Advice for dealing with addicts?

[garnetgirl29]

I'm in a detox clinic & this is my first nursing job & first experience in addictions. We have standing PRN orders for 25 mg Vistaril Q6H PRN, Phenergan (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 ridiculous, 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 adamant. I had 4 argue with me last night because I would not give trazodone & vistaril or benadryl & vistaril at the same time at bedtime. 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 phenergan 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 phenergan IM. I offered mylanta and that really ****** her off or phenergan 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 delivering 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 anti anxiety meds. How do you handle drug seekers?

Sometimes I wish we didn't have Vistaril or Phenergan 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)

[stephanie.]

People with addictions don't think the way a "normal" person does. Sadly, until they want help they won't change. And even the sober ones struggle to stay sober. It's not cut and dry. I'm thankful I've never been addicted to anything harmful however we all have some type of addiction. It's not our place to judge how or why a patient is where they are in life. It's our job to give them the best care possible to get them through today, even if its fruitless.

[Dhalia27]

all those meds you mentioned... vistaril, phenergen, benadryl, are at the bottom of the list of what an addict would ever abuse. especially if the addict is in rehab... i'm assusming they are there for REAL drugs of abuse, not antihistamines. why do you care if the are asking for vistaril every 6 hours? it's your freaking duty to dole it out as the doctor ordered. also, YOU have CLEARLY never suffered from withdrawal. why not make withdrawal as comfortable as possible? these patients are trying to allay their anguish, not get "high", while you sit there.... even if you gave these patients all of the mentioned drugs at once they would STILL be in pain. yet you have the attitude of "how dare they want to feel better? don't they understand they must suffer to understand what they have put themselves through? don't they get the puritan ethic of no pain no gain?" wow. simply. wow.

[Elle23]

I guess I am not understanding why you feel the need to withhold medications that are legitimately ordered for these patients to take as needed during the period of detox.

I understand that dealing with addicts can be frustrating, but if Vistaril is ordered Q6 hours prn, I don't understand why you are giving them a hard time for taking them as they are prescribed.

[Topaz7]

First of all, phenergan can and is abused. I've taken it, it can and with a lot of people myself included give you a high, not to mention knock you out cold. Out of the list of meds the OP mentioned the only one I would even be concerned about evaluating real need versus med seeking with IS the phenergan. Vistaril, Benadryl, antihistamines I don't really care. If my patient wants an antihistamine ill usually give it. It's not like its Valium. I usually don't withhold phenergan unless the patient is requesting it for nausea they have rated at a 1, I will try mylanta first or ginger ale, or if they just ate 2 sandwiches. My theory is if you have been out there snacking and eating you can't be about to vomit. With the trazodone- I give it unless they are sleeping. If I have to wake you up to take meds there's no need for a sleeping pill. If you find you can't sleep later third shift can give it.

[Orca, ADN, ASN, RN]

Neurontin is one of the most abused non-controlled substances around here

I work in a prison setting, and we have pretty much stopped prescribing Neurontin at my facility. We had such a serious trafficking problem that even crushing didn't stop it. We found out that inmates were pretending to swallow it, spitting it out in a cup of water and handing the cup to whoever they agreed to sell/trade it to (it's amazing what lengths inmates will go to, and what they will endure, to get the pills they want). We have pretty much restricted Neurontin orders to inmates who are HIV positive and cannot tolerate other seizure meds.

We had similar issues with Seroquel, and we took it off our formulary. Our first hint of a problem was when we started getting mental health service requests from inmates stating that they needed Seroquel without even bothering to identify why they believed that they needed it.

[CASTLEGATES]

I give everything and anything TOGETHER for these people who are in the throes of withdrawals. It's only for a few days, 'till their system clears. None of those meds mentioned are addictive, or they would be scheduled meds. It's amazing the stuff people can write and not be questioned. Phenergan is not addictive! Hydroxyzine isn't, either! Please look it up and recheck abuse statistics. Better yet, study and take the CARN exam! Make it your business to UNDERSTAND addiction, not treat it as a moral deficiency.

I slam them with everything my judgement allows, because after all, they're not my own personal supply of meds (so why act like it)? Why be so stingy with them? We recently had a nurse FIRED for not doling out meds as ordered and requested. It's not my job to try to talk them out of their PRN's. Addictions nursing is a field for the very few who truly understand the disease of addiction. Others should move to straight psych wards. Many get into hot water for not giving meds as prescribed and requested (that's a dangerous game with your license being played). Our nurse who was fired did not give the meds the patients were requesting that the providers were ordering! If they say they're sick, then they're sick. The old saying that addicts are bad goes against the very fact that addiction is a diagnosis, not a moral deficiency (so don't treat them by controlling them; work with them)!

Imagine throwing someone in jail (who has diabetes) for eating a cookie because they had a craving for one! It's just that simple and these meds are there to reduce cravings, help them sleep or feel more relaxed so they can cope. It's a horrible disease and you want to keep them there so they don't leave AMA and potentially die (relapse is a dangerous time when they may, or may not make it back). The reason they don't add other diagnoses for ANYONE in the throes of withdrawals are because withdrawals can mimic schizophrenia, panic disorders, phobias, bipolar, and explosive disorder. We, as med nurses can't expect to "fix" them by controlling what they take in the moments we interact with them. Why not give Trazodone and a little this and that? Why not give a couple, or a few meds at a time? I throw meds at these guys 'till the cows come mooing home and they appreciate my efforts to helping them feel comfortable. Upon admission, I go through their list of meds with them, discuss what effects each of them have, then we decide on what's most likely to snow them (if they're opiate addicts and it's night time). If an ETOH addict is uncomfortable, I throw benzo's at them to stay ahead of the game, so I'm not chasing withdrawals (I'm more careful with the ETOH and benzo's, though but I always stay ahead).

The nurse who was fired was investigated by the board and found guilty of playing this dangerous medication withholding game. If it's ordered and the patient requests it and the patient says they're having symptoms (the kind we cannot see), then that's a legal basis for a complaint and a case. Anxiety isn't fun, neither is addiction or withdrawal. If I were uncomfortable, I'd play whatever games I had to, in order to gain some relief! It may turn into a game of getting through the med nurse-barrier between me and the meds my prescriber ordered. If I'm comfortable, then I'm more likely to be precontemplatiive about addiction versus sobriety. That's where I need them to be.

[Topaz7]

Disagree ... I've taken phenergan and it made me feel like I was on Vicodin for a couple hours before it knocked me out. It's not a scheduled med but its naive of you to think people don't abuse phenergan lol. I recently cared for a patient who admitted to being addicted to and abusing neurontin.

[TriciaJ, RN]

Seems to me the OP is trying to develop the judgement needed to support people in their efforts to get well and not support them when they manipulate to stay sick. It is a very fine tightrope and I think some facilities put way too much onus on the nurse. In a place rife with manipulative behaviours, it is really essential to have very clear MD orders and unambiguous unit policies. Most nurses don't withhold meds for the fun of withholding them; we are trying not to add to the problems people already have. Maybe addictions should be covered more thoroughly in nursing school so we have a better idea how to genuinely help people and not feel like we're sinking or swimming.

[CASTLEGATES]

I agree. If she felt it right to withhold, then that's her professional judgement at the time. Education is another thing; judgement from knowledge-base, where the RN was at the time, with the tools she had at her disposal, is the key (and the quality the hospital expects via training). It's not her fault...I like it when they put the onus on us (personally); it forces me to make it my business to learn my specialty. After all, patients come to hospitals 'cause they need nurses (not MD's). This is our time--things are changing. Not so long ago, there were no specialty certs. Mark my words, APRN's will be doing surgery within the next 20 years or so. Remember when Doctorate's were PhD's, now they're practice DNP's? We're moving into the fast lane, so buckle up! I worked in an ICU that leaned heavily on RN's...We did all Hosp codes w or w/o MD's; tons of things other hospitals (I later learn) wouldn't fathom leaving up to RN's. I do understand places can vary, just like experience.

Acute withdrawals {which I was assuming they were in--(again assuming also they were in a hospital type setting)} for me, isn't the time to wean. I try to keep 'em there, keep em comfy, so once they're out of acute withdrawal, we can deal with the PAWS and really "talk." It's not easy understanding addiction, what makes a difference (a real difference), and what's just a treatment nuisance. It's hard not buying into the "bad addict" thinking. I stick to acts that will make the difference, allowing meds they want because after all, it is THEY who need to make the decision. I can't force 'em (it will never work, anyway). My one or two petty things won't "fix" an addict. It's deep within, where they change. I try to connect with that part, soon as I can. I love the manipulative one's (especially when I'm suckered) Every once in a while they get me & I've got a big S on my forehead keeps it fun & interesting!

I can't understand how phenothiazines could be (physically) addictive...I wouldn't know those withdrawal symptoms (or treatment thereof), if I was hit in the face with 'em:specs: Anything, including ibuprophen is psychologically addictive, however.

[NC29mom, ASN, LPN, RN]

Disagree ... I've taken phenergan and it made me feel like I was on Vicodin for a couple hours before it knocked me out. It's not a scheduled med but its naive of you to think people don't abuse phenergan lol. I recently cared for a patient who admitted to being addicted to and abusing neurontin.

Theres a DIFFERENCE between ABUSE and ADDICTION.. ..

People dont go through physical withdrawals from not having phenergan. ...nor do people" drug seek" phenergan. (that ive ever heard...)

[Topaz7]

There's psychological addiction then there's physical, I never said a person would need to detox from phenergan, but that doesn't mean it can't be abused or psychologically addictive, and yes our docs have said it can be that's why they order us to withhold phenergan after the person has had and is REQUESTING IM phenergan around the clock.

[Meriwhen, ASN, BSN, MSN, RN]

Theres a DIFFERENCE between ABUSE and ADDICTION.. ..

People dont go through physical withdrawals from not having phenergan. ...nor do people" drug seek" phenergan. (that ive ever heard...)

Actually, some patients do seek Phenergan as it can get them buzzed. I've had MDs cut off patients who were overusing Phenergan. Other docs won't even prescribe it and will use Zofran instead.