Drug seekers

Pangea Reunited, ASN, RN · Oct 10, 2015

They make me sad, more than anything. I've seen doses of dilaudid as high as 5mg IV Q3 hours.

The bright side is that they're at the hospital instead of our robbing and killing people to get money for narcotics. I do wish that people had more assistance getting "off" these types of drugs before being discharged, but there's not much hope unless you counsel and help them pretty early in the game. It seems like they start out with legitimate problems 99% of the time.

ERGirl83 · Oct 10, 2015

In an ED with lots of frequently visiting friends, I see my share of patients who are clearly not in the department for actual medical emergencies, but for an acute narcotic deficiency. And the nursing theorists can pretty much shove their "pain is whatever the patient says it is," hoity toity crap. When a patient's DOPL is longer than the last book they read, with twice as many authors (prescribers), and they've been in my ED more often than I have in a given month, it isn't hard to put two and two together.

It used to bother me too, and not just in an altruistic sense, either. The waste of resources, use of a bed, staff time, it really got to me. I used to be furious with the docs for pandering to their demands. But, now, I figure that the longer I drag my feet and cajole the doc into ordering Toradol or Nubain instead, the longer this song and dance goes on. Not to mention the more work for me. Now, I look at Dilaudid like my diamond, a girl's best friend. Because I can give it, they shut up, and after a thirty minute narc watch, they are out of my hair, off that bed and not continuing to waste any more of my resources.

One visit with me was never going to solve their problem anyway, no matter how many community resource sheets I hand out or crisis Evals I recommend. Might as well treat 'em, street 'em and move on to someone who actually needs the help.

That's not to say I won't stand up and hold my ground when the doc holds his, or helpfully inform a busy doc that this is a patient's fourth visit this week, and the last doc clearly put a no further narcs order in his/her chart, but I no longer fight a losing battle, or waste any more of my time worrying about my contribution to their addiction. I didn't prescribe it, and as long as they are clinically stable I have no reason to argue about the order. If I don't give it another nurse, either in this facility or any of the other ones nearby will. The sad truth is, you can't win 'em all.

Now, that being said, if someone truly wants help, I'm happy to oblige. And I do all of this with my best nurse face and impeccable customer service. There are no throw away people and everyone gets the same courteous care from me, regardless of what I really think of their motives or life choices, lest you believe I'm one of those...

allnurses Guide · Oct 10, 2015

I mistyped, I meant to type "drug-seeking." So, a person who is sitting in bed, on the phone, laughing, BP is great, HR is great, snacking on chips is truly experiencing 10/10 pain. Doesn't add up to me I guess. This particular patient has a history, based on his physician notes, of "numerable admissions complaining of vague pain, then becoming angry demanding IV Dilaudid." He is a non-compliant in his medication regime for diabetes, does not take his HIV meds, etc. This admission was for chest pain. All markers were negative, etc. Not only was he getting Dilaudid, he was getting Percocet along with it. Administered together.

I spent 6 years of my nursing career working with addicts and alcoholics so I what you are saying here. However it is not your place to decide if the patient has a substance abuse problem and take it upon your self to hold their medication. A person who has long term chronic pain does not present in the same manner clinically as does the person in acute pain. Often their vital signs are normal as is their appetite. Unless they are in the hospital for a detox protocol you can put them into very real physical danger by holding their medication. I have seen people have seizures among other things. If this patient has Diabetes he could have neuropathic pain. Trust me I have three auto-Immune diseases all in remission but I know what it feels like to be in constant unremitting pain. I always got up, went to work took care what I had to take care of all with a smile. I would have been highly insulted if someone tried to tell me I wasn't in pain.

When I work with patients who appear to be med seeking I really look at their medical history then I might try to chat with them when they are comfortable about alternate modes of pain relief, but it is not my place to decide if they need that medication or not. If in fact they are addicted they do in fact need the medication.

hppy

angeloublue22, BSN, RN · Oct 10, 2015

I had the same thinking you did many times and it created a war in my mind. I wanted to prevent addiction especially since that is my specialty but when I went from LPN to RN and had my clinicals in Medsurg, I worked with a patient who was on dilaudid every 3 hours and demanded it every 2 hours. This patient had been there for 2 weeks and was going home the next day. Same thing, said he was 10/10 on pain but would show no signs. My preceptor gave me some good advice after I brought up some concerns. She said, "You can't cure them of their drug seeking ways and we are not here to prevent addiction. If they get addicted or are addicted there are places to help them, our only concern is giving the medication that is prescribed and making sure he doesn't get too lethargic from it." She also would write the time on the his board when he could have his next pain med so he didn't keep asking. She also said you don't want to chart that the patient reports a 10/10 and do nothing for it. That actually made me feel a little less "dirty" as you call it. I hope that helps.

michlynn, BSN, RN · Oct 10, 2015

Like other posters have mentioned, you're not going to fix this patient during your 12 hour shift. If this person is actually a "drug seeker" then they are going to need more long term treatment and that isn't going to be up to you either. Yes, it is annoying when those "frequent flyers" come in and docs continually give into them but there's really not much you can do about it unless the pt is unstable. It used to make me upset too but now I just look at it like any other scheduled med. If they're due for it and they are clinically stable then I'm just going to give it without argument. I do enjoy the option of the functional pain scale though, so if you're chatting on your phone, laughing, eating and joking with me but then say your pain is a 10.... I don't think so... your functional pain scale says you're a 2.

Whispera, MSN, RN · Oct 10, 2015

I need to remind people that while a person may function, he may have adapted to his pain and functions because he has to function. I have intense pain all the time, but you wouldn't know it to see me. Our patients can be like me in their responses to pain...

dream'n, BSN, RN · Oct 10, 2015

It's not the giving of the medication that bothers me, it's the whole dramatic package they present. If one type of pain doesn't get them Dilaudid, then they start having 'issues' in another body part. Which is investigated again and buys them more time. After that problem is 'solved' they come up with something else. And another round of testing begins. That's what drives me batty.

calivianya, BSN, RN · Oct 10, 2015

It's not the giving of the medication that bothers me it's the whole dramatic package they present. If one type of pain doesn't get them Dilaudid, then they start having 'issues' in another body part. Which is investigated again and buys them more time. After that problem is 'solved' they come up with something else. And another round of testing begins. That's what drives me batty.[/quote']
I agree, it's the waste of resources that gets on my nerves. I would be cooler with someone coming in and saying, "Hey, I'm an addict, I need my Dilaudid so I don't go into withdrawal," than I am with someone complaining of "chest pain." And "belly pain." And "back pain." Or whatever the complaint du jour is.
You know these people aren't paying their hospital bills. So, that multi-thousand dollar abdominal CT? Yep, we're eating that. And, in the long run, what does the hospital paying out millions in unreimbursed tests due to their budget? Where do they make the cuts to still come out positive? Oh yeah, it's usually the nurse staffing budget that's hit first when the hospital needs to free up some extra change.
That being said, I never withhold narcs and I give them as soon as the patient can have them. The patients are with me to have their acute, life threatening problems treated, not their chronic ones. The patients' addictions are not my problem. I am not addressing that.

poppycat, ADN, BSN · Oct 10, 2015

I agree with hppygr8ful. I have rheumatoid arthritis & am in pain 24/7. I can't stop living my life just because I have pain so I've adapted to be able to continue functioning in spite of the pain. To look at me, you would not guess that my pain level is usually 7-8/10. A lot of the things people point to as signs that the patient is not in pain (talking on the phone, texting, etc.) are ways I've found to distract myself from thinking about my pain.

You cannot possibly know from looking at a person whether he/she is in pain. You have to take their word for it. As others have said, if the person is addicted, you're not going to change that fact while they're in the hospital. The decision to change has to come from them.

canigraduate · Oct 10, 2015

It sounds like you have issues with addicts. You may not be aware of it, but your post is judgmental in tone.

I'm sorry you feel "dirty" for helping them. It's because of your own biases, not because of their behavior.

This patient just wants Dilaudid. Other people have told you that it's just to get high. 1 mg of dilaudid doesn't do anything to get people high. It may, however, blunt some of the severe pain of withdrawal from another drug.

One of the reasons why patients lie to emergency personnel is because of the attitudes that people like you have. Patients know they will be completely disregarded and treated with contempt if they tell the truth, so they lie to get what they need.

If I wanted to get high, it would be much easier to do it on the street than in the ER. There's a guy who hangs out on the corner a block from the hospital who could get me anything I could ever want, and would be happy to take my money. That's a far cry from having to wait to be seen in the ED, with people looking at me like I am lower than sewer dirt. The only reason to put yourself through that gauntlet is because (a) you have fallen so far that you don't care about being judged anymore, you just need some kind of fix, (b) you have withdrawal symptoms and you are too ashamed to tell the people in the ED the truth, © you are in constant pain and can't take your current level of pain anymore, or (d) you're hoping that this time the people in the ED will actually help you.

In your case, OP, it sounds like option ©. This guy knows what works for him to get some relief. If he was out to get dilaudid to get high, he sure wouldn't settle for 1mg Q6. I have given more than that for a lap chole.

jadelpn, LPN, EMT-B · Oct 10, 2015

I mistyped, I meant to type "drug-seeking." So, a person who is sitting in bed, on the phone, laughing, BP is great, HR is great, snacking on chips is truly experiencing 10/10 pain. Doesn't add up to me I guess. This particular patient has a history, based on his physician notes, of "numerable admissions complaining of vague pain, then becoming angry demanding IV Dilaudid." He is a non-compliant in his medication regime for diabetes, does not take his HIV meds, etc. This admission was for chest pain. All markers were negative, etc. Not only was he getting Dilaudid, he was getting Percocet along with it. Administered together.

Diabetes and HIV can cause a great deal of pain. And 1mg every 6 hours is not an over abundance of pain medication even with the Percocet. Knowing that you are not going to get pain relief for 6 hours, and one needs to do something to get their minds off of it.

Further, with HIV there can be some dementia like issues. So his "yelling" may be organic in nature.

What troubles me most of all is that this patient obviously doesn't have a plan in place that is working. Everyone stands around groaning about his behavior, his lack of compliance, his pain or nurse's perception of his pain, yet, here we are, once again and nothing changes.

There needs to be a consistent plan in place, a care conference, and something done so that this patient can try and function.

And a ml of dilaudid every 6 hours even with 2 Percocet my not be adequately covering....and you are chasing the pain.

Remember, your personal feelings need to stay away from the bedside. Addiction is a disease and not a character defect. Along with HIV. "Feeling dirty" should not even be in your realm of thinking.

PghRN15 · Oct 10, 2015

As a hospice nurse I have given Dilaudid 1mg every 10 minutes at times. I know that this is not a comparison, and yes we use the concept that pain is indeed what the patient says it is. If a patient has chronic pain, his or her vital signs may not change. Pain is a symptom that we look for in advanced HIV disease. I am not sure where your patient is at in the process.

Is it possible that because your patient HIV he could have been inappropriately labeled as drug seeker?. Is it possible that he is non-compliant with his therapy because he does not have the resources or anyone acting as his advocate? It is also possible that he is drug seeking. My point is that we don't know and we have to meet these patient's where they are.

Please do not assume that people are drug seeking. If you have a concern that your patient is over medicated talk to the MD about it. Giving medications as ordered should not make you feel "dirty".