When Your Patient is an Addict...How to Deal - page 3

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... Read More

  1. by   KatieMI
    Quote from not.done.yet
    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.
  2. by   BostonFNP
    Quote from 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.
    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.
  3. by   KatieMI
    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.
  4. by   Rocknurse
    Quote from russianbear
    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.
  5. by   JerseyTomatoMDCrab
    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.
  6. by   BostonFNP
    Quote from russianbear
    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?
  7. by   BostonFNP
    Quote from JerseyTomatoMDCrab
    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.
  8. by   KatieMI
    Quote from Rocknurse
    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.
  9. by   Rocknurse
    Quote from KatieMI
    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.
  10. by   BostonFNP
    Quote from KatieMI
    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?
  11. by   KatieMI
    Quote from BostonFNP

    Post-operative analgesia is standard of care; don't the vast majority of major post-op patients chase pain with narcotics?
    Precisely so. 1 mg of dilaudid IVP Q2H PRN for "pain" (no other parameters) is an order which practically chases the pain. It can be ok for "naive" patient who has no other pain issues but not for someone who was taking Norco 10 Q3-4 (prescribed for Q6 originally but "I found an online site and another doc") for years before.

    I didn't write about "holding meds". I wrote that I would question such order, even if it is "legitimate" because AFTER I give patient that 1 mg of Dilaudid I will speak with him and explain that if we can arrange for scheduled meds in pill form, he will feel better, but I need to know what he was taking when he was at home. Then I will call the doctor and ask not for 2 mg of Dilaudid but either for pain consult or for some prolonged action narc to be given on schedule. Methadone often works spectacular.
  12. by   BostonFNP
    Quote from KatieMI
    Precisely so. 1 mg of dilaudid IVP Q2H PRN for "pain" (no other parameters) is an order which practically chases the pain. It can be ok for "naive" patient who has no other pain issues but not for someone who was taking Norco 10 Q3-4 (prescribed for Q6 originally but "I found an online site and another doc") for years before.

    I didn't write about "holding meds". I wrote that I would question such order, even if it is "legitimate" because AFTER I give patient that 1 mg of Dilaudid I will speak with him and explain that if we can arrange for scheduled meds in pill form, he will feel better, but I need to know what he was taking when he was at home. Then I will call the doctor and ask not for 2 mg of Dilaudid but either for pain consult or for some prolonged action narc to be given on schedule. Methadone often works spectacular.
    I agree that acute pain can be difficult to manage in a patient with a history of narcotic abuse, for a number of factors, including using sufficient and safe dosing schedules. I also agree that sort-acting opioids have a limited role in treating chronic pain and are often more dangerous for creating psychologic dependence.

    I don't know if I agree with using long-acting narcotics for acute post-operative pain when there is no plan for the patient to go home with the medication, as is the case for street-drug users. Methadone is a underutilized chronic pain medication, however, I would not use it to manage acute pain as by the time a steady state was reached the patient would be out of the hospital (4-5+ days to reach steady state). I would be very hesitant to have any plan to send a patient home with narcotics if they are actively abusing street drugs.
  13. by   madricka
    The saddest thing I have seen is surgical patients who are too afraid of judgement to reveal their addictions and thus receive FAR LESS pain medication they need and I walk in to see them pale, sweating, shaking and in absolute agony. I assure them that what they do at home is none of my business (which it is not) and my job is to take care of their pain and help them recover from surgery. They will not recover smoothly if their pain is not controlled. They will not eat, do physio, get out of bed or communicate well. Having a pain team on call is a blessing. But encouraging those with addictions to feel safe to reveal their true use is crucial.

    As for my opinion, I should not have one. I am NOT qualified, educated or trained as an addictions specialist, a social worker, or interventionist. The patient has not invited me to help them heal their addiction issues. If anything, their time in hospital is the absolute worst time to try and take away their (likely) sole coping mechanism since they are experiencing an enormous amount of stress. It's not the time or the place. Am I contributing to their addiction? Please. It's not as simple or as straightforward as that. And misunderstandings like this are why I have to do extensive education with so many other (non-addicted) post-op patients about how they will not become addicted to opioids if they take pain medication that they desperately need (or have had it in recovery).

    There are some nurses who insist patients couldn't possibly sleep if they had severe pain. As someone with chronic severe migraines, I assure you, it is possible. Other times I lie so still I appear to be sleeping, because if I move, the pain intensifies, the room spins and I will vomit. I could be in agony but trying to use deep breathing and meditation to cope so by outward appearances it seems that I am calm and relaxed but inside I feel like my skull is being ripped apart. It's heartbreaking when someone doesn't believe you. My worst fear is being in horrible pain and no one will help me. Sadly, it happens far too often.

    Thank you for this article!

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