When I went to nursing school (over 20 years ago), I distinctly remember being taught that pain is subjective. Therefore pain is whatever your patient tells you it is. If my patient says they are in pain then I am only to assume that they truly are and take the necessary actions to mitigate their pain.

Nurses in long-term care are exceedingly cognizant that addiction is a serious and omnipresent problem within the long-term care population, just as it is in the general population. When we look at addiction in this country, you may first think of the resurgence of heroin abuse in our young adult population. I found it surprising that according to a study from 2015, 40 percent of the prescription drugs sold in the United States are used by the elderly, often for problems such as chronic pain, insomnia, and anxiety. The National Clearinghouse for Alcohol and Drug Information states that as many as 17% of adults age 60 and over abuse prescription drugs. Narcotic painkillers, sleeping pills and tranquilizers are common medications of abuse.

Difference Between Physical Dependence and Addiction to Prescription Drugs

When discussing abuse it is important to understand the difference between physical dependence and addiction:

Physical Dependence

Physical dependence to opioids means that the body relies on an external source of opioids to prevent withdrawal. Physical dependence is predictable, easily managed with medication, and is ultimately resolved with a slow taper off of the opioid.

Addiction

Addiction is a primary condition manifesting as uncontrollable cravings, inability to control drug use, compulsive drug use, and use despite doing harm to oneself or others.

During my career in long-term care, I have seen a disconcerting upward trend in the use of the phrase “drug seeking”. This term is typically used to label a patient who is requesting medication regularly despite having minimal or no outward signs distress or pain. It is also used for patients who ask for a higher dosage of medication than is typical for the treatment of the patient’s condition. Every time I hear those words I find myself feeling mawkish. This goes against everything that we have been taught about pain being subjective. Physical dependence and addiction can also manifest as pain as well if narcotics are withheld.

When a patient requests pain medication, it is the nurse’s responsibility to administer the medication per the physician's order, document medication administration, and complete a pain assessment. The pain assessment should include the patient’s description of the pain as well as any objective findings from the nurse. This can include any outward signs seen by the nurse as well as vital signs. Do not project your own subjective feelings about the patient’s pain into the situation. We should not be passing judgment on our residents based solely on their narcotic usage. We are supposed to advocate for our residents, not reproach them.

PQRST Pain Assessment Method

There are many types of pain assessments that are available for use, one of my favorites is the PQRST Pain Assessment Method. This assessment is simple to use and yet comprehensive in nature. By using the following questions, nurses can help their residents more accurately report their pain which will ultimately help the nurse to treat the patient’s pain. Here’s how it works:

Let’s tackle the elephant in the room. All the information in the world will not incite change unless we have a plan on how this can be accomplished in the real world. How do we as nurses ensure that we are meeting the diverse pain management needs of all of our residents?  The first step is to espouse the idea that pain is subjective, even in the case that the patient is addicted to narcotics. It may be more difficult to manage their pain because of their high threshold to narcotics, but not impossible. The scheduling of medication can be a key element to your success. By providing routine medication you can decrease breakthrough pain and decrease the need for additional PRN dosing.

Another option is gene mapping. Gene mapping will provide the physician a map to what medications will work best based on the patient’s individual genetic makeup, thereby optimizing pain relief. The uses of antidepressants like Cymbalta have also proven to be helpful in conjunction with traditional pain medications. When dealing with addiction psychotherapy can prove to be invaluable. This can allow for the resident to talk about the underlying problem and identify much needed coping mechanisms.

Awareness and education regarding the complexity of pain management issues are only half the battle. Nurses have a responsibility to ensure ALL of their patients receive appropriate pain management without condemnatory actions or disdainful responses. Everyone metabolizes medication at a different rate and each person has a unique tolerance to pain - never presume to know how another person feels or how they feel their pain. Pain is subjective, therefore everyone’s pain is different.