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

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    Every nurse knows the frustrations of caring for a patient with a substance abuse disorder. Read about Jake...you may have met him.

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

    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 phenomena 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 somethings 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?
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    71 Comments

  3. by   BlackMagicGypsy
    I really enjoyed this article!
    It is so sad when patients are surprised to be treated like people by medical staff....
  4. by   nutella
    I think that self-awareness, self-reflection and mindfulness are generally good ideas when coping with feeling manipulated, supporting an addiction, and questioning motivation, needs, ad truth.
    I think it is also true that it is helpful to clearly see ones limits - my power as a nurse is limited - I will not change the patient through trying to "parent him into insight" or that he will suddenly have an epiphany.
    Other strategies are to
    utilize policies that require to administer dilaudid via infusion over 15 minutes and could be ordered by the MD as it will not produce the "high" as much
    ask for a pain consult if patient has reasons to be in pain as it can be very difficult to control pain when the person is also using or has been using and a pain service may be able to recommend something that is better for pain control or combinations
    Use "care plans" for high utilizing patients with pain "problems" including clear guidelines of what medication may be ordered and so on. We utilize care plans so that everybody is doing the same thing to avoid further manipulation and message congruence.
  5. by   macawake
    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
    These patients are tough.What’s your experience? What helps you get through your shift?
    I can honestly say that I've never once felt tarnished, used or complicit in a patient's addiction. I have however sometimes felt that patients try to manipulate me. Not every patient who tries to manipulate me is addicted to opioids, people from different backgrounds and of different personality types do this. In my opinion it's just par for the course when dealing with a cross section of humankind.

    I definitely don't regard myself as a compassionate angel of mercy. I associate such an self-image with someone teetering precariously atop a pedestal with an inevitable brutal crash landing looming on the not too distant horizon. I think that it places unnecessary stress on a person to have that self-image and try to live up to that unrealistic standard. We're all just human. I'm rather pragmatic about my profession. I do try my best to do right by my patients by keeping current with evidence-based medicine/practice and treating folks like I'd like a loved one or myself be treated if we were sick/in pain /scared/ hospitalized, but at the end of the day to me, nursing is a profession, not my identity.


    Now I'm not sure if you OP personally experience all the thoughts/feelings described or if it's an illustrative amalgam of various thoughts expressed by many different posters in previous threads on the subject? When reading how Jake makes you feel my first reaction is that you're giving Jake way too much power. We can all decide how we choose to react to someone else's behavior. I make an active choice to not allow someone else's behavior sour my mood. Sure, I need to remind myself about this occasionally but it really does work.

    OP, I like the rewind, try again new tactic you describe at the end of your post It's win-win. A nurse who chooses that approach will benefit from it, so will the patient. The nurse doesn't have to have her/his shift ruined by experiencing negative, non-productive feelings and the patient doesn't risk having their pain undertreated due to a nurses' personal bias/judgment.


    On this admission, Jake had an appendectomy. He also has a substance abuse disorder.
    My advice, focus on the fact that Jake has had a surgical procedure. That is after all what's relevant here. While I personally can't fathom why anyone would ever want to play Candy Crush, poor taste in games shouldn't mean that we don't treat post-surgical pain appropriately All patients deserve that.



    Pain Intensity on the First Day after Surgery:A Prospective Cohort Study Comparing 179 Surgical Procedures | Anesthesiology | ASA Publications

    Results:: The 40 procedures with the highest pain scores (median numeric rating scale, 6–7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many “minor” surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of “major” abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia.
  6. by   russianbear
    Drug seekers are a problem and sadly nobody wants to address it. "Pain is what the patient says it is" makes as much sense as "the customer is always right." No, the customer is not always right. The only problem with your scenario is you indicate Jake has recently had a surgical procedure. That causes pain. Change the scenario to "Jake presented to the ED having bumped his arm on his kitchen table, has no bruises, no fracture, nondislocation and was admitted because he screamed at the ED doc, called th nursing supervisor and heartened to sue if they didn't make him comfortable." Oddly enough, the hospitals which utilize carenplans don't get this as often.
  7. by   Irish_Mist
    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.
  8. by   Lev <3
    I have dealt with many "Jakes" and I will dilute their pain medicine and push it over the recommended minutes.
  9. by   Alex_RN
    Excellent article.
  10. by   ohiobobcat
    Quote from Lev <3
    I have dealt with many "Jakes" and I will dilute their pain medicine and push it over the recommended minutes.
    And I don't "flush it fast". When asked why, I tell them, like I would any other patient, that if I push the med too fast it could slow down their breathing enough that I might have to help them breathe, and I would rather not do that today if I don't have to. I used humor when appropriate and firm boundaries with people like Jake. Sometimes it worked, sometimes it didn't.

    This is a good article because I struggled with some of those feelings about addicts when I was a newer nurse.
  11. by   russianbear
    Quote from ohiobobcat
    And I don't "flush it fast". When asked why, I tell them, like I would any other patient, that if I push the med too fast it could slow down their breathing enough that I might have to help them breathe, and I would rather not do that today if I don't have to.
    Or, you can also add that we are not enablers and will not help them get a fix. This "I'm gonna take the high road" stuff is getting old. Drug seekers are a drain. They drain resources. They drain the energy from staff. You know, there are facilities that do things differently. They don't give seekers Dilaudid Q3H for vague pains. Guess what they have fewer of? Why can we not be honest about this problem? Not to mention how we've created a disgusting opiate epidemic.
  12. by   oldpsychnurse
    Psych is full of drug addicts. I always tried to be very nonchalant when dealing with them. If you try to reason with them, it turns into a power struggle. Some of them will talk with the nurse about their addiction (while we're pulling the opiate of the hour out of the pyxis) but most of them deny having any problems. If you can make the interaction as pleasant as possible (while explaining to them on day 1 that you will always get their meds as soon as possible but sometimes you can't be there that very second) it's easier for them and you. I also tried to always work with the doc to get their prn's and scheduled meds as in synch as possible. That cuts down on their constant requests and also seems to make them more satisfied with their meds. And my posts are in the past tense because I finally got out of nursing. I had enough of the patient and family centered waitressing, and kow-towing to addicts was a big part of it.
  13. by   cwentworth
    This was a fabulous read. I also have experience working with patients with addiction in the ER. To say it's "frustrating" work is a gross understatement. In any other context, their behavior towards us would be considered abusive. Like many of you, I've been called vulgar names, had my life threatened, had objects (usually food items) thrown at me. If I went to Staples, demanded a turkey sandwich and a giner ale and then proceeded to melt down in the store when I was told, "it might be a little bit", I would be arrested. However, I remind myself that these people are sick. They are emotionally, physically and spiritually bankrupt. Their drugs have robbed them of any positive qualities and ability to care about their life or the lives of others. Fortunately, I am in the position where I bare witness to their recovery. I witness the benefit of your hardwork, nurturance and compassion. Knowing that recovery is possible maintains my equinimity.
  14. by   SobreRN
    I find it odd anyone has such issues over other folks addiction; hubris and judgement although the author appears to recognize some of it. I've held a personal theory for some time that the nurses' who react in a strong & negative manner have past or current issues with an addict and/or alcoholic much closer to home than the patient (i.e. untreated AlAnon.)
    The reaction is just out of proportion to the situation, I don't see nurses carry on that an NPO patient thinks they are 'starving' 2 hours into NPO status and really, I would not say people who cannot go 2 hours without thinking about food have a healthy relationship with food.
    Repulsed? That is extreme although when I was in acute care I did find myself mildly annoyed by everyone saying pain was 11/10 but they are addicts and addiction is a disease...I actually have more respect for street drug addicts and just go to their connection rather than exploiting overcrowded ERs and playing that it is not an addiction if the nurses pushes it; at the end of the day if it is safe to give and it is ordered I just don't care if they want to get high, I am not their 12-step sponsor.

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