Advice for dealing with addicts?

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    I'm in a detox clinic & this is my first nursing job & first experience in addictions. We have standing PRN orders for 25mg Vistaril Q6H PRN, Phenergen (must see vomit),75-150mg Trazodone for sleep or 50mg Benadryl for sleep. My clients want the vistaril like it's candy, and are lining up at the nurses station every 6 hrs (or less) to get it. It's rediculous, but it's that addicted mentality, I know. I'm trying to be as therapeutic as I can & try to tell them that they do not need another vistaril just because the 6 hours is up. Some walk away, but others are VERY adament. I had 4 argue with me last night because I would not give trazodone & vistaril or benadryl & vistaril at the same time at bed time. I tried to explain that trazodone also helps with anxiety & they don't need both or that benadryl & vistaril are both antihistamines and I cannot give that much at once. Now, my standing orders do not say anything about giving meds together, but my gut and nursing judgement tell me that's just too much. Also, they beg me for phenergen all the time, and I have two whom I'm sure are making themselves vomit to get it. One (heroin addict) was begging my for phenergen IM. I offered mylanta and that really ****** her off or phenergen suppository, but she said she had diarrhea & couldn't do that.
    So, can anyone give me some advice on handling these situations? I'm often the only nurse on & don't have anyone to back me up. I don't feel that handing out meds every time they ask is doing them any good. It gets exhausting when they are constantly knocking on my door and shouting out med orders while I am delivereing scheduled meds to others. (I ignore the shouts because that's just rude and I am no one's servant).
    These people are here to detox and learn coping skill (well, not everyone has good intentions), but I want to know that I'm doing right by not handing out a med when I don't think it's legitimately needed.
    Now, some of these people who are demanding Vistaril from me are already on Buspar or other antianxiety meds. How do you handle drug seekers?
    Sometimes I wish we didn't have Vistaril or Phenergen to offer.

    Also, a few weeks ago, we had a client who was soliciting others to get Vistarils for him cuz he wanted to snort them. What wold be the effects of snorting a vistaril? (this client was kicked out)
    BlueLightRN and RxOnly like this.
  2. 32 Comments so far...

  3. 7
    Girl, I could have written the same post. When I worked detox on the night shift, I was lucky enough to at least have another nurse to back me up.

    I never tolerated shouting or demands. My response was always "I have doctor's orders that I have to abide by. I apologize, but I can't stray from them for anyone." or "Excuse me, I haven't cursed at you and I'd appreciate the same courtesy. I am a professional and would like to be treated as such" or "I expect to be treated with the same respect that I give you"
    And then, I would DOCUMENT MY BUTT OFF. Every swear, every derrogatory word they'd say and what my polite but firm response was.

    Another thing I'd do is get clarification from the MD about what meds can be given together. I used to have patients scream at me for both Tylenol and Motrin together. The order didn't specify if they could be given together or not, so I had my nurse manager get it clarified since it seemed like every nurse did it differently. Same with benadryl and melatonin for sleep. It seemed like when I got in at 11pm there was a line at the nurse's station for benadryl. I had enough to worry about with new admissions and scheduled meds. Finally nurse manager and Doc decided that they could choose either one or the other with their 10pm PRN meds. After all, they are there to detox- not take alternative mood altering meds.

    One thing that SOMETIMES helped me was when I told the patients "We don't want you to suffer, but unfortunately detox isn't pain-free. We're trying to help you learn to live without these meds." ...if they persisted, I'd tell them "If you lay down and honestly try to sleep for 45 minutes, I'll give you a dose of (insert name of whatever PRN sleep med is ordered), but I really need you to try it first."

    PM me anytime... I could vent about working detox for days...
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    "We don't want you to suffer, but unfortunately detox isn't pain-free. We're trying to help you learn to live without these meds." That's good. I'll have to use that one.

    One of the clients told a crisis worker that she was going to have seizures cuz I wouldn't give her any vistaril & that she was supposed to have it 3 times a day to prevent seizures. Um, either she doesn't know the difference in neurontin (which she does and did get 3 times a day) & vistaril, or she was just trying to find any reason to get sympathy from someone. She & and I started off on the wrong foot because when I did her nursing assessment, she didn't meet the COWS. She argued & cussed me because I wouldn't start her on suboxone right away. I remained professional, tried to explain the purpose of the COWS and that I could not deviate from it & didn't treat her any differently, but we have 3 right now who are really manipulative & will look you straight in the eye and lie and are constantly seeking meds. It's really frustrating, especially when they get the others riled up & thinking they need more meds, too. Ugh.

    One of those three was stretched out on the couch in the day room when I was delivering scheduled meds to some others and when she saw me, she raised her hand up in the air and yelled, "Tylenol!" I completely ignored her. I don't treat anyone else that way & I'm not going to accept that type of treatment from anyone.
    blueheaven, sharpeimom, Orca, and 5 others like this.
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    When I worked addictions and clients were rude, I became conveniently deaf until they asked politely, or at least quit yelling and demanding whatever "right now!" I felt (sorry, the bold won't go off)that was a big part of the respect I required they give me and the psych aides on my shift. When they would ask for meds it wasn't time for yet, not ordered by the MD, or whatever, I'd tell them, over and over if necessary, that we could only give what their doctor had ordered. I documented very very thoroughly and in detail -- vile and vulgar language and my responses included. If necessary, I kept repeating the same thing over and over. Rely on the psych aides because they're a great source of patient info. I take Neurontin for simple and partial complex seizures along with Keppra and Neurontin was never intended to be a stand alone drug. The way my neuro orders it for most of his adult patients is to order 100 mg capsules with a range dosage instead of a set dosage. For example, I must take a total of 700 mg spread out through the day, but during summer, humid weather, when it thunderstorms, when I have a temp, etc., I may add up to 500 mg more. The patient claiming to be having seizure may actually have been having one. When I have a seizure, it's nearly invisible. I can talk, follow a conversation,and except for muscle contractions of vice grip strength, very few people know. If Neurontin alone was ordered for seizures, your patient might indeed be having a few.
    Last edit by Meriwhen on Jan 16, '13 : Reason: formatting (removing extra bolding)
    blueheaven, poppycat, and aknottedyarn like this.
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    Thanks, sharpiemom. Our doctor frequently orders neurontin for our detox clients while in our care to prevent seizures, ease pain, & help with mood stabilization. She has no hx of seizures, so I think she was just running her mouth. She has many of the characteristics of borderline personality disorder. Fun, fun.
    sharpeimom and BlueLightRN like this.
  7. 2
    I feel your pain. Addicts will wear you out - body and soul...
    BlueLightRN and krob0729 like this.
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    Quote from garnetgirl29
    Thanks, sharpiemom. Our doctor frequently orders neurontin for our detox clients while in our care to prevent seizures, ease pain, & help with mood stabilization. She has no hx of seizures, so I think she was just running her mouth. She has many of the characteristics of borderline personality disorder. Fun, fun.
    I don't know if it's a regional thing, but south of Boston the kids call them "Johnny's" or "Johnny Rottens" Neurontin is one of the most abused non-controlled substances around here. One night shift, I even heard a guy sharing a recipe for a "Southie Cocktail" which involved peeling open several Neurontin caps and pouring the powder into a can of Redbull. What the heck!? Neurontin will give you a buzz at a high enough dosage, and it will also increase the effects of opiates (by some chemical reaction in the brain that I can't quite recall).

    I used to call it Vitamin G (for Gabapentin) because the doc's prescribed it for EVERYTHING... I had guys say they were on it for seizures, mood disorders, anxiety, headaches, nerve pain, sleep, the list goes on.

    And about you ignoring the girl who raised her hand and yelled "Tylenol!" GOOD JOB! I know we're nurses and are supposed to take care of patients, but part of taking care of them is promoting independence and self care. So, if she can walk and talk there is no reason she can't sit up and say "Nurse, do you mind grabbing me some Tylenol?"

    I used to call our nurses' station the "fish bowl" because it was surrounded by plexi-glass windows. Patients used to knock and point at me, then make sign language about that they wanted (meds, a sandwich, whatever) ...I used to magically turn blind when that happened until they appeared at the nice wide doorway to the station where they had plenty of room to make their requests.
    silverbat, blueheaven, sharpeimom, and 2 others like this.
  9. 4
    Our jobs are tough for many reasons. We are nurses because we care and want to help. We run ourselves into the ground trying to take care of those who may not know how to take care of themselves or may not want to take care of themselves.
    I have to be tough sometimes. I have to be strict and sometimes I have to be the nurse I didn't like when I was sick (Nurse Diesel). It's all about what is best for our pts. I have to remember that. And if the pt doesn't like me because of it - it's ok.
    It's ok RxOnly. It's ok.
    BlueLightRN, weemsp, poppycat, and 1 other like this.
  10. 6
    I am so mentally drained somedays that I often wonder what in the heck i'm doing working a rehab hosp. Especially when you see your frequent flyers. It's like "why do I bother"? You know they are going to be back next month, then, I find myself not wanting to give them PRN's because I think if they actually went through detox the hard way, they might not want to put their bodies through that. Then here comes that one patient that you can see in their eyes and soul that they want to get clean. They won't even take the prescribed Norco for pain because they want off of all drugs. Then my hope is renewed. All I know is that being a Psych nurse is a whole different animal that what I'm used to.
    blueheaven, sharpeimom, BlueLightRN, and 3 others like this.
  11. 4
    Don't argue with them. Get a Doctor's order stating that these meds need to be given an hour apart, and clarifying which one should be given first. You could even make a valid argument for rearranging your standard protocols.

    About a month ago we were surveyed by Jhaco, and this was THEIR correction to our standard methodology. We changed our protocols to reflect that when two prn's are given for the same reason, the doctor's order MUST indicate which is to be given first. We already had the one hour apart thing going on but the surveyor was horrified that the nurse, and not the doctor, determined which med(s) to give for anxiety and/or sleep first.

    I tell my patients that this way, we can tell what works for them and what doesn't without overloading them on meds that may be working against each other, or producing horrible side effects. And when my rationale doesn't work, there's the doctor's order in black and white. I can't lose, and the addict's whining won't help either of us.
    blueheaven, sharpeimom, canoehead, and 1 other like this.


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