Opioids Pain Rating system and persons with addictions

[laschenova]

I am not entirely sure if this is the perfect forum for this question/survey, if not, I apologize to the moderators. I tried looking around and settled on this forum for the topic.

I am a PA and I have worked ER, urgent care, primary care and gastroenterology. I have noticed something and was reminded of it while perusing the pain mgt thread.

The self assessment scale of pain. I am sure that you are all aware of the 1-10 chart with the frowning faces. In school we were tolds that a pain level of 5 is like a really bad headache, a 7 is something like a woman in the middle of labor begging for her epidural, and a 10 is so bad that 99% of people would be in shock, or lose consciousness.

I can't tell you how many times a nurse came to me and told me that a patient who I had spoken to minutes before who was sitting upright, smiling, playing on his or her phone, etc was claiming to have level 8-10 pain and needed pain meds. Only when it was explained to them that a 10 in pain would be an open fracture with 3rd degree burns or a severed limb did it dawn on them that 10 was a bit too extreme.

I am not saying that people were inventing pain. I believe that they were geniunely in pain. Even people who admitted they were in recovery from addiction and only wanted non narcotic meds would tend to overrate their pain levels.

It makes me wonder if people who are addicted or have a tendency to be addicted have a hightened emotional reaction to pain? I know that I can not stand to be in pain. I have a decent tolerance to pain, but it seems to make me more irritable than your average bear.

How have you rated your pain levels in the past and what do you think of this?

Sorry if it seems a bit incoherent and rambling, I just got off work and had no break all day...poor me (tiny violin). Now where did I put my Lortab?

 

[NeighborhoodThreat]

I am a user of opiate pain medication and have been for some time.

Myself and most opiate users that I know certainly have a lower pain tolerance.

I think it's part of why some people get addicted to opiates easier than others.

 

[Deblanc]

People who use and or abuse opiates my well have a heightened emotional response to pain, but I think you need to remember that what you learned in school about the pain chart, the patient has not.

It may be surprising to you or to doctors that someone is off the mark based on your understanding of where pain should lie on that metric, but people are responding to it based on their subjective evaluation of how they feel. I have never been able to figure out where my pain falls along that chart when it has come up. I usually err on the side of caution so as not to seem drug seeking, because I know as well as anyone that jaded ER docs are predisposed to see drug seeking behavior even when there is none in evidence.

In fact, the one time I called it a 9, where I had what was ultimately diagnosed as bone on bone contact from an unhealed break, the doc gave me Ibu 800's. He gave me a grudging apology when I came back in, citing the stream of drug seekers thru his ER. I gave him my finger, figuratively.

There is more than enough confusion for patients in emergency settings, the real problem of drug seekers aside. Doctors and health pros should educate their patients to elicit responses that fall within the guidelines they will ultimately use to evaluate patient suffering. Otherwise, the disconnect will continue, to the detriment of the patient.

Interesting research you are doing. Good luck.

 

[THC2LSD]

How the hell is someone in pain supposed to know that a 10 is like getting shot or burned and a 7 is like giving birth? Especially if they haven't experienced these. Also how do they know if the patient just handles pain different from expected but is still feeling it inside?

Tell them a 5 and they'll usually give you Tylenol, if anything.

 

[Coraline]

I am a Nurse and Chronic Pain Patient. Just because a person is sleeping, playing on a phone (distraction from pain), watching tv, or another activity, doesn't not mean a person isn't expierencing real 6-10 pain.

Source my own expierences and evaluation of patients.

Pain is subjective and is what ever the patient say it is and hurts where ever the patient says it hurts.

Someones 2 may feel like a 5 to someone else and so on.

Source medical school.

Some people may want stronger pain medications for various reasons, but you have to treat it.

DO NOT start thinking that some one isn't hurting and they may be an addict and just want drugs.

If you are that type of person get out of the medical field. We don't need more people like this.

I would rather treat 100 drug seeker for pain to make sure the 1 person who was in direr need got the meds they deserved.

It is not for us to decide if they are hurting and influencing MD's that they are drug seekers benifits nobody really. Even drug seekers have level 10 pain.

Sorry if I seem angry and offensive but I deal with a lot of non caring people who are suppose to care for patients with out judgement.

 

[Swimmingdancer]

I wouldn't call it just a heightened emotional response to pain, I think there is also heightened sensitivity to pain, which is very real pain. I think of "emotional response" to pain as meaning just being mentally unable to bear pain, but it somehow implies that the pain is actually perceived just the same as by an "average" person but they're just more upset by it. Whereas I think that the pain also truly feels worse. I definitely believed people with a heightened pain sense and/or people who are less able to bear pain are more likely to become addicts, AND that addicts are more likely to have a heightened pain response, particularly opioid addicts. Opioid addiction causes both allodynia (pain due to something which does not normally provoke pain in most people) and hyperalgesia (extreme/exaggerated pain from something which is normally painful). Especially when the person stops using opioids or doesn't have enough. Allodynia and hyperalgesia are also very common in people with depression and chronic pain disorders, 2 groups (although there is a lot of overlap between those groups) which are very likely to be prone to addiction. People who don't have enough natural endorphins are more sensitive to pain and more likely to have addictions.

One thing I have been very frustrated in my life is with is health care professionals not believing I am in pain because they thought I was too young or "didn't look sick" (what does that look like anyway?) or didn't have severe enough provable/visible injuries. If they had taken me seriously back when I was a teenager I truly believe I may not have turned to heroin to self-medicate.

 

[BeachBum4u]

I am a Nurse and Chronic Pain Patient. Just because a person is sleeping, playing on a phone (distraction from pain), watching tv, or another activity, doesn't not mean a person isn't expierencing real 6-10 pain.

Source my own expierences and evaluation of patients.

Pain is subjective and is what ever the patient say it is and hurts where ever the patient says it hurts.

Someones 2 may feel like a 5 to someone else and so on.

Source medical school.

Some people may want stronger pain medications for various reasons, but you have to treat it.

DO NOT start thinking that some one isn't hurting and they may be an addict and just want drugs.

If you are that type of person get out of the medical field. We don't need more people like this.

I would rather treat 100 drug seeker for pain to make sure the 1 person who was in direr need got the meds they deserved.

It is not for us to decide if they are hurting and influencing MD's that they are drug seekers benifits nobody really. Even drug seekers have level 10 pain.

Sorry if I seem angry and offensive but I deal with a lot of non caring people who are suppose to care for patients with out judgement.

Boy you really said a mouthfull there~! I particularly agree with a couple of your points - "DO NOT start thinking that some one isn't hurting and they may be an addict and just want drugs. If you are that type of person get out of the medical field. We don't need more people like this." And this one, "I would rather treat 100 drug seekers for pain to make sure the 1 person who was in dire need got the meds they deserved." I really wish more healthcare professionals would follow those truths. I really hate when docs automatically make assumptions based on age or appearance etc., they should know better. Lastly, as patients we need to be aware that most docs actually receive very little formal training on "pain" and those that do probably get it from older jaded doctors who probably pertetuate all the stereotypes us pain patients hate so much! I know I'm throwing out a bunch of assumptions and personal observations, so please take them for what they are, my experiences and opinions.

Sorry but as a 30-40 year CP'er, I can tend to rant on this topic occasionally. Well said Zoe!

 

[Coraline]

Thank you Beach

I hope other people chime in and give their points of view.

I think the OP has never been in pain and dosent know what it's like to be hurting and nobody believes them and suffer.

 

[Skeeef]

Nice you sound like a really good nurse zoey. I wish more doctors had empathetic logic like that

 

[Snake_Eyes]

I hate the whole pain scale they ask because I've had migraines and toothpain that caused me more pain than my motorcycle accident did and I shattered my left wrist, broke my left thumb and fractured my right elbow but my adrenaline was so high I didn't feel much and by the time the pain really started to come on I was in the process of being doped up.

I'm not an addict nor have I ever been one and I find it very insulting that I get flagged a drug seeker because I go to a doctor when I'm having pain but because I don't have the paperwork to show it I'm refused treatment and told to go to PT.

 

[mrflowers00]

4 to 9 i have sever chronic neck shoulder and upper back pain

 

[tricomb]

I am a Nurse and Chronic Pain Patient. Just because a person is sleeping, playing on a phone (distraction from pain), watching tv, or another activity, doesn't not mean a person isn't expierencing real 6-10 pain.

Source my own expierences and evaluation of patients.

Pain is subjective and is what ever the patient say it is and hurts where ever the patient says it hurts.

Someones 2 may feel like a 5 to someone else and so on.

Source medical school.

Some people may want stronger pain medications for various reasons, but you have to treat it.

DO NOT start thinking that some one isn't hurting and they may be an addict and just want drugs.

If you are that type of person get out of the medical field. We don't need more people like this.

I would rather treat 100 drug seeker for pain to make sure the 1 person who was in direr need got the meds they deserved.

It is not for us to decide if they are hurting and influencing MD's that they are drug seekers benifits nobody really. Even drug seekers have level 10 pain.

Sorry if I seem angry and offensive but I deal with a lot of non caring people who are suppose to care for patients with out judgement.

Seriously, this could not have been put any better.

If someone can't be impartial and treat everyone with respect and compassionate care, they should get out of the medical field.

To quote Swimmingdancer,

One thing I have been very frustrated in my life is with is health care professionals not believing I am in pain because they thought I was too young or "didn't look sick" (what does that look like anyway?) or didn't have severe enough provable/visible injuries. If they had taken me seriously back when I was a teenager I truly believe I may not have turned to heroin to self-medicate.

^this.

I wish more healthcare professionals had your compassion Zoeylynn, I've really been screwed over time and time again by doctors. No shit I'm drug seeking, I'm not ignorant to the medications that are out there, I know what works for me better than some Quack doctor who's telling me I should be taking ibuprofen or naproxen.

Attention Doctors: Don't assume a pt is drug seeking just because they know the medications by name. They are no secret, so stop being so threatened by patients who actually know about the medications they take.

 

[BeachBum4u]

Attention Doctors: Don't assume a pt is drug seeking just because they know the medications by name. They are no secret, so stop being so threatened by patients who actually know about the medications they take.

I will usually address this right upfront with doctors. I tell them I take ownership in my healthcare very seriously and therefore make it my business to know and understand the medications I take and ones that may work for my problems. Honestly, all this info is out there and pretty easy to get to if you have the inclination. Therefore, with that out of the way, I don't usually get the raised eyebrow when I am up on what he/she may prescribe. So I'm armed and can ask intelligent questions. I'd encourage everyone to take ownership in their healthcare, it's not a crime (unless the DEA decides today's the day to ruin yours and your doctor's day). Slightly joking there, but the strong arm of the DEA really pisses me off sometimes!

 

[Snake_Eyes]

Exactly, the old days of having complete trust that the doctor knows best are over. With being able to look up anything on the internet it's naive for doctors to think people aren't going to do their own research on what their prescribed or possibly prescribed.

For example(s): I can get zolpidem handed to me like it's candy, my regular doctor never said a thing about it being habit forming just handed me 60 pills and sent me on my way, luckly I got put on mirtazapine not too long after and no longer needed them. I get temazepam from my psychiatrist and if I followed the directions on the bottle I would be taking them every night for 2 months before running out, once again not a single mention of their addiction potential. I do my own drug research and it was from that where I found out about the problems that comes with benzo dependency.

A couple weeks ago I was at the free clinic talking to their counselor and we were discussing anxiety and benzos. He was aware of the addiction problems with xanax (he went through it) but then said he didn't think lorazepam was habit forming.

 

[Swimmingdancer]

I am not saying that people were inventing pain. I believe that they were geniunely in pain.

It makes me wonder if people who are addicted or have a tendency to be addicted have a hightened emotional reaction to pain?

I think the OP has never been in pain and dosent know what it's like to be hurting and nobody believes them and suffer.

I think some of us (not trying to single out Zoeylynn) may be being too hard on the OP. They were not saying that people aren't in pain or are lying to get drugs, they were just trying to find out why people appear to over-rate their pain according to the numeric pain scale, when health care professionals are told that a certain number is supposed to represent pain caused by a certain level of injury. They were asking if one possibility could be that some people are more distressed by pain than others, and I think there is a lot more to it than that, but I don't think the OP was being ignorant or prejudiced, they seemed to genuinely want to understand and were not making the typical assumption that anyone who says they are in pain and isn't missing a limb or dying of cancer, or is under the age of 40, is lying just to get drugs. The only potentially false assumption I saw was that someone who isn't behaving like someone expects someone in severe pain to behave means they must not be in severe pain.

I do think another issue is that in some cases people don't understand the pain scale, or some people assume they should overrate their pain in order to get taken seriously, since most health care professionals tend to assume everyone is overrating their pain anyway.

 

[tricomb]

I wanted to clarify my post wasn't to the OP, I was responding to zoeylynn. I am aware the OP is a pain patient as well since she is taking lortabs.

Yeah it's pretty common for people who have not felt pain to claim they are feeling 10.

 

[BiggDirty01]

I have a lot of experience with the pain scale in hospital settings, and the only '10' to me was the few moments post-operatively from my spine being fused together and lasted until they shot me with enough dilaudid, morphine and methadone to bring my pain under control. One time I was put in a chemically induced coma for 3 days via a ketamine/dilaudid drip and PSA.

5 out of 10 to me is the experience I had 6 months after my first fusion where I went without narcotics for 6 months because I had become tolerant/used to a certain amount of pain that I defined as "manageable".

I think though, with my prior history of opiate addiction, that some pain from my first two surgeries was due to hyperalgesia both because I had a huge tolerance pre-op that required heavy duty opiate prescriptions after. The hyperalgesia really stimulates the pain I had, both nerve pain and skeletal pain so where I was answering a 7/10 five months post-op with meds turned out to be a 5/10 without meds.

It is truly insane that the level of pain one senses can be so magnified by use of opioids for a long term. The only way to get back to a baseline in reality is to either go down significantly on meds, have meds rotated or changed every few months, or like I did... completely off the narcotics, NSAIDs and muscle relaxers (with yoga and high dose lyrica).

I recommend all my fellow chronic pain patients to consider the ramifications of long term high potency opioid use when understanding how to grade their pain. Its not to say the pain is all in one's head, but rather, there exists potential for hyperalgesia and over sensitivity to pain.

 

[Coraline]

I know I'm being harsh. I'm just very passionate when it comes to treating pain. Even when I was not taking narcotic I was this was. Then when I was in pain and had people treat me like I'm lying made me angry and I became more of an advocate for pain patients.

Patients do embellish a little so people will take them seriously. I'm sure 50% of patients do this. Does it mean they don't deserve treatment? No. That means society has made them this way. Just on the other hand patients will deny being in pain because they don't want to be attached to the stigma society places on people who use narcotics for pain. I have seen it first hand. This makes me angry too.

Yes hyperalgia is common and the only cure is to decrease the medication. It is still real pain but needs to be handled differently than acute traumatic pain. Idk. I could go on and on.

 

[tricomb]

I think people might appear to have jumped on the OP just because this is a very highly emotional and physical topic, and most of us CPPers know what it's like to wear our heart on our sleeve into the doctors office and be metaphorically pissed on and told it was rain.

 

[milagro]

I wouldn't call it just a heightened emotional response to pain, I think there is also heightened sensitivity to pain, which is very real pain. I think of "emotional response" to pain as meaning just being mentally unable to bear pain, but it somehow implies that the pain is actually perceived just the same as by an "average" person but they're just more upset by it. Whereas I think that the pain also truly feels worse. I definitely believed people with a heightened pain sense and/or people who are less able to bear pain are more likely to become addicts, AND that addicts are more likely to have a heightened pain response, particularly opioid addicts. Opioid addiction causes both allodynia (pain due to something which does not normally provoke pain in most people) and hyperalgesia (extreme/exaggerated pain from something which is normally painful). Especially when the person stops using opioids or doesn't have enough. Allodynia and hyperalgesia are also very common in people with depression and chronic pain disorders, 2 groups (although there is a lot of overlap between those groups) which are very likely to be prone to addiction. People who don't have enough natural endorphins are more sensitive to pain and more likely to have addictions.

One thing I have been very frustrated in my life is with is health care professionals not believing I am in pain because they thought I was too young or "didn't look sick" (what does that look like anyway?) or didn't have severe enough provable/visible injuries. If they had taken me seriously back when I was a teenager I truly believe I may not have turned to heroin to self-medicate.

I have been in pain management(PM) for 7 years for treatment of spinal degenerative disorders and abnormalities of the bones in both shoulders. As far as those addicted to/dependent on opiods and currently being treated for chronic pain there is a condition that is well documented known as "hyperalgesia". I skimmed the posts in this thread so I do not know if I am being redundant. Hyperalgesia from opiods or opiod induced hyperalgesia is a result of the pain signals/pathways being thrown off their normal function because of the pain receptors being subjected to overstimulation. This makes the patient feel increased sensitivity to pain, creates a lower pain threshold, and there can be a worsening of pain despite an increased dose of pain medication.

Separating emotional and physical pain levels is too subjective to provide a definitive answer to the OP's question. I wanted to weigh in here because of the ER problem that exists with the clinicians are trying to determine how much pain the patient is truly in using, in my opinion, a poor tool such as the 1-10 pain scale. What is an 8 for one person is a 5 for another so how can the people working on the patient get an accurate sense of how much pain the patient is in using this scale? I am sure it will be removed in the near future.

I want to give the OP a little insight by using a personal example of hyperalgesia and trauma in the ER. I have dislocated my shoulder 3 times due to my humeral head having a large lesion. I recently dislocated it by simply leaning on it. I am not one of those people that can pop their shoulder out and pop it back in because the shape of the humeral head looks like a lunar eclipse with sharp edges at the top and bottom. It causes the humerus to get stuck into the dislocated position and makes it very difficult to reduce. Enough of my physiology.

I arrived at the ER in excruciating pain having taken my last dose of pain medicine 10 hours prior to my admission. I am supposed to take it every 4 hours but didn't feel I needed it that day. I would like to provide health care professionals, especially those working trauma, some information about patients with opiod inuced hyperalgesia. The patient is going to feel the pain significantly more than a non medicated individual. That might seem counter intuitive because if the patient already has medication on board "shouldn't they feel less pain'? It doesn't work that way with people that have a high tolerance to pain meds due to chronic dosing for chronic pain.

I told the attending about this possible problem in treating me and saw immediately that she was young (not to be prejudiced, she just looked inexperienced) and felt I was probably seeking drugs and not in as much pain as I was indicating. She didn't even feel the abnormal position of my shoulder that the paramedic noticed right away. I did not have my pain doctor's phone number on me to prove I was telling the truth. She casually asked if I needed anything for the pain while she was leaving the room. I had tears rolling down my cheeks because of the pain. They gave me 1 mg of dilaudid about 1/2 an hour later. Look on line and you will find that opiate tolerant individuals should be given a 10mg dose of dilaudid in trauma. I did not know this until after this event.

I said, "please, the pain is not letting up". They gave me another 1mg of dilaudid an hour later and it had no effect. This led to the problem of my being unable to hold still for the xrays that they ordered which were incorrect and did not show the posterior dislocation that I had. After another hour of lying in horrific pain they ordered a CT Scan to make sure it was "really dislocated". I was furious. I could not hold still for the scan but did my best.

After 3 1/2 hours and consulting a physician that had reduced my shoulder 4 years ago they all entered the room and knocked me out with propafol and reduced it. The decrease in pain was immediate. Three and a half hours of ungodly pain and suffering that could have been avoided if the attending had a little more experience with treating a patient such as myself.

I did not intend to go on and on but since the OP worked in an ER I implore you to share this with your colleagues. Yes, if I had my doctor's phone number he might have been able to help with the pain but it was in the middle of the night so who knows? What pissed me off was treated like someone that was seeking drugs. There is no other explanation. My pain Dr. was in complete agreement and spoke with the charge nurse at the ER. I let it go even though they wanted me to file a grievance. It is difficult for ER docs to treat people in pain with all the seekers using ER's to get their fixes. Additionally, giving someone 10mg's of dilaudid who is not as tolerant as myself could lead to severe consequences.

Yes, I got off on bit of a tangent but the 1-10 pain scale is an f-ing joke and completely subjective. I have been asked to rate my pain using the scale many times, too many times, and I honestly wonder if the people asking even care what my answer is. As the incident I described indicates, my answer of 9 didn't make a damn bit of difference. Crying with a pain level of 9 and 2 mg of dilaudid over 3 hours? Raise your hand if you think that they may as well have left the 1-10 scale out completely.