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?

[jdub6]

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.

I obviously am not inside the head of the member to whom this reply is directed, but i do agree with some of that person's opinions and my reasoning is a bit different than what you are describing. i will say right off the bat that many years ago i was ruining my life with an addiction to heroin and cocaine that began when i recieved narcotic pain meds, used exactly as prescribed, for acute on chronic severe pain for a condition diagnosed based on imaging and labs. I have spent years in the recovery community meeting addicts (many of whom are health care workers) -some in stable recovery, some chronic relapses and some in active addiction. some have died, gone to prison, become permanently disabled etc. so my view is certainly biased but also based on lots of experience.

I am frustrated when spending an hour getting an IV in someone with scarring from either old iv sites or needle tracks so i can give them dilaudid after they came to the hospital for chronic pain-again- and either have had a negative exhaustive workup or no workup because they never follow up. It's not that i want to deny an addict their fix or that i believe i can cure them.

Rather i have 2 reasons:one being that as heroin use and related deaths skyrocket, the vast majority of new users started with prescription drugs,often taken as prescribed for legitimate pain. the other is that evidence does not support the routine use of narcotics for chronic pain.

someone who is "seeking" may be at the point of abuse but not addiction. if my doctors had stood their ground when i began to display classic seeking behavior and my condition was improving, there's a good chance that my life would have been very different- because at that point i love my dilaudid but had not yet developed the strong craving and my physical dependence was mild. (I'm not blaming the docs at all for my addiction though). At that time i truly believed i needed meds to control my pain. and they did control the pain. at first. as my tolerance and addiction increased, as happens with many chronic pain patients, i found that very large doses did still help but that overall my pain continued to get much worse. soon i found myself also dealing with withdrawal symptoms within hours of my last dose. eventually the original painful condition and my withdrawal could only be relieved with iv heroin.

Encouraging any and all alternative treatments is compassionate in my opinion-if someone is at the line between addiction and not, cutting off their supply could prevent a full blown devastating addiction. Also, evidence does not support the idea that narcotics are the best treatment for chronic non-cancer pain- despite the anecdotes, studies generally show that narcotics do not improve general function, ability to work, quality of life or even average pain level long term. in fact the stronger and long acting narcotics fare often FDA approved only for cancer pain. those taking them long term often end up with withe true opiate induced hyperalgesia or simply finding that eventually opiates don't work for them at all for any reason regardless of dose.

it is a myth that people who take their meds as prescribed when they truly feel severe pain do not become addicted. if the predisposition is there, they will. and then there's all the other risks-increased falls, respiratory depression/ failure/ fatal OD (which can also occur in someone taking meds as prescribed)/major depression etc

for some fascinating reading check out the complaints filed in the lawsuits brought by various states against pharmaceutical companies (available free online with some searching). very enlightening about how access to narcotics has changed, including thefact that the American Pain Society and other "professional" groups (responsible for the push for pain as a vital sign and aggressive pain management including opiates for chronic pain) were nearly entirely funded by the Big Pharma players who were marketing new opiate painkillers.

[jdub6]

Precisely. We are not in any way shape or form, in the acute care setting there to diagnose/ try to treat , or judge an addiction!!!.... we are not substance abuse counselors , or addictionologists !!! It's not the time nor the place to even Adress it.

I'm sorry but i have to disagree with that last sentence. certainly nurses do not diagnose addictions or provide therapy/ rehab. and obviously if someone is, say, intubated after CABG, or on the burn unit with 80% burns, or otherwise in critical condition or too sick to really think about anything then you don't address it.

But someone awake, alert, recouperating steadily and expected to make a full recovery, like Jake, can and probably should be addressed while in the hospital if there is a known diagnosis of addiction or if the patient reports and/ or displays red flag behavior. I'm not advocating addressing it by simply withholding need. at the same time, if the patient was admitted for something that is not seriously painful and/ or depending on the substance they abuse, they should be offered appropriate detox meds-perhaps this is an ideal chance for them to start the road to recovery (esp if admitted for consequences of their addiction). if there is acute pain and it's not the time for detox you can still provide a referral to rehab once discharged and lots of education on the health effects of substance abuse, the resources available, and in some cases perhaps obtaining narcan at home. also providing encouragement, and treating them respectfully while gently refusing to validate or support their rationale for addictive behavior can go a long way. this can be done by SW,chaplain and/ or nursing.

i also believe that the provider needs to discuss this with the patient as well, encourage them to obtain treatment and assist in connecting with resources if they agree. The provider also can discuss harm reduction such as needle exchange, narcan and risk factors for OD. with opiates and alcohol the provider can discuss pharmaceutical treatment (naltrexone, methadone, suboxone, disulfiram) and provide a prescription on d/c or for methadone/ suboxone refer to a qualified provider. a psych consult is also not a bad idea to assess for untreated mental illness that may be contributing to addiction and start treatment if needed.

[jdub6]

Yes. Furthermore, the opiate dependent/ addicted actually requires MORE pain relief , post op / post trauma etc than a patient who is opiate naive...

Surely all the RNs here do know this, understand it, and keep it in their mind while a " Jake" is in your floor, post op, and reflect this knowledge in your treatment of " jakes"???

And this is why we should be cautious about prescribing narcotics in the first place....because with people dependent on high doses (legal or not) it is often (though not always) literally impossible to safely provide a dose that will relieve their pain to the same degree that 4mg morphine will work for someone totally naive. being "compassionate and non judgmental" while providing script after script for percocet for a 30 y/o with chronic toe pain and negative workup may actually leave that 30yo in a bad spot when he nods off behind the wheel and has multiple long bone fractures.

and tolerance to (certain) uncomfortable and dangerous side effects is not always equal to tolerance for analgesia and euphoria....carefully titrating to the level needed to begin to relieve pain can in fact lead to stat narcan when they turn blue. I've seen it happen.

ETA: someone with no signs of addiction and chronic pain on, say, percocet qid can also be harmed more than helped in the long run. i recently had an elderly patient admitted for pna. chronic back pain on percocet. she reported constant moderate pain but remained functional and in her own home with her husband. following protocals for her report of 7/10 pain the MD orders IV morphine for pain 7-10/10. this woman's pain is exactly at baseline, no worse from her pna. she liked the IV morphine and began taking it basically ATC everytime she came back in with more respiratory disease. when discharged after about 8 days, she reported that suddenly the 5mg percocet she took for years stopped working and asked for morphine. MD wrote for oxycodone 10. pt fell 5 times in three weeks, required surgery for fractures and now lives permanently in a nursing home away from her spouse with minimal mobility (and thus even more frequent pna) and chronic pain worse than ever due to the recent fracture as well as immobility. was the IV morphine and resulting increased oxy with modest reduction in pain initially really the kindest thing for this woman?

[BostonFNP, APRN]

And this is why we should be cautious about prescribing narcotics in the first place.

The key part of this, which differentiates from the original post/article, is are you personally prescribing the narcotic. If you aren't, then the rest is a moot point.

...because with people dependent on high doses (legal or not) it is often (though not always) literally impossible to safely provide a dose that will relieve their pain to the same degree that 4mg morphine will work for someone totally naive.

Do you have some evidence that it is "impossible to safely provide a dose that will relieve pain"?

[wonderwhy]

You call it Disgusting" but do you feel that way about alcoholisim or obesity? All addictions. The desire for something over your health and common sense that is detrimental to your health and often the time and safety of others.

[RNOTODAY, BSN, RN]

I'll re iterate ... just because a patient is an addict, OR a chronic pain patient on a **** load of narcotics from pain management....does NOT mean that we disregard or minimize their pain... especially after a surgery!!

its simple... If a patient is on xyz on a regular day, do you not think that the pain of whatever they Had done requires MORE pain meds to control it? BECAUSE ITS TRUE...It's really simple . Daily meds for baseline pain will NOT COVER SURGICAL/ADDITIONAL PAIN!!!

Also... you might be willing to bet your mortgage that a patient is an addict. But... guess what? In the acute care setting, it's irrelevant. You are not going to cure the patient, teach him a lesson or any of that ...addressing the addiction you believe is evident in the setting in this article a inappropriate... the PT isn't going to attend their first NA meeting from what you have to say, so save it, and do your JOB as pertains to the setting in which you work!!! you are not an addiction counselor, or an addictionologist ... it's simply not the setting or time to even Adress it. The patient has orders for pain meds ? Guess what? You GIVE IT TO THEM!!! On time , as ordered, and with the same courtesy and smile you gave a previous " non addict " patient, in your opinion . Do you really think the doc doesn't know the score? It's beyond your scope, it's not the time, it's not the place to even Adress whether l " jakes" and " Jill's" are addicts!!!..I know many nurses WANT it to be within their scope and control.... but IT IS NOT..... so cut the sanctimonious nursing care , and medicate and advocate, as ordered , for ALL jakes and Jills.... because it's YOUR JOB

[RNOTODAY, BSN, RN]

I'm sorry but i have to disagree with that last sentence. certainly nurses do not diagnose addictions or provide therapy/ rehab. and obviously if someone is, say, intubated after CABG, or on the burn unit with 80% burns, or otherwise in critical condition or too sick to really think about anything then you don't address it.

But someone awake, alert, recouperating steadily and expected to make a full recovery, like Jake, can and probably should be addressed while in the hospital if there is a known diagnosis of addiction or if the patient reports and/ or displays red flag behavior. I'm not advocating addressing it by simply withholding need. at the same time, if the patient was admitted for something that is not seriously painful and/ or depending on the substance they abuse, they should be offered appropriate detox meds-perhaps this is an ideal chance for them to start the road to recovery (esp if admitted for consequences of their addiction). if there is acute pain and it's not the time for detox you can still provide a referral to rehab once discharged and lots of education on the health effects of substance abuse, the resources available, and in some cases perhaps obtaining narcan at home. also providing encouragement, and treating them respectfully while gently refusing to validate or support their rationale for addictive behavior can go a long way. this can be done by SW,chaplain and/ or nursing.

i also believe that the provider needs to discuss this with the patient as well, encourage them to obtain treatment and assist in connecting with resources if they agree. The provider also can discuss harm reduction such as needle exchange, narcan and risk factors for OD. with opiates and alcohol the provider can discuss pharmaceutical treatment (naltrexone, methadone, suboxone, disulfiram) and provide a prescription on d/c or for methadone/ suboxone refer to a qualified provider. a psych consult is also not a bad idea to assess for untreated mental illness that may be contributing to addiction and start treatment if needed.

Respectfully disagree... the acute care setting, post op is not the time nor the place, in addition... most of the time there's not enough time to even make that assumption that one is an addict... they might just be a patient with a low threshold.post op, in the hospital is NOT the time for this....

[eternalbride]

This article provided an insightful perspective and I'm glad to have read it.

On a side note, drug abuse /addiction is an epidemic. That needs to be dealt with more agressively.

Drug addiction should be recognized as a disease that needs to treated. In an acute care setting, it seems to be brushed over and enabled.

Patients with these issues should be provide resources, a plan, and education ( rehab, counseling, etc).

Whether or not the patient is compliant, at least they are more informed and have the choice when they are ready.

[RNOTODAY, BSN, RN]

I'd just like to add, a post op Jake, and a vague complaint Jake, are two different things... the post op Jake, due to tolerance, requires MORE pain coverage than an opioid naive patient......

[K9lover, ASN, RN]

Indeed regs did increase Heroin use, I saw that coming. Now they could always make it illegal to alter ones mood...Wait we already do with everything except alcohol. The drug scheduling laws were written on a cocktail napkin.

[K9lover, ASN, RN]

Well said!

[Guest957596]

I had a dialysis patient who was noncompliant. When she came into the hospital, she was "allergic" to everything but Dilaudid and Phenergan. She was on a Cardene drip for her out-of-control BP. When I tried to titrate the drip, she would refuse. Yet she called for her pain meds on the exact minute. She would tell me not to dilute her Dilaudid! I explained to her I had to and she would watch my every move. She would soon ask for her IV Benadryl after the former two meds. I told her NO. I wasn't going to basically sedate her and not treat her HTN. So later on, I talked to the MD and PA and got them to cancel the pain/antiemetic meds and only give her Tylenol for pain. Guess who signed out AMA? Job done!