"I'm NOT going to support his habit...." LONG

  1. I've had two patients who are well-known drug addicts (UA's done and they tested positive for every drug on the panel) who had large abscesses drained from their arms. Abscesses were due to IV drug use. Both patients required QID wet to dry dressing changes. I've done QID changes on 'non-addicts' and always in the orders I've had PRN morphine to give prior to the change. But not with the addicts. Both addicts only had 1 PRN 7.5 mg Lortab ordered q 3-4 hours for pain. Now, I'm really new to nursing (I've only been one since September), so maybe I am not fully understanding what's happening. But I do know those wet to dry changes are PAINFUL, even with the morphine. It seems to me that it's downright cruel to expect a heroin addict to deal with these dressing changes with only one lortab q 3-4 hours. Am I wrong? I suppose the rationale could be that it's impossible to give them enough morphine to ease the pain without killing them with an overdose. But when I talked to my nurse manager about the latest patient, she said that she would not, under any circumstances, support his drug habit by ordering morphine for dressing changes. The physician feels the same way. I guess I need some validation that I'm not wrong, or at least some advice on how to emotionally deal with these dressing changes. I'm really distressed by the pleas I get from them for something to help with the pain, and me being powerless to do anything other than pre-medicate with one lortab. Any words of wisdom? Thanks!
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  2. 41 Comments

  3. by   partyof5
    ya know, I have a problem with this too. Just because someone is an addict does not mean they are not in pain. They have every right to pain relief just like the next person, if it is necassary. And of course they will need more than the average because they are an addict. They deserve the same treatment the next person would get in the same situation. Sometimes people forget that addiction is a disease. A nurse would not withhold treatment from a diabetic that could be under control if they lost weight would they? no they would not. Also, a nurse should not let thier personal beliefs stop them from treating just because thier beliefs do not match the beliefs of the patient. just my thought on it.
  4. by   tencat
    Thanks for the response! My coworkers are fabulous and supportive, but this is a 'taboo' subject for us all, so it's hard to discuss at work.

    Are there other medications like Torridol (sp?) that could be used instead of morphine? Maybe if I had some other medication ideas to put on the table the physician and manager would be more willing to think about the idea.....
  5. by   Jolie
    You have a legal obligation to question and refuse to carry out inappropriate medical orders. To do a painful dressing change without sufficient pain medication is indeed an inappropriate order. Let your charge nurse know that you will NOT participate in carrying out this order. She can address it to the physician and/or do it herself.
  6. by   UKRNinUSA
    I know where your coming from. Its tough. But these addicts are dealing with the adverse consequences of their addiction - the abcesses, poor pain control. If you remove these adverse consequences, they have no incentive to stop using therefore they are enabled to keep using and so the cycle of addiction continues.
    However, having said that, as an RN with substantial wound care expertise/education, I can tell you that QID wet-to-dry dressings are NOT appropriate and may even be considered by some to be positively pre-historic - they actually delay wound healing. Significant advances have been made in wound care in the last few decades. Contact a wound care specialist or ET nurse for a more appropriate dressing and then spend some time pondering the law of Karma. Good luck and remember that these patients are expert manipulators -keep it in mind whenever you have to deal with them.
  7. by   tencat
    Any ideas on alternatives to opioid meds?

    Quote from Jolie
    You have a legal obligation to question and refuse to carry out inappropriate medical orders. To do a painful dressing change without sufficient pain medication is indeed an inappropriate order. Let your charge nurse know that you will NOT participate in carrying out this order. She can address it to the physician and/or do it herself.
    Easier said than done. I really like my workplace, and to go against the surgeon would mean a loss of my job and an 80 mile commute one way to work at another hospital. Most of the charge nurses also agree with him....

    Yes, I know that they've brought it on themselves, and yes I know they manipulate. It's just that I know I haven't done everything that is possible to at least reduce the pain, and I don't see it as my 'duty' or 'calling' or whatever to meet out 'justice' to these guys by not doing everything possible to at least attempt to address it. It's real pain. There's no faking when someone is poking around in your gaping open wound with peroxide. What kind of Karma do I bring on myself by inflicting unnecessary excessive pain on another?

    I did think that wet-to-dry changes 4 times daily was not best practice. It is usually a temporary measure for us until a wound vac is secured, but it still lasts a few days. The wound vac changes are also painful.
  8. by   TazziRN
    Even addicts deserve pain relief. Not sure about how you should handle this, though, if refusing to carry out the dressing changes as ordered would jeopardize your job.

    However........you say you really like it there. Do you think you'll feel the same way 6 months from now if this is how all addicts with pain are treated? Would you be able to look at yourself in the mirror?
  9. by   Antikigirl
    I have come up with problems like this before, some dealing with addicts...some dealing with folks with mental probelms/brain injury/ or odd reactions and can't take narcotic pain medications.

    What I have done is talk to the MD about other alternatives to this. You sugested Toridol...that is going in the right direction to me, or at least worth sugesting. How about ice or heat before dressing changes (per MD)? A PCA but set very structured and limited? A local? Just anything!

    You can't refused to give good pain management to patients (not you, but your MD) anymore. It is considered unethical and is just plain out wrong! Pain is now considered a vital sign and must be addressed and treated. If a plan, like the one lortab, doesn't work...other methods must be tried till pain management is achieved.
  10. by   MultipurposeRN
    Well, you could say most patients w/ obesity, diabetes, heart disease, etc who have lived an unhealthy lifestyle and diet have brought their problems on themselves, but they are still entitled to the best care that is available out there. No less should a drug abuser get the appropriate care for their injury. Not to mention that it's possible the physician, staff, and hospital could be found liable if one of these patients were to sue and it was proved that they were deliberately undermedicated. There have been lawsuits over patients having inadequate pain control.
  11. by   topkat
    I went to a seminar on acute pain mgmt. It had some good ideas for guidelines on treating chemically dependent patients. Here is an excerpt:

    " Pain Mgmt Guidelines

    Periods of acute illness often represent opportunities for meaningful intervention in addictive disease

    Aggressively encourage entry into addictions treatment

    But, addiction treatment is not the priority during the period in which the patient is experiencing acute pain"

    As nurses, we have a responsibility to assure our patients receive adequate pain relief. Treating acute pain doesn't equate to feeding in to their addictive habits.


    remember the pledge:

    With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care.

    best wishes to all those that care for these patients...they can be very manipulative and demanding...remember they often develop drug/alcohol addicitions because they have poor coping mechanisms to begin with...disease only exacerbates the issues....

    topkat
  12. by   Pompom
    Perhaps a pain clinic consult would be in order. Other than than premedicate with the medication ordered, chart that you notified the physician and nurse manager that patients states c/o inadequate pain management.
  13. by   augigi
    I agree and was going to suggest a consult with pain management department. That takes it out of your hands. It's great that you're questioning this.
  14. by   UKRNinUSA
    Quote from tencat
    There's no faking when someone is poking around in your gaping open wound with peroxide. What kind of Karma do I bring on myself by inflicting unnecessary excessive pain on another?
    I did think that wet-to-dry changes 4 times daily was not best practice. It is usually a temporary measure for us until a wound vac is secured, but it still lasts a few days. The wound vac changes are also painful.
    Peroxide -another big no-no -it can cause air-embolism - I think it could become a legal issue if it actually happened especially since evidence based clinical practice guidelines (i.e. standard practice) are being violated; it also delays wound healing, it also hurts like hell. Normal saline is your best option. Dressings that optimize wound healing can actually reduce the pain. Maybe your wound vac rep can gather together some literature that can persuade the doc to change his practice -there is a mountain of research out there. You could also check out the wound care forum.
    I did not mean to be glib about the Karma thing, its just that pondering philosophy has always helped me to see the bigger picture. I have suffered from abscesses myself and I know how painful they can be. I had a disagreement recently with one of our docs because I did not think he was addressing the patient's pain sufficiently as he was I&D-ing an abscess for the second time in 2 days. Eventually after IV morphine had no effect he agreed to do a nerve block and the patient managed to get thru the procedure -but just get thru it -she still had pain. Anyway I was glad to have been able to help out the patient but was still mad at the doc and muttered under my breath "I hope you get an abscess, so you can see how painful it is." Five minutes later he mislanded on a step and broke his foot. Coincidence? Karma? Who knows, but it was pretty freaky.
    BTW, I wouldn't let your doc within a 100ft radius of an abscess of mine.

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