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?

[russianbear]

It doesn't appear that anyone ever argued that drug seekers don't exist or that it's fine for physicians to order opiates for the sole reason of 'feeding their addition'. Maybe you could specify where you feel that statement was made?

Clearly you've not been reading this thread.

[MunoRN, RN]

Clearly you've not been reading this thread.

I've read through it a couple of times, no such statements exist.

[NottaSpringChik, BSN, RN]

None of these things justify holding a pain medication.

I don't think the poster was suggesting the pain medication be held. I think they were suggesting more information and communication with the patient and shared with the physician to customize a pain management.

[ComeTogether, LPN]

We recently had a patient on our sub acute unit who was 100%, unequivocally a drug seeker and addict. What was so upsetting though, was that this person had a seriously horrendous past most of the staff was aware of. Think saving private Ryan meets a clock work orange - that bad.

I noticed this didn't stop any of her primary nurses from referring to her as "my drug seeker" or "the addict" every time the bell rang. It made me really sad, especially as the sister of two addicts, to see this happen.

I wasn't ever this persons nurse, so I didn't get to experience it myself, but I really hope this mentality starts to become the exception and not the rule.

[CG1979]

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?

[Rocknurse, MSN, APRN, NP]

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?

By 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.

[Rocknurse, MSN, APRN, NP]

Since 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?

[BostonFNP, APRN]

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?

Again, 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.

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.

[ComeTogether, LPN]

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?

Jake 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.

[macawake, MSN]

How many people do you know personally who have died because of an epidemic that we play a role in?

Why did you ask this? Have you lost someone close to you to addiction? Is that what's affecting your response in this thread?

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.

Something seems to be affecting your interpretation of what posters have written. I've reread this thread and I can't find a single poster/post who has claimed that "drug seekers" don't exist.

...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.

(partial quote and my bold)

Now, will you be courageous to say that physicians should not order them narcotics for the sole reason of feeding their addiction?

(my bold)

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.

[3ringnursing, BSN]

A 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.

[K9lover, ASN, RN]

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...