Pain Control for Patient with Addiction Past

  1. 0
    First I would like to preface this by saying I am a new nurse, with 4 months on the floor experience only.

    Second, I have limited access to net these days, so I may not be able to respond frequently to any replies on here, but will greatly appreciate any and all posts

    Okay, so I work on a busy TCU, alst week new patient "Jane" comes in. Jane is a 40 something yr old, morbidly obese diabetic with many mental health dxs. She is admitted for recovery from a fall she had in which she fractured her left elbow, fractured two ribs on the left and bruised some on the right. By her own admission, she was on vicodin when she fell, for no apparent reason.

    Okay, so when I go to meet her, Jane is slurring her words and slumped over in bed- I go to double check her meds, and this is what I find

    Scheduled:

    zoloft, 150 mg
    ativan
    geoden
    neurtonin
    MS contin
    trazadone HS
    Ambien HS

    PRNS

    percocet, q6
    vicodin q6
    oxycodone q6
    Mobic q4
    Ultram 100 mg q4
    roxenphol q4

    (I don't remember all the doses off hand, but I know they were all at or near the highest allowable limit)



    Umm, what? I know breaks are painful, and pts who have abused drugs have a high tolerance, but holy crap..

    I did NOT feel safe giving this person this many drugs- she was injured due to a fall, are we trying to have that occur again???


    So I pass it along to the NP on call and she dc's several ( vicodin and roxenphol) and chages the perc and oxy to q8

    Now the patient is all over me, asking for pain meds EVERY HOUR ON THE HOUR, but also flat out refuses to try any other non-pharm methods, such as an ice pack or guided relaxation/imagery that our OT's offer.

    She is driving me NUTS but now I feel bad too- did I do the right thing? This pt seems to feel there should be NO pain, but that is also not reality- any insight would be much appreciated!

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  2. 3
    That is tricky. My last job was at a detox center. Sounds like she has built up tolerance. Also depending on what her psych dx are she may be just so used to taking a pill to fix everything. That is typical behavior. They take a pill for every single little thing. It becomes a coping mechanism and they seriously have no coping skills to deal with anything. I saw this a lot. It is hard when the patient actually does have a serious injury with valid complaints of pain. You might do well to see about consulting her psychiatrist and or a doc who specializes in addictions. The doc we had would often stop all the narcs and use Suboxone only. Then eventually taper the Suboxone once the injury heals. This kind of patient needs more therapy too. She needs to learn some coping mechanisms. I may be wrong but I would not be suprised if you find a dx of borderline personality disorder. This is typical for them. After you work with A LOT of people with this dx you can spot them pretty easily.
    Suboxone can only be prescribed by docs with a special license for it but I would check on that and on a consult--a psychiatrist who specializes in addictions and can prescribe suboxone would be ideal. Good luck to you.
    ohmeowzer RN, Anoetos, and Meriwhen like this.
  3. 0
    I don't have much insight here.. but I see this a lot as well. I think there is a fine line many docs are scared to cross between real pain and addiction 'cravings', for fear of being sued.

    I do not however, see the need for all those PRN's. Oxy AND perc's AND vic's amongst other narcotic drugs like ambien and long acting morphine..? Clearly this lady likes her chemicals and other interventions.. ie: opiod dependence counselling- may need to be explored.. in our place people on those types of drugs get an initial psych consult and go from there.
  4. 1
    it's impossible to give a real answer here regarding pain control for lack of information (i.e. pain scale, amount and frequency of meds given prior to your assessment, ect). for that reason i will look at the part of your post that deals with your perceptions and reaction.

    the fact that the patient has an addiction history is not all that relevant because the prn's are based on nursing assessment. whoever the doc was likely was just making sure that he gave the nurses on duty the tools they needed to control this woman's pain. if your suspicion was that the woman was being over medicated with prn's then common practice would be to talk with the administering nurse or nurses about her/his rational for giving the med. what i am saying here is that if the patient was indeed over medicated the problem was not that a prn was available but rather that it was given. it seems that all that was accomplished by the route that was taken was that staff following ended up with fewer tools to do their job.

    your actions and wording in this post suggest to me that this was an emotionally charged and ethically challenging experience for you. i believe that at the core of this issue was a concern for the safety of your patient, but i wonder if the feelings you are having now might be that at some level you suspect that your perception and reaction may have been clouded by the stigma and stereotype that addiction carries. the fact that you posted here suggests to me that you are caring around some moral residue, but i also think by looking for input from your peers you show maturity beyond your experience and a true passion to be the best nurse you can. keep asking questions it is the sign of a good nurse.

    tom t. rn, nrc
  5. 0
    A recent issue of Nursing2010 had an article on pain control for opiate addicts. I remember it suggested long-acting forms of Morphine and Oxycodone.
  6. 0
    old post but recent topic for myself. to the poster who mentioned that the OP may be carrying around 'moral residue' because she felt uneasy about the situation..is that really fair? clearly safety is an issue.
    i have seen both sides of the coin and sometimes the people bringing up the questions are automatically seen as negating real pain of an addict because 'its a disease'. nurses worth their salt know addiction is a real issue and in an of itself causes real pain. but it seems that the one bringing up the question is in a subtle way accused of being sanctimonious when really in plain english the nurse may be concerned for safety and his or her license.
  7. 0
    I had almost forgotten about this post, but cannot resist posts with big words such as sanctimonious. I will assume you mean it as obsolete rather than a pios hypocrite. Let me start by saying that I would not suggest either of a nurse who is fresh out of school. Likely her knowledge is current and stance is one of unknowing and openness. I fully agree that her initial reaction was based on her perception of patient safety. I don't doubt that the patient could have been over sedated. What I called into question was her rational for the action she took.

    Was the problem that the drugs were available, or that they were given?
    If it is that they were available then she took the right action (assuming that it was the NP who ordered the meds in the first place). If it is that they were given then she ought to have, as I mentioned earlier, sought the rational of the nurse for giving the meds she did. Being able to do this is a crucial part of a young nurse’s development (in my mind as important as being able to admit what they do not know).

    As for moral residue I mentioned that in direct response to "She is driving me NUTS but now I feel bad too- did I do the right thing". Of course moral residue has nothing to do with actual right and wrong, but rather our perception of how we act in relation ethical self perception. Only she knows if this was in fact the case. Maybe she'll post again. I love hearing other prospective on the profession. Oh and to that end thanks for the post.
    Tom T
  8. 2
    I too came accross this older post but thought it an important one to comment on. The beauty of nursing is the great variety of patients we come accross. The challenge to treat without judgement and bias is our duty, but we are human so emotion and morality always get into the mix. I have learned that when I have a client who may be acting out a "drug seeking behavior", I call for a psych consult. These patients will be time consuming, but with the right care plan and the same primary nurse at each admission some bad behaviors can be avoided.

    However, when the patient comes to you with their own mini pharmacy on-hand and say has a broken bone, these clients actually feel more pain. Their tolerance is low. their receptors not responsive like a non user, and they require higher doses to achieve pain control. At this point an Addictionologist/Pain consult should be ordering the pain meds.

    For those who are new to the profession: I myself find it hard not to want to judge. It is ok to think about what brought this person to this place in their life. The nurse is still a human. We still think and feel. we still have opinions. The patient may very well be a drug user or even a drug abuser, but if they are in pain then as a nurse we have to treat that pain.
    Ruas61 and NRSKarenRN like this.


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