IVDU pt kept asking for pain meds. Managment kept saying to just give it to her.

  1. I have a question, I'm a newbie nurse with only 2 years of experience. So, I work at a med/surg tele floor. I was assigned a pt who was very well known to be an IVDU and frequent flier. Pt was POD 7 from a spine surgery (totally forgot what the actual surgery was) and was getting pain med basically q1hr. She had orders for:

    1. dilaudid PO 4mg q3hrs scheduled
    2. dilaudid 2mg PO q4hrs PRN
    3. diladid 2mg IV q2hrs for BTP PRN
    4. oxycontin 10mg PO q12hrs scheduled
    5. toradol 30mg IV q6hrs PRN

    (**YES THERE ARE PAIN LEVEL PARAMETERS, but this pt is very manipulative and will do anything and I mean ANYTHING to get her beloved pain meds***)

    So the nurse from previous shift was basically giving her pain meds every hour!! I did not feel that it was safe for her (and for my license) to be giving her all those pain med. It was a weekend and that particular surgeon who did her op was off. So I called their office and asked to for the on call dr. to be paged.

    Dr. K came in to round on that pt, I told him my concern that Ms. so and so had been getting these kinds of pain meds basically every hour. The dr. was shocked when I told them all the kinds of pain meds and diff doses she was taking. He asked me who that pt was again and who was her primary ortho surgeon. I told him it's Dr. ***. Dr. K reacted very nonchalantly and said "Oh yeah she's known to our practice. She has high tolerance for pain meds since she's an IVDU. If she's still breathing just give it to her." I told him that her BP was low and his reply really caught me off guard, "I don't want to mess with whatever Dr. *** prescribe to her. Just wait for him to come back on Monday."

    I was literally speechless!!! Pt's bp was already in the mid to low 90s, pt was not hooked up to tele.

    Bottom line, I did not cater to her, I did not give her pain meds EVERY HOUR I made sure that atleast 2 hours has passed before I give her another pain meds. I explained her the legal side of nursing. Needless to say, she threw a **** show and threw the biggest tantrum a grown woman could every throw.

    That pt filed a complaint against me to my director. My director talked to me and told me to just give her whatever MD ordered for her to have. I told her, NO it is my license on the line and not yours, if something were to happen to my pt it is not YOU AND YOUR LICENSE that would have to sit in front of the BON trying to explain why you did what you did. She said that it is very important that we earn pt's satisfaction.

    I felt defeated and seemed like her priority was pt's satisfaction and not pt's and nurse's safety.

    I told her and the charge nureses (whoever will be doing assigments) that I NEVER WANTED HER BACK as a pt.

    DID I DO THE RIGHT THING? I MEAN I KNEW HER TOLERANCE FOR PAIN MEDS ARE HIGH GIVEN HER HX. BUT YOU REALLY NEVER KNOW WHAT WILL HAPPEN. 1 DAY SHE COULD BE FINE THE NEXT 2 FOR ALL I KNOW SHE'S OD from pain meds.
    Last edit by traumaRUs on Jul 20
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  2. 91 Comments

  3. by   caliotter3
    They can fire you for not complying with the requests, but they won't be there when her depressed respiratory rate becomes zero. Then they will say you caused the patient's death by not doing what a prudent nurse would do. You cannot win.
  4. by   MunoRN
    If you're concerned about your license then you should be just as concerned about holding indicated meds without any apparent rationale other than what appears to be a personal bias. I get that it often feels like you're losing some sort of personal battle every time you give a patient an opiate where there is some component of seeking involved, but it's important to keep that separate from an objective assessment of whether or not the medication should be held, particularly in a post-surgical patient.

    It would be reasonable given that list to ask that it be condensed to a single long acting and prn order in addition to the toradol. but the doses are all relative and can't really be compared to every other patient, it's quite possible that giving a Norco or two to another patient is far more risky than giving an opiate tolerant patient 4mg of dilaudid.
  5. by   Double-Helix
    Did you have any evidence that the medication was affecting her respiratory or neurological status in such a way that it was unsafe to give her additional narcotic? What was her RR? SpO2? LOC? If you have no clinical basis for withholding meds other than your opinion that she was drug seeking and really not in pain, then I’m sorry but you were wrong. If you were truly concerned you could have asked for the patient to be on continuous pulse oximetry. You are not going to fix drug seeking behavior over the course of a post-op admission by withholding pain medication for an hour. You’re right that patients with chronic opioid use require progressively higher doses to achieve the same effect and this patient very well could have been in pain that went untreated.
  6. by   macawake
    Quote from ella2990
    (**YES THERE ARE PAIN LEVEL PARAMETERS, but this pt is very manipulative and will do anything and I mean ANYTHING to get her beloved pain meds***)
    Bottom line, I did not cater to her, I did not give her pain meds EVERY HOUR I made sure that atleast 2 hours has passed before I give her another pain meds.
    Considering how you've worded this, can you honestly and confidently tell me that patient safety was the ONLY thing that affected your decisions?

    So the nurse from previous shift was basically giving her pain meds every hour!!
    How did the patient tolerate this? How were her vitals during the previous shift? Any concerns?

    Needless to say, she threw a **** show and threw the biggest tantrum a grown woman could every throw.
    A patient addicted to opioids whose postoperative pain is adequately treated but who is craving the next "fix" might display this behavior.

    A patient addicted to opioids and craving the next "fix" and whose postoperative pain isn't adequately treated can display this behavior.

    A patient who isn't addicted to opioids and whose postoperative pain isn't adequately treated can display this behavior.

    See where I'm going with this...?

    I MEAN I KNEW HER TOLERANCE FOR PAIN MEDS ARE HIGH GIVEN HER HX. BUT YOU REALLY NEVER KNOW WHAT WILL HAPPEN. 1 DAY SHE COULD BE FINE THE NEXT 2 FOR ALL I KNOW SHE'S OD from pain meds.
    If you are going to administer pain medication according to what might possibly happen in the future, you'll have to quit treating all your postoperative patients pain. Period. Withhold it all, you never know what could happen. (I'm obviously not recommending this course of action).

    If the patient describes pain that meets the parameters where you should administer the prescribed medication and the patient's vitals permit it, give the med as ordered. Always follow up on the patient's status after administration. The same rule applies to all patients whether they are IVDUs (I'm none too fond about referring to patients as acronyms or abbreviations, but that's another story), or not.

    Someone addicted to opioids and who has had surgery will as you've correctly identified normally need higher doses, sometimes significantly higher doses in order to adequately treat their pain, than a patient who is opioid-naive.

    Do you even know what her regular intake of opioids is? It's actually possibly that by not giving the patient her prn's when she asked for them (I'm assuming those are the ones you chose to withhold?), you were actually giving her less than what she normally takes on a daily basis, only now due to her surgery she's experiencing more pain than normal.

    From reading your post, I think you really need to do some soul-searching here. Make sure your potential biases against intravenous drug addicts or a fear/dislike of being manipulated, isn't affecting your decisions. You have a patient who has had surgery. The patient's reported pain and vital signs are the only things that matter here.

    "Customer" satisfaction isn't in my personal opinion a factor or a priority here, but good control of post-surgical pain, darn well is.
    Last edit by traumaRUs on Jul 20
  7. by   nursej22
    (**YES THERE ARE PAIN LEVEL PARAMETERS, but this pt is very manipulative and will do anything and I mean ANYTHING to get her beloved pain meds***)

    Wow, this is so judgmental. Yes, every hour is a lot, much you have no idea what her tolerance level was prior to surgery. Addiction is more that wanting one's "beloved pain meds", there are psychological as well as neuro-chemical changes to deal with. And you are not going to cure her addiction during an immediate post-operative period.

    If you are so concerned with the patient's safety (which I sincerely doubt), did you ask for a continuous pulse-oximeter? Or create a care plan for hourly respiratory checks? Did you do anything to offset the BP (and if asymptomatic, not such a concern to me as respiratory status.)

    People can become "manipulative" when there is a lack of trust or fear that their pain won't be treated or withdrawal may occur. Did you take the time to talk to the patient, assure that you would work with her for pain control, or create a schedule? I suspect not.

    Addiction is an awful thing, in fact, opioid addiction is at epidemic, crisis levels. It ain't gonna be solved by health care professionals who resent treating addicts who have acute pain.
    Last edit by traumaRUs on Jul 20
  8. by   quazar
    I will just say this. I had an IV drug user post op once (okay, I've had more than one IVDU patient, but this one in particular was severe), and she required massive doses of pain medication to keep her levels stable. From a clinical standpoint, I knew that she would require much more medication than a non drug using patient, and thankfully her physicians understood this as well and prescribed accordingly. My job was not to judge her drug use habits outside of the hospital. My job was to manage her post operative course safely, and that included appropriate pain control, which meant giving much higher doses at much more frequent intervals because to do otherwise would have left her in pain and suffering.

    You were not in your patient's body, you don't know how much pain she was in. To withhold pain medication when there is no clinical evidence that doing so would be detrimental to the patient from a physiologic standpoint (e.g., their vitals go in the tank) is cruel. You cannot judge another human being's pain without being in their actual body. You simply can't. Maybe she was drug seeking, or maybe she just really had a lot of pain because she had *spine surgery,* which I hear is pretty brutal, and she NEEDED pain control. Maybe she threw a fit because she was hurting. People lash out when they are in pain.

    In the future, I would recommend that you try your best to leave your personal opinions and judgments aside where pain control is concerned, particularly for patients who struggle with addiction.
  9. by   ella2990
    I probably didn't explain myself well enough. In no way was I bias. I do not have anything against IVDU. I had her way before her 3rd surgery. Her first surgery she was wayyy worst. We were all catering to her needs and what not. I was one of the nurses who NEVER, I repeat NEVER bad mouthed her. As unprofessional as it may sound, our former charge nurse and some colleagues were very nasty to her and would always huddle around nurses station talking about how they hated her and that she's a "whiny little *****". I believe that addiction is a disease, and I feel sorry for the pt. Like I said this was her THIRD surgery. Her 1st one she stayed in our unit for 6 months for abx tx. She was sent to a facility to help with rehab. After 3 weeks she left the facility and went back to the streets. She came back to the ED and requested to be admitted to our unit with osteomyelitis on her R foot where she was shooting her drugs. Again she had PCA and all sorts of meds. I didn't have her days after her sx. I had her about 4 weeks after surgeons signed off on her. She stayed in our unit again for more than 1 month for abx tx for septicemia. 2 weeks before she left AMA I had her and always catered to her needs what so ever. I NEVER had any issues giving her pain meds because I know that it was safe.

    She was getting dilaudid 4mg PO q3hrs toradol 30mg IV q6hrs and oxycontin 10mg q12hrs (which she refused to take in the morning so she can get her 4mg dilaudid PO). I felt comfortable giving her all those pain medicine because they are spaced out enough.

    Then she left AMA right AFTER (like in 5 mins) when her bf came in and "spoke" with her. Our own unit director even suspected her bf that he was persuading her to get back in the street. Again that did not come out of my mouth although I had an inkling.

    not even 2 months she was back again, another surgery done because she was shooting again and apparently developed an abscess.

    Pt was put on PCA for more than 1 week. When the surgeon ordered to dc the PCA she threw a **** show again. She "faked" a convulsion just so they'd put her back on PCA. (I say faked because a neurologist saw her and he specifically wrote on his note that it was not a real convulsion/seizure after he assessed her).

    Despite neurologist's note, the surgeon put her back on PCA.

    I don't know when and how it happened, but at shift change they were doing bedside reporting and doing iTRACE, so apparently they found an empty syringe hooked in her distal port of CL. So my director suspected drug diversion and had to do investigation. I don't know how it all went down since I was not the primary nurse and the details of the investigation was only made available to the nurse who had her that night and incoming nurse that witnessed everything.

    They DC'd her PCA and put her on multiple pain meds.

    So again the nurses who had her after that incident were catering her needs of pain meds q1hr just to avoid her tantrums. Then 10 mins before shift change they had to call a rapid on her. I was not involved in the rapid because I was asked to man the nurse's station because our DA left early while the charge nurse was running the code. So I did not get the whole story on what led her to a rapid response.

    After that I was afraid to give her pain meds every hour.
    Last edit by sirI on Jul 21
  10. by   Sour Lemon
    Quote from ella2990
    I probably didn't explain myself well enough. In no way was I bias. I do not have anything against IVDU. I had her way before her 3rd surgery. Her first surgery she was wayyy worst. We were all catering to her needs and what not. I was one of the nurses who NEVER, I repeat NEVER bad mouthed her. As unprofessional as it may sound, our former charge nurse and some colleagues were very nasty to her and would always huddle around nurses station talking about how they hated her and that she's a "whiny little *****". I believe that addiction is a disease, and I feel sorry for the pt. Like I said this was her THIRD surgery. Her 1st one she stayed in our unit for 6 months for abx tx. She was sent to a facility to help with rehab. After 3 weeks she left the facility and went back to the streets. She came back to the ED and requested to be admitted to our unit with osteomyelitis on her R foot where she was shooting her drugs. Again she had PCA and all sorts of meds. I didn't have her days after her sx. I had her about 4 weeks after surgeons signed off on her. She stayed in our unit again for more than 1 month for abx tx for septicemia. 2 weeks before she left AMA I had her and always catered to her needs what so ever. I NEVER had any issues giving her pain meds because I know that it was safe.

    She was getting dilaudid 4mg PO q3hrs toradol 30mg IV q6hrs and oxycontin 10mg q12hrs (which she refused to take in the morning so she can get her 4mg dilaudid PO). I felt comfortable giving her all those pain medicine because they are spaced out enough.

    Then she left AMA right AFTER (like in 5 mins) when her bf came in and "spoke" with her. Our own unit director even suspected her bf that he was persuading her to get back in the street. Again that did not come out of my mouth although I had an inkling.

    not even 2 months she was back again, another surgery done because she was shooting again and apparently developed an abscess.

    Pt was put on PCA for more than 1 week. When the surgeon ordered to dc the PCA she threw a **** show again. She "faked" a convulsion just so they'd put her back on PCA. (I say faked because a neurologist saw her and he specifically wrote on his note that it was not a real convulsion/seizure after he assessed her).

    Despite neurologist's note, the surgeon put her back on PCA.

    I don't know when and how it happened, but at shift change they were doing bedside reporting and doing iTRACE, so apparently they found an empty syringe hooked in her distal port of CL. So my director suspected drug diversion and had to do investigation. I don't know how it all went down since I was not the primary nurse and the details of the investigation was only made available to the nurse who had her that night and incoming nurse that witnessed everything.

    They DC'd her PCA and put her on multiple pain meds.

    So again the nurses who had her after that incident were catering her needs of pain meds q1hr just to avoid her tantrums. Then 10 mins before shift change they had to call a rapid on her. I was not involved in the rapid because I was asked to man the nurse's station because our DA left early while the charge nurse was running the code. So I did not get the whole story on what led her to a rapid response.

    After that I was afraid to give her pain meds every hour.
    Either I'm not good at following, or that's really difficult to follow. It seems like your shift reports are lacking if the patient had a rapid response called and you have no idea why, though. It might have been due to her "fake" seizure(s)? I've seen that happen on more than one occasion.
    Anyway, I don't mind these types of patients too much. They scare newer nurses, but they're extremely tolerant and pretty much impossible to kill accidentally. A blood pressure in the 90s doesn't phase me. Get it down to the 70s and I'll start paying closer attention.
    Last edit by sirI on Jul 21 : Reason: quoted edited post
  11. by   CCRN2BE
    I must agree with the many good points of the pp's, especially seeking an order for continuous pulse oximetry. You would be amazed, truly amazed, at the amounts and dosages that opioid dependent folks can tolerate. You cannot compare them to the average person, who would need intubated at the same dosages.....apples and oranges.
  12. by   quazar
    Quote from ella2990
    Then 10 mins before shift change they had to call a rapid on her. I was not involved in the rapid because I was asked to man the nurse's station because our DA left early while the charge nurse was running the code. So I did not get the whole story on what led her to a rapid response.

    After that I was afraid to give her pain meds every hour.
    I would be interested to know what led to the rapid response as well.

    I have had "that" frequent flyer patient who was a drug user who turned tricks to get her fix who would sign out AMA frequently only to return when her situation was dire. I have discharged patients to rehab instead of home, only to have them bounce back again, using. I work OB. Let that thought settle in a little bit and think about the implications.

    It is hard. It wears on you. Yes, I get that. Addiction is a brutal disease, and in the acute care setting it gets really complicated. HOWEVER....that doesn't change the fact that addicts have pain, that their pain is real, and that yes, they do a lot of the time have a lower threshold for pain and need more medication than their non-addict counterparts. You still have to treat their pain, not for patient satisfaction, but because there is actual documented research out there that shows that poor pain control post op leads to slower recovery time which in turn can lead to greater post op complications.

    You can't control their behavior outside of the hospital. You can only treat the after effects when they come to you for treatment. It's all you can do. I made my peace with that a long time ago, and am so thankful for people like Social Workers and Psych who can an do come in and do what I consider to be the "tough stuff" and confront the issues of the addiction, poverty, prostitution, etc., head on. Thank God for the multidisciplinary approach. You don't have to do it all.

    The others made a great suggestion about asking for continuous o2 sat monitoring if you're worried about her respiratory status. Put the patient closer to the nurse's station so she can be observed closely. When you're burned out and feel you can't go into that patient's room one more time without screaming (it happens), ask a colleague to check the patient for you, just so you can take a quick mental health break. I get that she was a challenging (understatement) patient. I still assert that drug user or not, her pain needs to be treated based on what she is reporting, as long as her vital signs and assessment are WNL.
  13. by   CCRN2BE
    Quote from Sour Lemon
    A blood pressure in the 90s doesn't phase me. Get it down to the 70s and I'll start paying closer attention.
    That's what I was thinking also.
  14. by   EllaBella1
    I do think you were wrong in this situation, but I also do understand your concerns and point of view. In this case you spoke with the provider, he explained that he was not concerned by the dosing and that you should follow the orders. So, I would have followed the orders, end of story. I would have documented your concerns, given her the meds, and closely monitored vitals. I also would have taken another approach with the provider when you spoke with them. Rather than trying to argue your point with them after they said to follow the orders (with your statements re: her BP, etc), I would have simply requested additional monitoring for her and also an order for narcan just in case. Specifically I would have asked for her to be on continuous end tidal CO2 monitoring- a simple solution to assessing whether her airway was impacted by the meds. Tele wouldn't hurt either.

    I do completely understand where you were coming from with your reluctance, but the doctor said to carry out an order and you refused. You mention the legal side of nursing, and from that perspective you were wrong here.

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