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- by al7139 Sep 23, '09Hi all,
I am just curious how you deal with drug seeking behavior as a nurse. I have a hard time with these people, because while I know they need help (like a rehab or psych hospital), their orders for meds sometimes contradict what I assess, and I feel like the MD's are not always helpful in these situations with setting limits.
For example I had a pt last night who was on a med surg unit at my hospital and was discharged, only to be found lying next to the elevators. So, she was readmitted to our unit. I had her last night, and she was constantly on the call bell asking when shecould have pain meds, and also asked at the start of shift to have her morphine changed to Demerol, and could I page the MD and ask. Well, the first red flag was that when asked her pain scale it was always 10/10 but she could get up and walk to the cafeteria or outside to smoke, despite my asking her to stay on the unit and ask for help when ambulating, then when informed the MD would not change her pain meds asked for morphine and ativan (by name) as I was giving her scheduled methadone. She was A&O, but stoned out of her gourd already, and I told her I can't give those meds at the same tme, and would come back and reevaluate her in an hour. She started in about how noone understands her pain and that she was fine, but yet she was constantly up and restless even after meds that would have put me in a coma. I realize everyones tolerance and pain is different, but her behavior was very manipulative and led me to believe she was drug seeking. She got very upset with me and asked to talk to the Charge Nurse who backed me on this (we suspected she was using illicit drugs in the hospital but could not prove it).
How do you all deal with these patients when you also have 4-5 other SICK patients who require your care and attention? They do not listen to reason, just watch the clock to get their next dose, and God forbid you are late giving their meds!
- Sep 23, '09 by Virgo_RNTo the addict who is hospitalized, you, the nurse, is a drug dispensing machine. They will use whatever currency they think will result in the payoff. Playing upon your sympathy or compassion, threatening your job security, whatever it takes. If I suspect that a patient is attempting to manipulate, the first thing I do is take my ego out of it. It is NOT about me. There are times when detachment is the most compassionate and therapeutic thing you can do. So, that is step 1. Detachment. I am neither sympathetic nor judgmental. Next, I turn it around and manipulate them. I'll say something like (very sweetly, acting as sympathetic as I can) "I believe that you are really hurting, but I can only give you X amount of drug every X hours. It's the rules, and I have to follow them. I'll do my very best to be in here at exactly X time for your next dose, but if I am a few minutes late, I want you to know it's not because I've forgotten you, I just have this little old lady/man down the hall who is really really sick. I'll do my best to be here by X time, but it might not be exactly that time.". Then, do my best to be there at X time with their drug. Whether the person has legitimate pain needs or is an addict, or both, which is common, they will be less likely to be on their call light if you show up like you promise, and if you act like you really believe them and like you care. The fact is, you're not going to "fix" an addict in the short period of time that you have with them. Maybe they do need rehab, but you are not going to make them make that decision. It is highly personal, and it has to come from them. The average length of stay and the amount of different caregivers a patient will have during that stay make it unlikely that you will develop the kind of therapeutic relationship that will inspire them to make changes. People become addicts for a wide variety of reasons, some start with real physical pain, and develop dependence and tolerance and addiction. Some start with emotional pain, and are trying to make those very real hurts go away. Some people have endured things that you have no idea about, things that leave scars that you can't see, but they are very real for that person. Nobody likes to feel like they are being manipulated or used, and it's easy to be annoyed with people that really aren't that physically ill compared to those patients that we can relate to more, but are nevertheless very demanding of our time, at the expense of those people we feel more sympathy for. It can be irritating. The key for me is to convey to the person that I believe they are in pain (whether physical or emotional is of no import), that I take their pain seriously, and to make sure that I put treating their pain on my priority list. If I have someone who I know is going to be on their light the second they can have their next dose, I write that time, the medication, and the dose on my worksheet as if it were a scheduled med, and I behave as if it is.
- Sep 23, '09 by Nurse1966I wonder, theoretically, if you had an addict for a pt, if you told them up front "this is what the dr. ordered. It may not get you high, but it will stave off the withdrawals", if that would have any impact. I know when my son relapsed and we were waiting for a bed in rehab, he rationed what remaining opiates he had, to hold off withdrawals, which he's terrified of. But then he wanted to get clean, not get high and that's probably the big difference between someone waiting a bed and drug seekers in the hospital. I don't know...just a thought.
- Sep 23, '09 by kanzi monkeyIf you are treating the patient in the context of pain management, then there's not a whole lot you can do, medically, for that patient. And there's not a whole lot the doctors can do either. For example, if the patient is an addict, but is hospitalized for a fracture, or surgery, you have to treat their pain, and their pain is whatever they say it is. If you feel like they're too snowed and are at risk of respiratory depression, that's your judgement, and you do not have to comply with their request (If someone said "kill me now" you would not do it). If they look comfortable, and are able to walk about the floor, and they say they are in 10/10 pain, you've got to do your best to address it (though I'd seek an order that the patient can NOT leave the floor, since they may OD on their own, but technically under your care).
You CAN make an impact on the psychosocial needs though, or at least you can try--which is the best anyone can do. Establish rapport or trust with the patient--that is, make a deal with your patient "I will do my best to bring you your PRNs without you having to watch the clock, but I need you to not go off the floor as I'm concerned about such and such." or "you wear your pboots/stop refusing lovenox as these can prevent life-threatening blood clots". Remind them that you are their to help them stay safe, that you have the knowledge and skills to do that, that it's your job, and it means something to you. If they break their agreement, call them out on it. It's ok to take it a little personally (in a calculated way--it's a little manipulative, but in a non-professional context when someone breaks an agreement with you, it hurts, right?)
If you feel comfortable probing a bit into their drug dependency, try in a very understanding way to get a little bit of their history with drugs (even if they are sticking to the "I don't have a problem, just chronic pain" line). What do they take at home? How long have they been taking it? Have they ever felt they had a problem with it, or been to rehab?
Then, use your resources. If there's an addictions service at your facility, do what you need to get them a consult. Relay all the information the patient has given you to the MD, to the addictions specialist, a social worker, etc. Also, a person who is addicted to opiates and has a high tolerance to pain meds who has an acute pain episode (surgery, etc) warrants a pain service consultation, to ensure you are actually covering this person's pain.
With all these resources, the patient has the best shot at getting appropriate hospital care, and a feasible discharge plan, where you won't be leaving the patient to go into narcotic (or benzo!) withdrawal on the streets.
- Sep 23, '09 by NurseLoveJoy88Pain is completly subjective. I agree kanzi monkey all the way. As long as they aren't sedated to the point that they can't breath, I would keep givin the pain meds as ordered. We just have to remove ourselves and treat the patient whether they are a drug seeker or not.
- Sep 23, '09 by anonymurseCIWA protocols provide ativan, whose metabolite of interest to the human body is indistinguishable from that of alcohol. IOW, you're detoxing alcoholics with the hair of the dog. And this is cool with me. I get pts on CIWA all the time. They're really there to get something else fixed. We're really just dealing with the alcoholism enough to make sure it doesn't get in the way of what they were admitted for--simple detox, and not rehab. If they come in alcholics or drug addicts or whatever, they're dc'd as such. I only get paid for being a nurse, and it takes all my attention. I don't have time to play moral reformer or amateur narc.
- Oct 24, '09 by CASTLEGATESQuote from Nurse1966I'd never say "It may not get you high"...just my thoughts. I'd focus on the number one fear; withdrawals, just like you did. Mentioning getting high in passing may offend (remember, the skin is crawling on them and they're terrified of w/d's).I wonder, theoretically, if you had an addict for a pt, if you told them up front "this is what the dr. ordered. It may not get you high, but it will stave off the withdrawals", if that would have any impact. I know when my son relapsed and we were waiting for a bed in rehab, he rationed what remaining opiates he had, to hold off withdrawals, which he's terrified of. But then he wanted to get clean, not get high and that's probably the big difference between someone waiting a bed and drug seekers in the hospital. I don't know...just a thought.
I usually ask how much they use or try to gauge based on what's been given and let them know "You've got x amount and based on your history, I think this will keep you from feeling crappy"
Place pain on top of that and you're going to have to advocate for a pain reduction dose which may mean lots more than most other patients get. If you used 30mg morphine daily (the equivalent) for 20 years, it's gonna take 40-50 to kill the pain. Monitor their resps and gauge it that way. That's what we do, though
Another thing is BUPRENORPHINE which is the miracle drug for opiate addiction. It brings them down while keeping them from being sick. Addicts are terrified of withdrawals and this works wonders BUT you need a doc willing to prescribe enough. You can get them clean in 3-5 days with maybe a sniffly nose but no shakes, no puking or runs.
- Oct 24, '09 by Nurse1966"Another thing is BUPRENORPHINE which is the miracle drug for opiate addiction. It brings them down while keeping them from being sick. Addicts are terrified of withdrawals and this works wonders BUT you need a doc willing to prescribe enough. You can get them clean in 3-5 days with maybe a sniffly nose but no shakes, no puking or runs.[/quote]"
Yes, buprenorphine (suboxone) is a miracle drug. I've only seen a couple pt's come into our ICU who were on it, but not many people knew what it was or anything about it. Just that it was a "home med". Unfortunately, addiction, recovery and pain management are more complex, and in most units (acute care) we just don't have time to focus on it. The only reason that I'm familiar with it is my son's on it. I'm quite certain that if it weren't for suboxone, he'd be on a far different road than he is now.
When dealing with drug seekers/addicts I try and treat them with respect, which is admittedly hard to do at times. I try to meet them where they're at and not to judge too harshly. Just my 2 cents.