Hi, So this is huge problem, as you have indicated. And difficult in the field to manage, but no impossible.
He can not be taking all meds. I would say, report to physician what the
patient is doing, and if you havn't already, notify the primary doctor now that prior to recent hospital admit patient was taking the med and not doing regimen as ordered, non-compliant. chart the physician was notified. The patient who is on a vent doesn't need to have decreased resp drive as he is at higher risk for pneumonia, right?
SO, must notify doctor, of non-compliance, of mental and cognitive changes in am, of continues c/o pain with altered mental status.
Can suggest to the physician that he be seen by pain medication team while in hospital to create a discharge plan that the patient and family agree to.
Family needs education, possibly patient too (although you already seem to know that he is not open to going with the plan), therefore enablers need to be educated to updated pain management system, and your expectations of compliance by all. Who is refilling the prescription? I assume he can not do that himself.
As long as all is documented and all providers/specialists made aware, you are ok and just have to chart everything, and monitor respiratory status.
Sounds like you know the client pretty well. Be forthright with physician, tell him you suspect dependency issues and discuss if with him your concerns. Ask him, based on my clinical findings and observations, do you feel this is a problem? Do you have knowledge of him being dependent or non-compliant in the past? What have you done about it? What should the plan of care be going forward?
Don't doubt your clinical findings, and BIGGEST THING OF ALL ::::::
COMMUNICATE!!! Don't hold back.
OH, BIGGEST THING OF ALL :::::
DOCUMENT EVERYTHING! education, findings, patient response, family response, physician notification, physician response, collaboration with other nurse and confirm findings documentation, and notification of clinical supervisor. You did right though, good job in a stressful situation, look for resp changes.