W hen I was in elementary school, we had this program called “Red Ribbon Week” where the school would spend a week teaching us about how bad drugs are and how to say no to drugs. We all wore red and tied ribbons all over the school. I imagined back then that this must be more important for city kids who were being offered drugs and needles every day. Somewhere else where drug dealers would wait in the parking lot and offer you new shoes if you kept a backpack for a few days. Where gang violence and lockdowns and police would come to the school. The only time police came to my school was when we saw a mountain lion on the football field, not 100 feet from our classroom, and we had to stay inside until he had moved on to another unsuspecting group of young children to scare and fascinate. Nature, in all its unpredictability, was the biggest danger to children when I was growing up. More kids missed school due to a misunderstanding with gravity then a drug dealer, and Mother Nature was the ultimate tardy excuse. Despite my lack of personal experience with the more mind-expanding and dental destructive elements of society, I still got the message. Say no to drugs.
Fast forward almost 20 years and it seems that lesson has ingrained itself into me and my peers much deeper then we realized. My patient today is Dan, and Dan is a badass. Not the “tattoo on the neck, colors hanging from a back pocket, seen some sh*%” kind of badass. Dan was the “hold down two jobs so his kids can go to school, work outside, has no insurance or debt” kind. Dan had an accident at work and broke his finger. What was once an instrument of detailed and delicate field work for long hours was now angulated, avulsed, and every color of the rainbow. Dan kept his cool, never cried. In fact, he hardly flinched when the doctor started to debride the wound. So I asked the Doctor,
“Are you going to numb that first?”
The Doctor was horrified, “Oh my gosh I’m so sorry! I saw you here so relaxed and I thought it had already been done.”
Badass Dan turned and shrugged,
“It’s OK. I’ve had worse.”
The doctor sent me to get lidocaine and to bring the pain med also.
Dan says, “It’s OK, I’m fine”
To which the doctor says,
“No you aren't, your blood pressure and heart rate are high and I can see you sweating. If you can relax a little with the pain medication it will make this repair a lot easier.”
“OK, if you think so.”
Dan was a total badass.
He never asked for pain medication, and now we were strongly suggesting it. Contrast that to….nearly every other patient ever! Most of the time pain meds are the second demand only to ice water or a sandwich. For years, pain management has been a point of debate. In recent history, pain was considered undertreated and became “the fifth vital sign” as a Joint Commission standard in 2001. Now in 2018, the opioid epidemic seems to suggest that we didn’t really help with all that pain medication. Dan was the sort of guy who seemed content to just cut his finger off in the field as an unnecessary annoyance and get back to work. Why is it that pain is such a personal experience, but it is my fault if a patient has it?
Many come to the hospital for answers. And we are pretty good at giving objective data to explain the problems people have. The answers to most problems in a traditional western hospital are called “pills”. As far as healing goes, I feel like a one trick pony. Every patient has a problem and every problem has a pill. The issue is that pills often are a double-edged sword and they only treat half the problem. For example, blood pressure is controlled by heart contractility, blood vessel contractility and elasticity, and the volume and viscosity of the blood. The mechanisms to impact blood pressure are numerous, including endocrine, exocrine, hormonal, mechanical, electrical, emotional and even mental. The beta blocker we take only interrupts one pathway. Many people have been able to control beta blocker managed blood pressure through diet, exercise, and mindfulness. My point is that pain is similarly multifaceted and we only have one stick to swing at that snake. All my patients know it as, “That one with the D.”
Managing pain well does not come from a goal of making it disappear. Nerves are up-regulated and down-regulated according to one’s own homeostasis. This is why smells are horrible at first, then you go “smell-blind”. That is your brain down-regulating a potent but unnecessary information input. Alcohol covers gaba receptors which cause the body to up-regulate and create more gaba receptors to accommodate the numbing and sedative effects of alcohol. The Delirium Tremens and withdrawal symptoms of alcohol is your body now having to deal with the noise by those many gaba receptors screaming at a volume of 10. Remember from your CIWA scale how many questions ask about being over sensitive? Tingling, noise, light, seeing or hearing things that aren’t there, are all manifestations of a nervous system cranked to 10. So the more you dull yourself, the more sensitive you become. The same is true with pain.
Pain meds have their place. And as far as I can find, it is exceptionally rare that people become addicted to pain meds used in the hospital. During the acute phase in the hospital, the stimulus is overwhelming and the pain medication does what it is supposed to. The addictive part of pain meds often happens when that person goes home. When the patient can control how often and how much they take, and why they take it is the greatest opportunity for abuse. Pain is as much an emotional experience as it is a physical and mental one. If we can recognize that, then we can help our patients understand that feeling the pain is the most important safeguard to avoid addiction.
As a nurse, when people ask for pain medication I am hesitant unless the situation and my personal sense of the patient lead me to believe the pain is appropriate. This sentiment is contrary to that 2001 Joint Commision standard, where the experience of pain is thought to be a completely individual experience. Because it is an individualized experience, I can not be the judge of what pain another person is experiencing, and thus must report pain as rated and provide the medication according to the order. This is a significant rock-and-a-hard-place situation about my job. I want to take care of people, but people seem naturally self-destructive. To what degree will I be mandated to participate in their destruction?
If you are interested in learning more about addiction, this amazing Ted Talk completely changed my whole philosophy and has really helped me reach people struggling with or who are afraid of addiction.
Leave a comment and share how pain management works in your facility.