IV Dilaudid problem patients!!!!!!!!!!!

dorimar, BSN, RN · Feb 28, 2009

Um..... I don't know where you are working, but it sounds like you need to find a different line of work or different area. You can get into a great deal of trouble for not giving pain meds when ordered. Also, pain is subjective and there are lots of issues with chronic pain patients and opiate dependency. It is not your place to determine if theri pain is legitimate. That is surely one of the first things you learned in school???

RN1982 · Feb 28, 2009

I totally agree with Dori. Pain IS subjective. And it's NOT your job to determine if the pain is REAL or NOT.

It's hard not to be judgemental but you have to remember that these patients are sick.

rngolfer53 · Mar 1, 2009

Im sure some of these addicts have pain. If everyone treated all the pts who had a drug hx like this it would be a shame to see where the world goes. Hell today some people see marijuana on the chart and OMG hes a drug addict lets limit his pain med to tylenol for his pancreatitis. Sorry thats how i feel. Pretty soon no one is going to be honest on there health hx becaause of the stigma of a drug addict or poss gettting addicted. Where does it end. I fight for my pts right for pain med whether they are a drug addict or not. All you can do is relay the info to the md and allow him to prescribe.

Excellent point. As McCafferey and Pasero point out, by not believing a Pt's report of pain, we set up an adversarial relationship with him/her. Is that the best model of practice?

rngolfer53 · Mar 1, 2009

Let me make another point.....Every patient that I admit to my floor I have to ask them if they are a smoker. It they say yes I am required to give them a smoking cessation packet. Smoking is an addiction....smoking kills and it is hard to quit.
So why am I trying to change a patients smoking behavior by addressing this addiction problem but when it comes to narcotic and prescription drug addiction no one wants to talk about it. It is not "politically correct" to inquire about a patient's drug use?
Drug addiction causes tons of other medical conditions and affects not just the drug addict but everyone around the addict.
We may not be able to change the behavior of the drug seeker but we can stop giving them the high that they want. In my research on Dilaudid I came across an article that said Dilaudid produced the same feelings as shooting up with heroin.
Yeah.....that's what I went to nursing school for....I am now your legal drug pimp!!! Just call me Nurse FeelGood.

Emphasis added.

But don't you think undertreated pain contributes to other conditions, including "drug-seeking" and creates problems for those around the Pt with that pain?

rn/writer, RN · Mar 1, 2009

We've been talking about addiction vs. pain. Another way to state this is addiction vs. dependence.

Here are a couple of excerpts from a good article about the difference:

Pain patients are highly unlikely to be addicted to painkillers (opiods). They are, however, likely to become dependent on a drug, which is very different than addiction.

Patients who take opiods may exhibit addict-like behaviors (called pseudoaddiction) — like hoarding pills and being preoccupied with taking the next dose at the precise time it is OK to do so. Understandably, seeing a patient with these behaviors make a doctor very cautious. However, pain patients stop behaving like addicts when they get adequate pain relief.

“The difference between a patient with opioid addiction and a patient who is dependent on opioids for chronic pain is simple. The opioid-dependent patient with chronic pain has improved function with his use of the drugs and the patient with opioid addiction does not.”

http://www.thedailyheadache.com/2005/10/opiods_addictio.html

In the limited amount of time you see a patient in an acute-care setting, how do you distinguish between an addict, a dependent person with serious pain, and and addict with serious pain? Seems like the lines are fuzzy enough to leave a whole lot of room for error. I'd rather let an addict "get away with" something than deny meds to a patient who really needs them.

I'm not sure that even the patients themselves always know which category they fall in.

rlene1275 · Oct 7, 2009

Before I posted I took the time to carefully read each and every post and I must say I am disgusted by some nurses views on IV DILAUDED>>For the people who claim "if it ordered i just give it" you guys are in for a pretty rude awakening and I hope what happens to you isnt half as bad as what happened to me.

My Story:

I was a MS nurse for 4 years. I worked on a "dump" floor.(this means the patients who no one else wanted came to our floor) We had a majority of the mentally ill, drug abusers, suicidal, and sickle cellers, cellulitis, pancreatitis and lap chole on our floor. Giving 4 mg of dilauded every two hours was like a standard tylenol order. There were patients who needed it, and others whom just requested it. Like may nurses here "i just gave it". ONe day last year my patient died in the middle of the night, two hours after I gave 4 mg of dilauded the patient had been on for 4 days OTC. THe patient has no signs of respiratory depression, she was alert and oriented and when I checked up on her 15 minutes after giving the med her level of sedation was 0. She was 31. She was one of those people who always wanted to be medicated. She would set her cell phone alarm to wake her so she wouldnt miss a dose and call the nurse 30 min then 15 min prior to make sure her meds were on x. That day, I was scarred. Autopsy revealed she died of cardiac arrest. Her opiod level was very high. I have since been fired from the facility i worked at, spent several thousands on lawyers, to prevent a black mark on my license, all because "I just gave it". The MD that ordered it wiped his hands clean because he wasnt the one who gave it and "it is per nurses discretion". My facility didnt have any monitoring guide lines for patients on high pain medications. But when all is said and done, she was the daughter of a doctor that worked at my facility. So they wrote me a check and sent me on my way. I have never heard or gotten support from any of the "so called" friends I worked with. Nurses whom gave her the same dosages before or charge nurses who knew she was drug seeking but did nothing about it. No one spoke up for me when I was let go.

Many of the "ignorent" nurses on this post who ask "who do you think you are" are nurses who have obviousley never been to a meeting with a lawyer representing a client's family who blame you for killing their daughter or a deposition. Nurses we are all burned out with the non compliant, manipulative patients. Sadly, those nurses who think we are fools to try to make a difference during a twelve hour shift are a glimpse into the sad life of a careless nurse who just needs a narcan scare to jolt them into reality. We as nurses CAN make a difference. Although there a positive and negative ways of going about it, the point is that we do something. Ill tell you WHO I AM: I am a professional nurse. I have the right to investigate and draw a conclusion based on my findings. I CAN HOLD PAIN MEDICATIONS if i deem it necessary, and if you think Im wrong, then you can go in there and give it yourself.

1 MG OF DILAUDED IS = 5 MG OF MORPHINE. dont let yourself be pressured by other nurses or the patient because when the dust clears youll realize youll be standing there alone. Licenses are individual. And our job is NOT to cator to those who abuse the system.

hereigoagain · Oct 8, 2009

Oh, I feel so bad that you had to go through that. I am intimidated by the nurses that say "who are you to know what pain the pt has?", but I hate Dilaudid. One morning I had to give one my pts Narcan...it was horrible, they put a pain pump in her and they forgot to take her off Methadone...I found her in respiratory depression at the beginning of the shift (thank you, RT, the respiratory therapist saved my ass, G-d bless her for ever, I thought that the pt was just drowsy from sleep when I checked on her the first time that morning), G-d gave me strenght and I had the Narcan close by, it was HORRIBLE (everybody was freaked out, doctors included, but I stayed calm and gave the Narcan and dealt with the exorcist look of the reaction, vomiting, drama, hyperventilation, craziness...run to ICU and the pt made it and thank us for it, but it was just DUMB luck, we could have all been in court because of it and loose sleep because someone died in our arms). Screw the drs orders, I use my own discretion when giving those poisons. I am a chronic pain sufferer and I don't take anything, I pray, I cry in pain...but I would not take anything. People on Dilaudid are just living for that, it seems....

I thank you for sharing your story. I hope you are OK with your license.

Virgo_RN, BSN, RN · Oct 8, 2009

Wow, 4mg of hydromorphone is a lot, especially for the opioid naive patient. Even though I tend to be in the "if it's ordered, I give it" camp, there does come a point where you question, and where you use your nursing judgment.

AnnaN5 · Oct 8, 2009

I had a scary situation during my last stretch of days on. A chronic pain patient was on our cardiac unit due to a PE and was transferred to us from med/surg unit. She came up with a Dilaudid PCA running at a continuous of 1.5mg/hr plus 0.8mg demand/7 min lockout with a max of 14 mg/hr. She also had PRN IVP Dialaudid 2 mg q1 hour. On top of this she was getting her at home pain meds of MS Contin 60 mg bid. I was shocked at the amount of pain medicine so I paged the on-call doctor for her care team and he said to stop the prn Dilaudid. When the patient asked for a prn dose I told her it wasn't available and she blew up and demanded I call anesthesiology who was managing her pain during her stay. After going through her chart for the previous 2 days and doing some investigating, I see that she has gotten almost 65 mg of Dilaudid in the previous 12 hours. She is completely alert and sats are fine on the continuous pulse ox but she is a bit hypotensive. I call anesthesiology and explain the situation and my concerns and am pretty much told this is how she wants her pain managed so this is what we are doing and they restart the prn Dilaudid. It was craziness. They were supposed to wean her PCA the following day but that was going to be a battle in itself!