Since beginning my career as a CRNA, on a daily basis I use the pharmacology and physiology I  learned to administer narcotic medications in a monitored and 'controlled' situation. This has given me the opportunity to see almost immediate cause and effect of the medications and increased my confidence level in administering high dose narcotics to those with tolerance and physical dependence. I have cared for patients with myriad non-narcotic, narcotic, alcohol, and ilicit drug use histories. Some are in agonizing pain and are opioid naive for fear of side effects or addiction.

After a couple of years I really began to notice that most nurses (and myself for the record) had received limited education in nursing programs on treating pain. Up until this realization, I had assumed (and we all know what that means) that some people just did not care. Let me digress and give you an example:

     It is 1993, in a level 2 facility in Meridian, MS. I was a SNA (student nursing assistant) on the night shift. The call bell had rang, and it was a patient requesting pain medication.  Her prn medication was Demerol (meperidine) q 4 hours. I alerted the LPN to the patient's request. The LPN was preparing to go out on a smoke break. Angry that the patient had requested medication, she stated "I'll teach her to ask for more Demerol". The nurse drew up the meperidine, and placed an 18g needle onto the syringe and proceeded to the patients room to administer the IM meperidine.

We have all taken care of 'clock watchers' but there are two important pieces of information about meperidine missing here that I know I was never taught, and other nurses I worked with in a parituclar ICU did not know until 1996, and here is how we found out:

     In 1996, a patient was legally drunk, and decided to climb a ladder to clean out his gutters.  Well, he fell and fractured multiple ribs. He was placed in the ICU for monitoring and high-dose meperidine PCA.  the settings and lockouts allowed the patient to utilize a 600mg meperidine PCA syringe every four hours. 12 hours into this gentlemans stay he became combative, delusional, and punched a nurse. Multiple doses of Ativan (for presumed early DTs) had no effect. It was decided by the physician to heavily sedate and intubate the patient to avoid further hypoventilation and pneumonia. Anesthesia was consulted for pain management. We (ICU physcian and staff) had caused this entire scenario in our treatment of the patients pain because we lacked the following knowledge:

Meperidine is a narcotic analgesic with a half-life of only 3 hours. This information would indicate that meperidine should be administed every 3 hours prn. However, meperidine has an active metabolite, normeperidine, with a half-life of 6 hours and has limited excretion by the kidneys. If meperidine is adminstered q 3 hours, there is an unavoidable buildup of the active metabolite leading to CNS irritation causing agitation and even seizures.

So, in the first scenario, q 4 hour prn meperidine is not adequate in the patient having ongoing pain (as opposed to treatment for breakthrough pain only). This is why the patient was on the call bell as soon as they could have medication...they had been in pain for almost an hour already, with their pain escalating as the meperidine levels in their blood continued to decrease. In the second scenario, this is a prime example of why meperidine is not a good medication for ongoing acute pain.  Meperidine is not as potent as morphine and carries the risk of toxic side effects in high doses and repetitive dosing.

These are a couple of caveats in managing pain that I learned along the way in my early nursing career. Both scenarios could have been handled differently, in that requests for alternative medication orders that would allow adequate dosing and appropriate intervals. Something else I have learned about pain management in the last few years, is that many physicians admit they aren't given much more of an indepth education on pain management--a complex and subjective experience for patients. 

We all need to take a proactive approach in broadening our understanding of pain and pain management. We owe it to ourselves and our patients.