How Can You Tell if a Pt. Is Addicted???

[Pretty in Ink]

I have been taking care of a pt. every weekend since she has been admitted. I would like to start off by saying I am a big pain advocate, however I believe that her pain needs to be reassessed. I do find pain management very therapeutic when used appropriately, and it is easier to prevent pain that relieve it. However, I believe my pt. is developing an addiction to her pain medication or we may be feeding a long-standing addiction. I noticed a certain "uncomfortable" feeling when speaking initially with her and her husband about pain management. Her husband became very quiet, did not keep eye contact w/ me and she was looking at him at times with a look like you better not say anything. I did not think too much of it at the time but did notice she wanted her pain meds around the clock, right on time, every time. I thought ok, no big deal, she has just had back surgery and she has a long list of past surgeries and DJD so she must be in pain. However something else peaked my suspicion which was that while getting report, the dayshift nurse told me she was speaking about pain medication w/ the pt. in-front of the pt's sister and that the sister had the most disgusted look on her face. So, with the husband's reaction plus the sister's reaction, there must be some history there we do not know about. Also, the pt. is constantly scratching herself. She states it's because she gets an allergic reaction to the pain medication and that Benadryl helps it, but I also know that scratching is a symptom to narcotic addiction. She also always seems to rate her pain at a constant 7 or 8 but objectively, she does not look to be in distress. I do not say anything because as nurses we are taught that a patient's pain is whatever they say it is, so I give her the medication but just feel like I am feeding into something but maybe that is what she needs to function. She gets Oxycontin 20mg qAM and 10mg qHS plus Soma q6 plus 2 tabs Norco 10 q4. And believe me...she watches the clock. So how can you tell?? Do you think any of the things I mentioned is enough to bring up to the Dr. and ask them to reassess her pain and perhaps prescribe her a lower dosage or possibly even dc one of her meds??? Thanks for your input...

[morte, LPN, LVN]

dependent DOES NOT EQUAL addicted!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

[cherrybreeze, ADN, RN]

dependent DOES NOT EQUAL addicted!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Can't say this enough!

Anyone on chronic pain meds becomes physically dependent, that's part and parcel with chronic opioid therapy. That doesn't equate being "addicted." I know the OP is old, but anyone interested in the topic should read up on "pseudoaddiction"....people with chronic pain and a true need for meds will begin to exhibit classic "seeking" behaviors due to being undermedicated and dealing with pain long term. It's a fascinating phenomenon, and a true problem, and when it occurs it causes MORE trouble for the person in chronic pain, as it heaps more *judgement* in their direction.

[crissrn27, RN]

I have had one patient leave our care b/c the DON at the time had labeled him an "addict" when in reality he was a long term chronic pain patient who knew what worked for him. He wanted name brand ER oxy and his IR oxy needed to be a certain brand to work for him, and he had to take it q 6 (under treated much?), anyway the DON refused to get an override to get the name brand, simply on principle, and the poor man was in so much pain, and probably withdraw at this point, he finally just left AMA. Which is what I would have done, personally. We weren't allowing him to have any control and we weren't listening to him when he told us what worked for him.

[tewdles, RN]

There are thousands of very sad stories about people with chronic pain who are under treated...

The fear of addiction and trouble with authorities gets in the way of too many professionals (MDs and nurses) when in comes to providing adequate pain control for some people. Some of these professionals are simply poorly informed and judgmental. I saw this in home health and I see it in hospice.

I am not sure how to completely describe it, but it is as if the concerns, complaints, and comfort of the patient become silent to the professionals while they hear only the roar of their own fear.

I remember one case in HH where the elderly woman would literally weep in pain during my visits...each time I would phone the physician...each time he would refuse to adjust anything. Sometimes she was unable to get out of bed because of the pain. She was on MSContin and Morphine IR...the doc was CERTAIN that the doses were adequate, yet they had not been changed in months. In my professional opinion, they were not excessive and were clearly inadequate doses of opioid.

The office nurse came right out and said that this poor woman was an addict and that I shouldn't worry about it. I guess that told me how the physician felt... How sad! There was not even an educated acknowledgment of development of tolerance...they simply dismissed this woman's suffering.

So I visited this woman twice a week...and the physician completely ignored my professional assessment and recommendations. He saw her every 2 months for 15 minutes and clearly cared more about his fear than he did about his patient's well being and comfort.

I had to leave HH in large part because of this phenomenon...too sad and stressful for this patient advocate.

[BabyLady, BSN, RN]

Be careful of reading too much into "looks" and the nurse that discussed a patient's medication in front of the patient's sister without first getting permission from the patient committed a HIPAA violation.

Addiction to pain medications from true, bona fide pain, is rare and makes up less than 5% of all addiction cases.

I would be watching the clock too if I was in pain...pain on a schedule manages pain much better than PRN administration.

It is very common for people that are NOT used to certain types of opiates to itch as well...keep that in mind, especially at higher doses...because that is what it does to me.

Research has shown that pain is undertreated in healthcare facilities and yes, pain is what the patient says it is.

Your job is to report objectively to the physician your concerns, but you MUST leave out judgemental comments such as "she had a disgusted look on her face" and similar comments.

If you cannot report and treat objectively then I would probably advise to ask for another assignment...it is not your job to diagnose an addict...objectively report your findings to the physician and that is as far as your job goes.

[iwanna]

There is a major difference between addiction and dependence. I am "dependent" on tramadol. I have been on it for over twelve years. I still take it as prescribed and do not abuse it. However, if I do not have it then I will have withdrawal symptoms.e.g. cold symptoms, pain, and restlessness. This is true of SSRIs as well, so dependency does not mean addiction.

It is not up to the nurse to decide if the pt. has an addiction problem, or is med seeking. I would get furious when I heard other nurses complain of pts. drug seeking, and they did not give med. And, if the pt. is an addict, that is something they will have to deal with when they are ready. An addict is not going to get help unless they are ready.

So, it is not up to the nurse to worry about giving the pts. prescribed med pains at the right time. Have pt. verbally rate the pain, 30-60 min later, ask to rate pain again, then document.

[PMHNP10]

dependent DOES NOT EQUAL addicted!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

it's interesting because the DSM IV-TR defines addiction as substance dependence; there is no separation, but many folks who study addictions medicine do not like using the term addiction or addict; however, IMO, the problem with the DSM is that an individual who takes their vicodin exactly as ordered could possibly meet diagnostic criteria for dependence if they display a tolerance, withdrawal symptoms, and repeated failure to cut down, but you would certainly not want to label that person an addict

IMO, a person crosses the line when they go to great lengths to use and use in spite of consequences (e.g., physical, psychological, occupational, social, etc)

[iwanna]

I was trying to copy and paste a page, but it was not allowed because there were too many images. Anyways, you can google this

What's in a Word? Addiction Versus Dependence in DSM-V.

This was a very good article on dependence vs addiction. There is a big difference! Please read.

[PMHNP10]

absolutely there's a difference; but the DSM IV doesn't highlight it; hopefully the DSM V will; the scenario I presented is clearly dependence based on hitting the minimum of 3 criteria, but in the current thinking by some, dependence=addiction, I suppose because the current DSM doesn't identify the difference, but like the article and I mentioned, for there to be an addiction, use in spite of consequences, etc. must be present

[franciscangypsy]

Thanks so much for this thread & everyone sharing this knowledge! I have a very hard time with this issue; I think everyone's input helped a lot!

My understanding and views have been greatly adjusted!