When Your Patient is an Addict...How to Deal - page 6
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
Mar 20, '17Quote from CG1979By this measure, the patient who is intubated, on 5 pressors and an IABP is taking time away from the patient who got their finger stuck in a door. Is it fair that the first patient gets more nursing time? These days we use individualized patient care models that reflect the needs of the patient. If that patient's needs manifest as mental health needs then that's what the time is spent doing. Being an addict doesn't make them any less deserving of time. You're stepping over a line when you determine that a certain patient is worthy of less time because of their social and psych history.Here's the thing: Jake may have the "same right" to pain meds and your time as other patients, but management of his behavior will take time away from other patients care. Not exactly equal or fair, is it?
Mar 20, '17Since the day I was judged as a narcotic seeker I have made it a point to never ever do that to a patient. It was a horrible and demeaning experience. I ended up in the ED in severe pelvic and back pain without any idea what was causing it. I was given IV Dilaudid (that I did not request) and taken for a CT scan. The CT scan revealed nothing and the sudden change in tone and attitude of the doctor was both abrupt and cold. She immediately discharged me without any further investigation. When I asked her what could be causing the pain she shrugged and made some flippant comment and I suddenly realized she was judging me as being a pain med seeker. I was outraged and embarrassed. I was off work for 3 months with the pain and eventually diagnosed with stage 4 infiltrating endometriosis, bilateral endometriomas and adenomyosis. I had three surgeries within one year, one of them requiring extensive excision of my entire pelvic wall and reconstruction of my ovaries, and now take pain meds long term. Endometriosis does not show up on a CT scan.
I will never treat a patient like the way I was treated that day. It wasn't even the first time. I was treated in a similar way many years before when I had a similar pain and couldn't walk. They sent me home without any treatment and the EMTs ended up bringing me back to the hospital because I couldn't get out of the ambulance. I didn't know I had endometriosis then. I remember the charge nurse snickering and being very dismissive of me. Think about that next time you make that judgment. Sometimes you don't know what's going on with that particular person. Yes, there are people who abuse drugs, just like there are people who abuse alcohol and food. You don't see people making the judgment to not give someone food in the hospital because they're 300lbs, do you? Even if someone is an addict, be very sure they don't have a legitimate medical issue going on before you dismiss them. We are not addiction specialists, and we are not social workers. Don't deny people pain relief because of your prejudice. I know what pain is. I feel it every day. Sometimes I can barely get through a 12 hour clinical day because my back hurts so much from my uterus. I don't look like I'm in pain because I've had it for 25 years and I've learned to live with it, but if you could only imagine what it's like to live in chronic pain then you'd never make that judgment again. People who genuinely need pain meds are being denied them because of this attitude. Addicts will always find something to abuse if they so desire. Why should everyone else suffer because of that?
Mar 20, '17Quote from russianbearAgain, your position seems to keep changing to more and more extreme examples in an attempt to justify a prejudice. I doing so you have missed the entire point of the thread, which is providing addicts with appropriate care, and most importantly, reflecting on how we as HCPs approach these patients.I have defended my position admirably. I'm shocked one of you finally acknowledged the existence of drug seekers. Now, will you be courageous enough to say that physicians should not order them narcotics for the sole reason of feeding their addiction?
There is no point in this thread where anyone has said that addicts and seekers don't exist. There is no point in this thread where anyone, other than you, have suggested that HCPs blindly feed anyone's addiction.
Mar 20, '17Quote from CG1979Jake still has a real medical condition, just like all the other patients. Addiction is a disease, which most of us know, but I don't think many really get it. Compassionate care with an non-judgmental attitude is only going to help.Here's the thing: Jake may have the "same right" to pain meds and your time as other patients, but management of his behavior will take time away from other patients care. Not exactly equal or fair, is it?
Mar 20, '17Quote from russianbearWhy did you ask this? Have you lost someone close to you to addiction? Is that what's affecting your response in this thread?How many people do you know personally who have died because of an epidemic that we play a role in?
Like I said before, I'd love to work in your hospital where "seekers" do not exist.I'm shocked one of you finally acknowledged the existence of drug seekers.
...because they know eventually the docs will give in as opposed to telling them they will not prescribe them controlled substances th do not have a need for.
Now, will you be courageous to say that physicians should not order them narcotics for the sole reason of feeding their addiction?
Again, I am trying to distinguish between people with medical issues versus those who do not.
I'm former law enforcement and in that capacity I met thousands of addicts. My nursing career so far has looked like this: med-surg ---> ER ---> PACU --> anesthesia. Despite having met a large number of individuals battling drug addiction I have yet not figured out a method that is 100% foolproof in indentifying if someone wants opioids "for the sole reason of feeding their addiction" or if that someone actually also experiences pain or some other type of medical issue. I'm going to go out on a limb here and say that neither have you. Because there is no method to objectively measure what another person is experiencing painwise.
To further complicate matters many nurses have a knowledge deficit as to how chronic pain presents. Most nurses have a good understanding of the presentation of acute pain but individuals who suffer from chronic pain will often show less of an effect on vital signs and behave in a way that you or I wouldn't intuitively expect someone in pain to behave. Whereas I definitely wouldn't be in the mood to fiddle with my iPad or be able to fall asleep with my freshly fractured femur a person with chronic pain can definitely sleep despite experiencing severe pain. Human beings simply can't stay awake for weeks or months on end. So they sleep, despite the pain.
When we as nurses evaluate a patient's pain it's based on what the patient says and how s/he presents. It's based on the amount of knowledge the individual nurse has on the anatomy and physiology (and psychology) of pain. That amount of knowledge varies. It's also based on the medical history available to us and it's also definitely affected by our own personal experiences and biases. It's important to be aware of the last part and how it might negatively impact our patients.
Russianbear, the way I interpret your posts is that you think that the least desirable outcome is that we as healthcare professionals inadvertently (or because of indifference) enable an addict and give them a "free high" by administering opioids without any verifiable medical indication. My take on this is different. My least desirable outcome is that we fail to properly treat even one single patient in pain. To me that's failing the patient.
As has been mentioned in this thread, the acute care setting is not the place to cure a problem with addiction. If I withhold a pain med because I suspect that the patient is "a seeker" I run the risk of undertreating someone's pain. If I was actually correct in my guess and the patient was actually "just seeking", I haven't really accomplished anything (apart from whatever satisfaction I/ a nurse might derive from denying someone their "fix"). It won't "cure" the addicted person, they'll find another way to get their desperately needed drug. From my earlier experience those ways often involve; mugging someone for cash to buy drugs, selling one's body for money to buy drugs or in exchange for drugs, stealing from department stores/businesses or stealing from family members or perhaps even robbing a pharmacy. All these are methods that result in some type of collateral damage. Since I can be quite certain that my withholding the med won't result in the addict saying; oh, this didn't work. With that in mind, I don't really see what good I will have accomplished. I think I'll just quit my habit" That won't happen before the addicted person manages to find the motivation to want to become clean.
In the case that OP described, giving Jake his medication is a no-brainer (providing his vital signs permit it). He's had a surgical procedure known to cause post-operative pain.
Mar 20, '17A lot of time, thought and teaching went into this article, and it shows. Yes, we've all met Jake I would guess.
I wonder how many of us have met Harry too?
The year was 2002, and I worked in a VA facility at the time. Harry was 71 years old, and among other things he was Dx'd with chronic pain. Harry had only recently started on MS Contin 30 mg PO BID in the past 6 months, and it worked fairly well for pain he had suffered for a long, long time. Harry had also been on coumadin for many years.
Harry was approximately 8 hours post-op. His post-op pain med orders were generic: percocet 1-2 PO Q 4-6 hours PRN, and demerol 50 mg IM Q 4-6 hrs PRN severe pain.
Because Harry was Rx'd coumadin the night nurse opted to D/C the IM demerol for safety reasons to prevent hemotoma, but didn't think about calling to get IV pain med orders. Harry was NPO over night, so not only did he not get his evening dose of MS Contin, he never received any PRN percocet either after being transferred from PACU.
I arrived at 0630 for report, and walked into Harry's room at 0700. Harry sat huddled in his bed sweating and shivering, gown and sheets soaked, goose flesh visible on exposed skin, miserable. Harry spent a sleepless night in pain, and unbeknownst to him, narcotic withdrawal too.
Harry smiles wanely, "Well hello there young lady. I think I may have the flu! I'm not feeling so good …".
"Hmmm, I'm not so sure", I say.
The residents are making AM rounds as I check the med sheets. I find a tired looking pair at the unit clerk's desk sitting in front of computers, eye bags large enough to be hammocks for small rodents (an unwillng, irritable audience, but an audience nonetheless).
I explain the situation unfolding in ICU room 12. The female of the pair turns to look at the male resident, "An addict" she says. He nods frowning, never taking his eyes off the computer monitor.
Internally I'm steaming - Mt. Vesuvius - while externally my face is wiped clean of all emotion. My eyes are on the prize, which is relief for my elderly post-op patient who never should be experincing narcotic withdrawal in the first place.
"I believe this would be symptoms from the abrupt discontinuation of a legitimate Rx medication doctor … physical dependence".
Both residents stare blankly at me.
I get a verbal one time IVP order to make my patient comfortable until rounds get to him, advance his dietary orders, and allow his PO meds to resume.
Harry gets medicated, his symptoms subside and he feels much better. Later we have a talk about physical dependence and education ensues regarding his MS Contin for future need (Harry had another elective surgery pending in the near future).
Harry was surprised to learn he should not abruptly stop his MS Contin, and was dismayed to discover the commitment he had made to be free from the worst of his chronic pain. He worried he was an addict - it took much convincing on my part to reassure him that he was not.
Why was it I understood what was occurring when some of the staff interacting with Harry did not spot it for what it was?
I myself am an addict, now 25 years clean and in remission. Even though Harry was not an addict per se, narcotic withdrawal looks the same regardless of the reason for it - and I know personally what it looks like like whilst others may not.
When all was said and done, and Harry was transferred to the step-down unit later that morning I should have felt relief rather than uneasy. But sadly this was not the first or last time I encountered a scenario like this in my nursing career.
I, as many of my colleagues understand that not all patients who take narcotics routinely are created equal, even if the residents that day did not.Last edit by 3ringnursing on Mar 20, '17
Mar 23, '17Actually that is what I said. I do not care if they want to get high. Was not my drug of choice but could've been I suppose...I feel a bit sorry for anyone who is strung out on Rx meds given the hoops they jump through. Really I do not see what the big fuss is over anyone altering their mood, that is the whole idea behind alcohol...
Mar 23, '17Quote from SobreRNIf I interpret your post correctly, I think that you are grossly downplaying/understating the effects/consequences of alcohol and narcotics addiction. Addiction is often a tragedy for the individual afflicted and has negative effects and huge cost on society as a whole. If it was isolated to people simply "altering their moods" and had no other detrimental effects I'd agree with you, but that's far from reality.Actually that is what I said. I do not care if they want to get high. Was not my drug of choice but could've been I suppose...I feel a bit sorry for anyone who is strung out on Rx meds given the hoops they jump through. Really I do not see what the big fuss is over anyone altering their mood, that is the whole idea behind alcohol...
Alcohol and narcotic addictions often lead to a number of crimes, both violent crimes like assaults, spousal abuse, child abuse (and neglect), robberies and murder, property crimes/thefts and prostitution. Addiction often has very negative effects for the addicts themselves. Loss of job, loss of home, loss of custody of children, loss of health, loss of freedom etc.
My opinion is that as a healthcare professional it's not my job to "police" my patients. My focus as a nurse is to provide appropriate treatment for whatever the patient is hospitalized for, and not moralize about someone's personal choices or withhold medication based on my own personal opinions and biases. My decisions should be based on medical considerations and since I'm cognizant of the fact that I can't objectively measure what my patient is experiencing, in an acute care setting I will err on the side of "overtreating" rather than "undertreating", as long as it's safe (for the patient) to do so.
Mar 23, '17I think we have to remember that every patient in a bed is not our favorite person. Drug addicted patient's are difficult but as you tried to do was to re-evaluate yourself and approach which is very important in this situation. With drug addiction the doctor should be more mindful with as though it seems the patients drug of choice. I worked in dialysis early in my nursing career and quite a few patients would ask for there pain meds (talwin) which would be given direvtly into the blood port. It seemed as though they would get a rush from the drug then it would be gone. We must realize that this is a very real disease that once a person gets sucked in they have difficulty finding there way out. Being a goid nurse is not to be judgemental of the many issues that you will witness. Nobody knows what is down that dark path for us. I commend you on the soul seatching that you've don't and with time you will get better at if
Mar 23, '17I'm certain I've been considered one but there are many things you may not know or have considered from my viewpoint. Laying in a bed crying with a t.v. and clock in front of me, pain meds relief are often all you can think of. I learned a few years ago, that a local dr. labeled me for reporting him for charging me for a 4 k test I never had, many old folks too that had to choose between medicine, heat and food. I've had so many nightmares since.Gallstone with a migraine, they left in observation and I was so nauseous I had to put my finger down my throat which labeled me. I am smart enough to know what observation means. They missed my vein, would not send anyone to fix it so I pulled it out and signed myself out. Lay on the hot sidewalk waiting on my family as I had been already told I needed surgery so he was taking the kids home to make arrangements. Had to be rushed back the next day and the ER dr. stood outside my door to talk to my dr.afraid since he neglected me. Anytime I have gone in for a migraine I refuse narcotics, there is a combination steroid and non narcotic that knocks it out but they don't want to hear that. I laid in a bed while a nurse pinched my line, smirking asking if I was afraid to die. When my family came in in the a.m. I lost it and told them. I wasn't the only one. She was given the option of another carreer or the infirmary at state prison. I feel sorry for them though. Just home from hip replacement after a year of being bed-ridden. Leg 2 inches shorter so all stretched and they were sure to send me the meanest nurses the last 24 hours. I ask for pain med in pill form because it lasts longer and try to be a good patient, I know they're busy and I'm not the only one but there are some that do not belong in that field. I have met more wonderful than horrible though. But because someone is really in pain and wants their meds ( including aspirin and tylenol) we are not addicts.Last edit by wonderwhy on Mar 23, '17 : Reason: typo
Mar 23, '17When I was an a CNA many years ago at a public hospital burn ward, we had a doctor that thought it wise to include a can of beer on the meal trays of alcoholics to prevent DT's. It was cheap generic beer (it literally only said beer on the can) but it did the trick.
Mar 25, '17I like my patients high, much better mood. One memorable patient was growing annoyed because all his home meds were not ordered yet, finally got them and gave him his usual home meds (muscle relaxers and opiates) plus his IV Dilaudid. Within 5 minutes he was all smiles, eyes glazed over, totally snowed. I said to him "you are loaded!". Then I reassured him I was driving the gurney...He gave me one of my happier work memories.
Mar 25, '17Quote from Irish_MistYou are dealing with addiction. Their behavior is born of real sickness.The problem I have with all of the Jakes I treat is that many of them expect me to drop everything I'm doing all at once to give them their IV dilaudid and phenergan even if I am providing care to another patient. If it takes me more than two minutes (not an exaggeration), they pitch a fit. If I don't "push it fast" or if I dilute it, my practice and technique is questioned. If I refuse it due to them being hypotensive or difficult to arouse, I am nurse ratchet who doesn't care about their pain.
They are so nauseous and in so much pain yet they can chow down on potato chips and starbucks despite being NPO. They claim that PO Dialudid doesn't "treat" their pain yet will ask for it one hour after getting their IVP of Dilaudid. That's interesting. I thought it didn't "work". And then, down the hall you'll have a patient ready to be discharged home with hospice already in the active stages of dying who fervently denies pain whenever I try to encourage him/her to let me medicate him/her.
Don't get me wrong. I am professional and courteous to every Jake I encounter. If I know someone with undeniable pain is going to be discharged soon, I try to encourage them to move over to PO pain meds because we all know Dilaudid or Morphine IVP is not available at home. I cannot make someone change their ways and I cannot cure a drug addiction. If a pain med is ordered, I will give it if it is safe to do so. However, it is incredibly difficult not to resent these type of patients when they use manipulation to get their way and monopolize my time. I have other patients whose needs are just as important as Jake's.