When Your Patient is an Addict...How to Deal

[Nurse Beth]

Jake is very sociable, and has a lot of ...colorful friends who visit him in the hospital. He's quite likable, because he's intelligent, funny and clever. He's not bad-looking, but at 35, his lifestyle is starting to take a toll on his looks.

On this admission, Jake had an appendectomy. He also has a substance abuse disorder.

Time: 1940. Right now, Jake is leaning against the doorjamb in the doorway of his room, looking up and down the hallway for me. He's holding his cell phone in hand and repeatedly checking the time. Just to irritate me, I'm sure. He always calls for his pain meds before they're due.

Funny, I've yet to ever see him exhibit any outward signs of pain. On the contrary, Jake always appears relaxed, but his reported pain level is always a "ten."

Jake Lies

Time: 1945. Only because I have to, I ask: "What's your pain on a scale of one to ten?" He automatically answers "ten" without blinking an eye or looking up from Candy Crush. I might as well have asked, "Yo, Jake, what's six plus four?"

Jake Gets His Dilaudid

Some patients always know exactly what time it is

Time: 2005. Ok, Ok! It's time. Reluctantly, I enter the room. My eyes roll as Jake scoots eagerly to the side of the bed nearest me and proffers his inner arm, exposing his antecubital saline lock. With his opposite hand, he pushes the sleeve of his patient gown up high and out of the way. His eyes are bright and his gaze is steadfastly fixed on the syringe in my hand.

He watches intently as I swab his saline lock port with an alcohol wipe. He's craving his fix. He swallows. He supervises as I pierce the rubber hub and finally inject the Dilaudid into his bloodstream. Then he asks me to "flush it fast." I don't respond or make eye contact. I flush the port and leave the room as quickly as I can.

I'm feeling repulsed. Did I say repulsed? Yes. I'll be honest here. You may stop reading now, you may be shocked, you may unfollow me. But I know that if I feel this way...I can't be the only one.

More on How I Feel

Dirty. Tarnished, as if I'm complicit in Jake's addiction. I'm pushing IV drugs on an IV drug user? Really? That's not what nurses do!

I'm angry.

• Angry because I feel manipulated and used
• Angry because Jake's not playing by My Rules
• Angry because I'm a tight-lipped, mean nurse with Jake. Not the compassionate angel of mercy I prefer to think of myself as! I hate when that happens, JAKE!!
• Angry because I'm angry
  I'm a tight-lipped, mean nurse with Jake, the drug addict

What about the Rules? I'm playing by the: "What the Patient Reports as Pain is the Gold Standard" Rule Book. And Jake's Rules? No rules. He's just playing me for a fool. Or so it feels.

Take a Deep Breath and Repeat

I don't like how I feel. So, for a minute, let's just step back from Jake and the floor and review some pain management terms.

Tolerance

Tolerance is a normal physiological response to exposure to a substance over time. Think coffee. You require more caffeine to realize the effects you enjoyed when you first started using, I mean, drinking, coffee. There's:

• Tolerance to side effects can include sedation or nausea, (opiates) and
• Tolerance to analgesic effects, which requires higher doses to achieve pain relief

I need my coffee strong, please!

Jake has tolerance to both. "Normal" doses of pain medication will not relieve Jake's post-op pain. Dilaudid one mg IV for Jake is like a lukewarm, watery, half cup of coffee is to me. Due to tolerance, Jake needs more pain medication, not less.

Dependence

Physical dependence develops with repeated exposure to opioids.

"Tolerance, withdrawal, and physiologic dependence are expected responses to opioids ...and are not by themselves indicative of addiction."

American Society of Pain Management Nurses (

ASPMN)

Position Statement on Pain Management in Patients with Substance Abuse Disorders, 2012

Many respectable, functioning members of society live with chronic pain that's managed by some form of opiate. Given enough time and drug, they become physically dependent. Dependence in and of itself does not constitute addiction.

Addiction

According to the American Society of Addiction Medication (ASAM), addiction is "A chronic, primary disease of (the) brain...characterized by inability to abstain." People with active addictions can't control their cravings or impulses.

Here's the thing- patients with active addiction have pain, too. Perhaps even more pain than other people undergoing the same procedure. There's a phenomenon known as opioid-induced hyperalgesia, in which patients dependent on opioids have increased pain despite increasing doses of meds.

What Else ASPMN Tells Us

The (ASPMN) Position statement further says:

"Patients with substance abuse disorders and pain have the right to be treated with dignity, respect, and the same quality of pain assessment as all other patients.

So when Jake, the post-op substance abuser, asks for his pain meds, it's complicated.

It's easier to dismiss Jake as a drug user than to sort this all out

Added to the problem is that few providers are schooled in managing pain in patients addicted to opiates. Dr. McSurgeon will most likely order his one size fits all post-op pain management order set.

Here are some things I've learned to reduce my frustration:

Six Resolutions that Help Me Cope with Patients with Substance Abuse Disorder

1. I will check my judgmental attitude. I remind myself that I don't know how Jake got to this place. I don't know his story, all the factors and forces that led to his addiction. Was he a cute little boy?

Did someone hurt him? Did his father leave him? I'm not saying that any of these are an excuse to use drugs. I myself didn't have a stellar childhood, and I don't use drugs. But reminding myself that I haven't walked in Jake's shoes instantly changes my perspective and helps me be less judgmental.

2. I will be realistic. Why am I surprised when a person with a substance abuse disorder displays behaviors... consistent with those of a substance abuse disorder? Folks with DKA have high blood sugars. Folks with an active addiction lie, cheat, steal and manipulate to get their drugs. When Jake lies, flatters, or wheedles, I won't take any of it personally.

3. I will understand my job. I can't cure Jake's addiction. I'm not that powerful. Even if I could, which I can't, and even if he wanted me to, which he doesn't, that's not why he's here. Jake's here because he had surgery. My job is to provide the best post-op nursing care I can.

4. I will take control. Of myself. My anger is my problem, not Jake's. I own it. I can only be manipulated if I allow it.

5. I will not engage in a power struggle with Jake. We both lose. I've worked with nurses who use passive aggressive behaviors, "forget" to medicate their patient, wait until change of shift, etc. Failure to treat pain is profoundly wrong, unethical, and unprofessional. Nurses who position themselves as "She (or He) Who is the Gatekeeper of Pain Medication" need to re think how they're using their authority.

6. I will be professional. I won't use stigmatizing terms such as "drug-seeking" and "clock-watcher." In handoff report, I will simply inform the next RN when Jake's pain med is due. Jake deserves the same access to pain medication as Edna, my 78-year-old female post-op hip surgery patient, and the same dignity and vigilance. (Actually, I have a hunch Edna was a little tipsy when she fell and broke her hip). I will respect Jake as a fellow human being who, for all I know, is doing the best that he can with what he has. As are we all.

Rewind and try Again

New tactic.

Time: 1945. I go into Jake's room, smile, make eye contact, and ask him if needs his pain med. He is completely taken by surprise, and his face and eyes show it. Someone is treating him like a human being?

As for me? My anger is gone! I'm in control and I feel much kinder towards Jake. I can do this. It just takes practice..to improve my nursing practice!

These patients are tough. What's your experience? What helps you get through your shift?

[BostonFNP, APRN]

Sonif soneone is admitted for [insert diagnosis] and he is a coke addict we should supply him with a steady dose of cocaine? We should provide alcoholics a shot and a beer every two hours? Crystal meth PRN?

Cocaine and crystal meth are illicit substances that are far outside the standard of care for treating post-operative pain. While there is perhaps an argument for letting alcoholics have a small amount of alcohol to prevent DTs rather than CIWA protocol, it doesn't apply here either.

I am not sure if this was a serious question or just a red herring, but getting back to addiction being a drain on resources. What is there to do about it? Do you think that holding dilaudid after an appy is going to cure the addiction?

[smf0903]

I have never quite grasped the thought process behind holding/rationing pain meds for an addict when they are in hospital for some acute process which results in pain. We have a lot of addicts (heroin is a HUGE issue in our area, one of the highest rates per capita in our state) that come to us for whatever reason. Cutting someone open will result in pain whether you're an addict or not. Acute bouts of pancreatitis result in pain whether you're an addict or not. The only difference is that an addict may require higher doses of pain meds to control/cut through the pain.

These are my issues: The patient who shows up religiously every three days in ED for pain. Said patient is with pain management. Patient knows darn good and well we will not go outside the parameters of the pain management contract. Same patient knows that #1, "chest pain" gets them to the front of the line in ED, and #2, no matter who they demand to see (all the way up to hospital president) they will not get any pain meds outside of their pain management contract. But they try every. single. time. and waste the time of RNs, supervisors, etc.

My other issue is the patient who decides to bring their illicit drugs to the hospital and shoot up in their room when no one is in there. Or you remove a patient's socks and needles and baggies fall out. Or flip a pillow and have a syringe with God knows what go flying across the bed. I'll admit it pisses me off to no end to walk into a room to find a patient gray and not breathing because they took something.

[KatieMI, BSN, MSN, RN]

It isn't always "addicts" either. I had a lady of advanced age who was in for a chronically recurring problem. She always requested Dilaudid be the narc prescribed from the hospitalist and, at this particular hospital, they always obliged. She would call for it on the dot of when it was allowed to be given again. On the day she was to discharge I spoke with her about switching to oral hydrocodone so we could be sure her pain would be controlled after leaving. She raised her brows and informed me that she didn't take pain meds at home but when in the hospital she "let herself have the Dilaudid". Apparently it was a little treat she allowed herself to compensate for having to be hospitalized. That was eye opening!

First, it is a classical example of not ADDICTION, but ABUSE (i.e. using substance with a purpose other than assumed therapeutic action). Second, you have no idea what this elderly lady occupies herself once out of acute care. Plenty of them sit forewer in their PCP offices or shop around in search of more scripts.

[BostonFNP, APRN]

I have never quite grasped the thought process behind holding/rationing pain meds for an addict when they are in hospital for some acute process which results in pain. We have a lot of addicts (heroin is a HUGE issue in our area, one of the highest rates per capita in our state) that come to us for whatever reason. Cutting someone open will result in pain whether you're an addict or not. Acute bouts of pancreatitis result in pain whether you're an addict or not. The only difference is that an addict may require higher doses of pain meds to control/cut through the pain.

These are my issues: The patient who shows up religiously every three days in ED for pain. Said patient is with pain management. Patient knows darn good and well we will not go outside the parameters of the pain management contract. Same patient knows that #1, "chest pain" gets them to the front of the line in ED, and #2, no matter who they demand to see (all the way up to hospital president) they will not get any pain meds outside of their pain management contract. But they try every. single. time. and waste the time of RNs, supervisors, etc.

My other issue is the patient who decides to bring their illicit drugs to the hospital and shoot up in their room when no one is in there. Or you remove a patient's socks and needles and baggies fall out. Or flip a pillow and have a syringe with God knows what go flying across the bed. I'll admit it pisses me off to no end to walk into a room to find a patient gray and not breathing because they took something.

Those are both valid (and concerning) issues.

In addition to your first scenario are the frequent flyers that run out of their 28 days of pain meds before then end of the month so they get admitted for chest pain for a few days because they know the pharmacy will supply them with their meds for a few days while in-house. These are examples of abuse of the system and there needs to be a systemic approach to address it.

The second scenario is a danger to the patient and the staff I think we can all agree on that. We recently had a problem in our area of heroin addicts getting high on hospital grounds so they could get urgent care if they OD'd.

[KatieMI, BSN, MSN, RN]

One part of the problem with addicted patients having legimate sources of pain is that most acute care physicians are not well familiar with principles of pain management for this category of patients. These patients need opioids as baseline to avoid withdrawal PLUS an additional dose to treat their pain, with the former one preferred to be equianalgetic to daily use dosing of prolonged-action opioid formulation to avoid "highs" and the latter one covered by oral immediate release medications like Morphine ER as much as possible.The short-acting stuff like IV dilaudid should be administered in lowest possible dosing to cover breakthrough pain (which should be accessed 30 to 60 min after injection). The pain relief 50% (i.e. 10/10 to 5/10) is considered to be adequate by pain specialists, therefore patients should be taught early that they should not expect to be entirely pain-free at all times. Same principles applied to benzo dependency (which is common in this population as well).

This is a basic knowledge included in USMLE II and III exams. It is a pity that so many doctors, particularly surgeons, forget about it as soon as they leave testing center, and thereafter prefer to chase the pain with increasing doses of IV dilaudid with no base coverage even on patients who are prefectly able to take meds enterally.

[Rocknurse, MSN, APRN, NP]

And there are no risks involved with never questioning an order?

Why would you need to question a legitimate order? I am assuming it would be because you are trying to imprint your own feelings/agenda on to it. Personal bias and judgment are not reasons to question an order.

[JerseyTomatoMDCrab, BSN]

This was a great read and I am surprised how accurately your experiences reflect my own. This is truly one of the hardest patient populations to care for. The standing by the door (or nurses station!) "reminding" their nurse 15 minutes before, asking to flush it fast. I've seen it in all 4 acute care hospitals I have worked in. I don't feel tarnished or complicit in their addiction after administering a dose, thought I do feel like some patients are trying to manipulate me. I really don't like when they try to split the staff, like "Well Night Nurse Susie didn't dilute the medication in saline and she flushed it as fast as she could!" or "I like you so much better than the nurse I had yesterday" and telling their friends "Nurse Tomato is the best nurse here!"

It's a common and growing problem, sadly.

[BostonFNP, APRN]

And there are no risks involved with never questioning an order?

Under what parameters are you questioning the order? Is the patient somnolent, delirious, bradypneic? Or do you just not think the patient has enough pain to warrant getting an ordered dose?

[BostonFNP, APRN]

I don't feel tarnished or complicit in their addiction after administering a dose, thought I do feel like some patients are trying to manipulate me.

I have the same response, though often it is when I am seeing patients in the clinic setting. I think we all have a visceral reaction to feeling manipulated, be it with narcotics or antibiotics.

[KatieMI, BSN, MSN, RN]

Why would you need to question a legitimate order? I am assuming it would be because you are trying to imprint your own feelings/agenda on to it. Personal bias and judgment are not reasons to question an order.

Because you may know something what the person who wrote the order doesn't, for one instance.

Patients may conceal the fact that they are using out of shame or fear or just assume that they will be able to quit cold turkey, think that they will "get pain meds as soon as they are asking about them because our floor is dedicated to be 110% pain free" (cited from preop teaching in spinal surgery unit, with limited tele, no RRTs, not commonly SaO2 constant monitoring and no automatic orders for Narcan, mind you) or think that withdrawal and cravings are not as bad, or that they do not take enough meds to go into withdrawal. When hard reality strikes them, it is one of the best outcomes if they just become "clockers" hitting call button the second they can get their shot. Getting them to tell the truth, fuguring out what and how much they were taking, and arranging either specialty or clinical pharmacology consult to set up correct schedule of meds is incredibly relieving for everybody. It is always more difficult and time consuming than to just "follow the order" or call that poor surgical fellow upteenth time, but results are almost universally better than just chase pain with more Dilaudid because it is what your order says.

[Rocknurse, MSN, APRN, NP]

Because you may know something what the person who wrote the order doesn't, for one instance.

Patients may conceal the fact that they are using out of shame or fear or just assume that they will be able to quit cold turkey, think that they will "get pain meds as soon as they are asking about them because our floor is dedicated to be 110% pain free" (cited from preop teaching in spinal surgery unit, with limited tele, no RRTs, not commonly SaO2 constant monitoring and no automatic orders for Narcan, mind you) or think that withdrawal and cravings are not as bad, or that they do not take enough meds to go into withdrawal. When hard reality strikes them, it is one of the best outcomes if they just become "clockers" hitting call button the second they can get their shot. Getting them to tell the truth, fuguring out what and how much they were taking, and arranging either specialty or clinical pharmacology consult to set up correct schedule of meds is incredibly relieving for everybody. It is always more difficult and time consuming than to just "follow the order" or call that poor surgical fellow upteenth time, but results are almost universally better than just chase pain with more Dilaudid because it is what your order says.

None of these things justify holding a pain medication.

[BostonFNP, APRN]

Because you may know something what the person who wrote the order doesn't, for one instance.

It is always more difficult and time consuming than to just "follow the order" or call that poor surgical fellow upteenth time, but results are almost universally better than just chase pain with more Dilaudid because it is what your order says.

I don't think anyone would argue that if a nurse assesses a patient and has concerns about that patient than he/she should absolutely have a discussion with the ordering provider/team. What I think people are arguing with is whether that nurse should unilaterally withhold the medication and/or administer it differently because they assume a patient is a seeker.

Post-operative analgesia is standard of care; don't the vast majority of major post-op patients chase pain with narcotics?