Patients with chronic pain: 4 things to remember

Chronic painPatients with chronic pain have often been on narcotic pain relievers for years – which means their bodies are opioid dependent and opioid tolerant. They come in for a procedure or surgery and are quickly labeled as “drug seekers,” which leads to poor pain management as doctors and/or nurses decide that what works for everyone else “should work” for this patient too. What can we do as nurses to advocate?

  1. Get a good history of what they took prior to admission. Those meds need to be restarted, especially if they took scheduled meds or anything extended release. Listen to your patient – they know best what works for them.
  2. Think outside the box – what else might be contributing to the pain? Is the patient cold? Get a blanket. Smoker? Ask the physician for a nicotine patch. Drinker going through withdrawal? Maybe a benzo is appropriate. Stressed? Sit down and chat for a few minutes, and really listen.
  3. Come at the pain from multiple directions. Gabapentin works differently than narcotics, and often when used together with narcotics they boost the effectiveness of both drugs. Toradol and tylenol might be weak on their own, but when you combine either of them with other meds, they can help get your patient over the hump. If there’s a possibility that there are muscle spasm ask the physician for an antispasmodic. Pain receptors are not all alike, and not all drugs work the same way. Administer different things so you can come at pain from many sides all at once.
  4. If the patient is dependent on narcotics they won’t have the side effects you’re used to seeing in other patients. Be willing to try strong drugs if they’re available – just have precautions in place and be prepared for changes in breathing and/or mental status.

I had a patient over the weekend who normally takes high dose oxycodone ir around the clock, high dose oxycodone er around the clock, ativan, and was on a dilaudid/ketamine pca. Every time the pain specialist told me to increase the dose I took a deep breath, terrified that I’d miss respiratory depression because I was managing 5 patients – I couldn’t monitor this one closely enough. Yet, every time we increased the dose the patient was absolutely fine. Not a single side effect, even when he was getting enough narcotics to kill a horse. By day 2 with this patient, I saw his smile for the first time. His pain was being controlled better than it had been in 20 years. We’d stumbled on a regimen that works for him, and he was able to walk long distances (300 ft for him was long distance) for the first time in years. He was going to get his life back and he was “tickled.” Quite a change from lying in the fetal position with tears streaming down his cheeks. Pain is real, it is subjective, and every body reacts differently to medications. Don’t assume you know what your patient “should” be feeling or what “should work.”

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