolerance. Every nurse has had a patient or two not long into their nursing career that they have at least thought in the back of their mind that they were “drug seeking”. How can you differentiate? It is understandable for physicians to be fearful of legal ramifications for prescribing opioid pain medication to a patient with a history of substance abuse. As a nurse, our patient assessment plays a vital role. Is the patient exhibiting any outward signs of pain? Are they crying in pain, screaming, writhing back and forth in the bed, grimacing, not able to eat or sleep? These signs and symptoms are a good indication that the pain meds are not working and need to be adjusted. This is one way that we can advocate for our patients. We can also recommend other non-pharmacological ways of reducing pain to coincide with the prescriptive medications such as: ice packs, relaxation techniques, Reiki therapy, etc.
ReplyDeleteDrug dependence and drug tolerance are similar, but do have some differences. When someone has a drug dependence or addiction, they most likely have a tolerance to the drug in question. However, someone who develops a tolerance to a drug, is not necessarily dependent on it. Tolerance is only one possible symptom of addiction. Being able to tell the difference between the two is one of many clues that will help you decide if someone has a problem with drugs. Drug tolerance happens over time when a person’s body gets used to the drug. When this happens, the drug can stop working for the patient, and the dose may need to be increased. After this cycle repeats itself , the patient could develop an addiction. Drug dependence can develop as a result of increased tolerance.
Pseudo-addiction is evidenced by pain forced behavioral changes similar to those displayed in an addicted individual. For example, if a patient is hospitalized, and the Dr. orders an opioid medication , and the patient does not achieve the desired results, the patient, based on past experiences with his/her own body, may “suggest” a stronger pain medication to the doctor.
When treating cancer patients, it is important to treat acute, chronic, and end of life pain differently. Acute pain is best treated with short-acting pain medications. Chronic pain when treated with opioids should be treated with long acting pain medications, with adding a short acting pain medication for breakthrough pain. End of life pain should be treated differently and an around the clock dosing schedule should be administered to keep pain levels in check without letting them get out of hand. The goal being to bring comfort to the patient, so they are better able to spend their last days, weeks, or months enjoying their loved ones instead of trying to work through their pain.
Brenda Chiappetta, RN
wound care
I agree with you Brenda, pain is always subjective and must be treated accordingly and respectively.
DeleteI can be an advocate for patients with substance abuse history by looking into my own biases and emotions. I will be making evidence-based decisions that will provide optimal pain relief for every patient. It might be helpful for nurses to ask the following questions:
ReplyDelete1. Are the patients’ preferences in pain treatment given the highest priority?
2. Does the patient benefit from my pain decisions?
3. What can I do to decrease harm when deciding on pain treatment regimen?
4. Did I do my best to protect the most vulnerable patient, treating his/her pain in the best possible way with respect and without discrimination?
Proactive management strategy for patients with history of substance abuse is by slowly tapering medications over several days under close supervision. Short-term admission to a detoxification unit may be necessary.
I can be an advocate for the patients with substance abuse as a nurse by doing the following things:
ReplyDelete1. I must be able to do a thorough assessment not only on the patient's pain but as well as personal history to make sure why a certain patient is having this problem. Establishing this will help us determine our approach on how to treat a patient.
2. As a nurse, i should know the difference between addiction, dependence and tolerance because this will help me prevent my biases on the care of the patient.
3. I should be able to educate my patient all the time regarding some misconceptions about pain management and by doing so it will greatly increase the knowledge of the patients and also decrease the improper use of narcotics.
Regardless of substance abuse history, several basic principles should be applied in pain management. First, is to provide effective pain management, and this requires certain strategies: One is medications should be chosen on the basis of their ability to afford adequate pain relief and an important principle is to use the level of pain the patient is experiencing in determining the strength of pain medication that may be warranted and as a guide for effectiveness of pain management. Another strategy is to provide pain relief around the clock. The use of around the clock dosing suppresses the pain and will provide better comfort for the patients.
Very good Post Richie,
DeleteI like that that you point out the issue of nursing Knowledge deficit when it coms to differentiating between Addiction, Tolerance, and dependence. That is very important not only for nurses but for physicians as well. I myself am intrigued by pseudo addiction, when patients display the signs of addiction such as hoarding medications over overstating the intensity of their pain. medical professionals who are not knowledgeable of the term may not fully appreciate the reasons for the patient's hoarding of their medication or over rating their presence of pain to achieve more medication. increasing this knowledge is one way for sure that as nurses we can advocate for these patients.
It is important to truly listen to our patients when they are telling us they have pain. Pain is subjective, and we have all been taught that pain is what the patient says it is. However, it is sometimes hard to put our own judgements aside. It is importatnt to do a thorough assessment, use the pain scale, provide education on using the drug (i.e. proper dose, timing, etc.) and ensure their pain is being well managed. As nurses we can advocate for our patients in many situations, and ensuring their pain is managed appropriately is anothe great opportunity. If we know that a patient has a history of abuse, it does not mean that they don't really have pain. Especially when dealing with cancer patients. Developing a trusting relationship with your patients and providing proper education are keys to decreasing the risk for abuse/addiction.
ReplyDeleteHi Julie,
DeleteGood point about developing a trusting relationship with the patient. This can definitely aid in pain relief. If the patient trusts the nurse they are more likely to be honest with the nurse and seek appropriate care. The nurse is then better able to advocate for the patient by working with the physician and even providing education to the patient.
Julie, I agree that a trusting relationship with the patient is extremely important especially when there is an addiction history. I think the goals of treatment and what will be prescribed, and how much of it need to be made clear to the patient. The patient needs to have a clear understanding that there can only be on person prescribing pain medication. We although do need to again maintain trust. That will be an important key to our success with them.
DeleteI could not agree more, we are fortunate that we have the time to develop relationships with our patents in our setting, ie long term. We able to build trust and understanding which enables us to assess our patient's needs.
DeleteThe fear of legal ramifications is well placed. More and more drug abuse is from prescription medications. Knowing this law enforcement are fighting prescription drug distribution very aggressively as they should. This puts a prescribing physician in a very troubling place. Caught in between beneficence and misfeasance, treating the patients pain can make the physician look complicit if the patient is misusing the medications either selling them or personally abusing the medications. The last thing anyone needs is to be accused of being complicit in distribution of narcotics when they are just trying to help someone. Physicians are rightfully fearful when prescribing narcotic medication to patient’s with a past history of drug abuse.
ReplyDeleteKnowing the risks involved there are many things that the physician and health care team can do to both help the patient medicate their pain appropriately and discourage drug abuse. Having the patient only receive all their pain management from one physician is one thing that they can due. Additionally holding the patient accountable for the management of the medications prescribed is another measure that can be taken. These are things that the physician can do to treat the patient and protect themselves from misfeasance. As a nurse we are expected to advocate for the patient and these are things we can point out when collaborating with the physician to properly address the patient’s pain.
Advocacy for patients with a substance abuse history would definitely include education and fact sharing with the prescribing physician and caretakers. Being an advocate also means ensuring that the patient is getting adequate pain relief. We need to take the patient's declaration of pain as what it is while also recognizing drug seeking behaviors and reaching out to the professionals who can help the patient.
ReplyDeletePain management strategies include choosing medications and medication routes that will adequately control the pain, and providing pain relief around the clock. Patients need to be educated on how the medications they are taking work, and how to take them in the most effective manner. They also need to be educated on the pain management process that may include drug screens and interventions if abuse is suspected.
John, I agree that it's important to educate patients on pain management process, medications, and what interventions to expect is abuse is suspected. It'a also important to ensure that care givers are educated on drug seeking behaviors.
DeleteIn response to you John, I would suggest these two articles become part of the ER/OICC library of articles to have on hand especially for those physicians who may have a fear of prescribing pain meds to those who have history of addiction.
ReplyDeleteWe an be advocates for our patients by pleading the situation to the physician. We need to present them with clear specific details as to the details of the pain, and that pain management is justified based on this and the extent of their diagnosis. In regards to proactive management of and education of patients with substance abuse problems, we need to make sure the patient has a clear understanding of the type of pain medication they are on and the goals of that treatment. We need to discuss the limits in terms of the amount of each medication that will be prescribed, and what the possible end point will be for those medications (if it is acute pain being treated). There also needs to be a fine line of adequately prescribing the right type and enough medication to properly control the patient's pain to avoid pseudo-addiction. It is important that we make sure there is only one prescriber for pain medications, and that the patient is aware of this.
ReplyDeleteAngela, great point that we need to make the patient aware that there's only one prescriber for patient medications. The entire team involved with the patient's care needs to know this too. We also need to let home MDs/care providers know of the pain management plan, so they can be on board with it as well.
DeleteI always tried to remember the axiom, "Pain is whatever the patient says it is.", when dealing with patients. When dealing with the patient with a substance abuse problem, the same principle should be used. Use of the pain scale, both before and after medication administration, determining alleviating/aggravating factors, and psychological support for this patient are even more important. Accurate assessment and communication of findings to the physician help them make an informed decision about pain control prescribing.
ReplyDeleteI agree with Angela. Presenting clear details and data to the physician help them make an informed decision about the patient's pain control needs. This information is not static and can change on a daily basis.
Part of the patient's care plan should include a collaborative effort by all nurses caring for the patient to apply the stated principles in dealing with their pain and adjusting their care, based on their changing needs.
Julie also makes a good point. As nurses, we need to put our personal biases aside. We can not view their pain needs as a demonstration of substance abuse behaviors. These patients are subject to actual pain, as well as any other person.
Yes, we certainly need to put our biases and prior experiences with the patient aside. It's important to view each interaction with the patient on "it's own merits", and while we need to be aware of prior history of substance abuse, we shouldn't let it negatively impact the management of the patient's pain.
DeleteMy goal is to be an advocate by ensuring my patient receives appropriate pain management despite their addiction history. First of all, completing a thorough assessment of their history of addiction is imperative. Ensuring that only one physician is prescribing their pain medication to prevent over medicating or hoarding. Secondly I would reassess their pain frequently to determine possible adjustments to the prescribed medication.
ReplyDeleteI could be an effective advocate for the patient by assessing and addressing their substance abuse history. I feel it's important to acknowledge the prior history and have a discussion about it. Additionally, I would assess the patient's current support systems and make sure they have access to psychosocial support. I would ensure that the entire care team is involved in the plan to address the patient's pain, and that they all communicate clearly with each other, so that we are all aware of what's been prescribed for the patient, and who is doing the prescribing. A complete, thorough assessment of the patient's pain and response to therapy is important. Also, I would reassure the patient that despite any prior history of substance abuse, we will work together to effectively manage the patient's pain.
ReplyDeleteDefinitely agree to obtian prior substance abuse history on patient before proceeding with a plan for pain management. This is crucial in moving forward with an adequate plan to address chronic and end of life pain issues for oncology patients.
DeleteAs a nurse I advocate for patients every day and I feel after a thorough assessment, communication with the patient regarding an effective pain relief plan is most helpful. In tackling patients pain, I discuss with them a plan usually alternating medications if possible. I have found that, combined with other relaxation methods pain is better controlled. I communicate the plan as well as 'tough' time estimates when I will be checking on them again so they know that they will not be left hanging after the first dose. If needed, the doctors or pain management is notified for additional assistance.
ReplyDelete"Rough", not "tough"
DeleteAddiction is a behavior where someone exhibits potentially maladaptive and drug-seeking behaviors. Examples of these behaviors are stealing drugs or seeking the same drugs from multiple physicians. The terms “dependence” and “tolerance” are not the same as addiction and should be understood by nurses working with the oncology patient population who may use pain medication. Dependence on a medication is exhibited by a development of a physical withdrawal syndrome following abrupt dose reduction. Its presence is a normal physiologic consequence of chronic use of many psychotropic medications and not an addiction. Tolerance is also not a form of addiction and can be defined as a normal physiologic response at the cellular level to chronic use of many psychotropic medications that results in requiring more drug to elicit the same physiologic response. Extended use of at least two weeks or more to psychotropic pain medications can lead to dependence and tolerance. This is a normal and predictable response to opioids and does not imply the presence of substance abuse or an addictive disorder. Pseudo addiction can mimic active addiction in cancer patients. As stated in the Journal Club article, “Successful Pain Management for the Recovering Addicted Patient”, “Out of fear of not receiving adequate pain medication, individuals may hoard medication or ask for amounts that seem out of proportion to their pain. This behavior may be particularly evident in individuals who have previously experienced the prescribing of inadequate amounts of pain medication by physicians who fear using opioids in patients with substance abuse disorders.”
ReplyDeleteWhen treating cancer pain in the oncology population, it is important to distinguish between acute, chronic and end of life pain. The goal of acute pain management is always elimination of pain. For oncology patient population, chronic pain and end of life pain are issues commonly confronted. The goal of chronic pain management is to obtain reasonable pain relief while also allowing the patient to maintain a maximum level of function in their daily lives. In pain management at the end of life, past history or risk for addiction should not be an issue. Providing relief from pain during the end of life is the same regardless of any current or past history of addiction. The amount of medication used for pain management, however, does differ. The recovering or active addict may require more opioids to control pain because of increased opioid tolerance than those who do not have a history of addiction. Because the acute, chronic and end of life pain patients all differ in their interventions, especially with regards to those with a history of substance abuse, it is crucial to perform a thorough personal history of drug use and abuse.
Finally, I can be an advocate for these patients whose prescribing physicians are fearful of legal ramifications when prescribing opioids to a patient with a substance abuse history. When caring for oncology patients in pain, it is our obligation as nurses to advocate for patients with a past substance abuse history. I have had many oncology patients who I knew to have a past history of substance abuse and I always make this known when discussing patient’s pain management and possible increase for more medication with their physician. Most physicians would welcome this information when prescribing pain medication for those with substance abuse issues in order to maintain the maximum pain control possible for patient. Proactive management and education to be used in this patient population would be to explain to the patient the goals of pain management for oncology patients who have a substance abuse history. This is especially true for end of life pain management as it is important for them to understand that addiction is not an issue at this point.
Pain is what a patient says it is and when they say they are experiencing it. A detailed history and a complete assessment is the first step in managing patient’s pain. In order for us to be a patient advocate we need to understand and put aside our own biases towards the patients. If the patient has history of substance abuse, we need to be proactive in educating them how they can prevent a relapse. One way to do that is by having a care giver dispense the medications if possible. The most important thing to do is to make the patient feel comfortable talking about their fears of falling back into old habits. Physicians might not be the ones that the patients feel comfortable discussing their fears with so it is up to us as nurses to be there for them and to help guide them.
ReplyDeleteFirst and foremost the patients need one physician to follow their pain control. When patients come in to see the doctors they need a good assessment by the nurse and the physician as we all know sometimes patients don't tell the nurses everything as far as pain medication that they are on. By being a good listener to these patients we can usually figure out what's going on with your pain and the medications that they're taking
ReplyDeleteI think that being open and honest about a patient's addiction and not being judgmental are ways of advocating for the patient. It helps to build a trust and rapport that are crucial in helping a patient with addiction concerns, manage their pain. Methods to remain proactive in their pain management care plan, would include a pain diary, psychotherapy, regularly scheduled dose reassessments of opiates and tolerances, recommendations for non narcotic methods of pain relief, A Pain Managenent consult and addiction counseling where appropriety are interventions I would consider. Christi Ables, IR X1517
ReplyDeleteChristi, good job on pointing out the need to build a patient relationship by having an open and honest dialogue in regards to their addiction. I totally agree with you on how nurses need to remain unbiased without any preconceived judgments. Recommending patient referrals for consults are great interventions for patients to manage their pain. Keeping a pain diary and log is a great idea as well.
DeleteGail Arai
Advocate by using active listening skills to really hear what the patient is saying, not just verbally but also physically. Patient’s non-verbal cues are just as important to take into account when taking care of patients. Their body language, eye contact and facial expressions need to be included when assessing pain. However, as nurses we should not make any judgments on our patients. When a patient reports any symptom especially pain, we must always acknowledge their feelings and treat accordingly. Teaching is only effective when patients are willing and ready to learn on pain management. At CTCA, we are fortunate to have a pain team that works with our patients on managing their pain. Gail Arai
ReplyDeleteProper pain assessment is very important when it comes to pain management. the rate and location is important but whether the pain is new? How did it start? What makes it worse, etc. Getting the proper information is necessary in order to give report to the physician to order the adequate pain medication. As nurses, it is our job to make sure our patients are comfortable. If the patients PCP or in our case medical oncologist does not feel comfortable dosing high doses of narcotics then a pain management referral is a must. Educating patients about narcotics and the proper use is very important especially to those that have a history of abuse. Living in pain is not a way of living and teaching patients that the proper dose and frequency will not cause an addiction.
ReplyDeleteTo be a patient advocate the person needs to be an assertive representative for the patient when they are receiving care from the health system; aiding the patient through the complicated processes, procedure and decisions that may arise. For me, being the patient advocate is constantly putting myself in the patient shoes and doing the best I can to see things from their perspective and supporting them to make the best decisions for care and comfort. Yet, when it comes to addictions; some people tend to forget that the patient is not defined by their disease and or past addictions and the care they receive should always be the best. Many patients that have had addictions in the past are the best resources on what it takes to successfully manage care; and the cues that need to be monitored. It is always best to listen to the patient and know that when it comes to pain; it is both objective and subjective. No one can truly measure the intensity of pain a patient is feeling; we can only educate them on all methods of management and make sure we advocate for the best care and support all decision making.
ReplyDelete