Drug seeking patients? - page 3
What do people think about the term drug-seeking patients? I guess I have a hard time with it because usually these people are complaining of pain and who are we to judge whether they are or are not... Read More
May 16, '01I too say amen to majic Pain is Pain and is a subjective and individualized. I have fought many times with Surgeons who feel that their pts. don't have pain post-op! I also get angered at co-workers that feel the pt. can wait, It is a PRN correct?
May 16, '01I too have always believed that if a pt states that he has pain and would like his "pain pill," then I give his pain medication without any hesitation. The only question I have is, "What number is your pain On a scale of 1-10, 10 being the worst?" then promptly return with the medication which on my LTC unit is usually Tylenol, Tylenol#3, Percocet, or Hydrocodone. Once in a while maybe MSContin. We had an resident admitted at the end of April. Dx: PTSD, depression, schizophrenia- chronic undiff. type, alcohol dependency, Post-op (surgery in Dec.2000) for hydradenitis axillary and groin regions and also diabetes Mellitis. His surgical areas were slow in healing. Axcillary completely healed, groin area, still has some weeping drainage. The res. is 51 y/o, does own ADL's,and does his own TX which is intrasite gel with DSD, OD. He has a MS04 30 mg IM q6 h prn for pain which he has been receiving since his surgery in Dec/'00. He transfers to his w/c by himself and once he's in it, he's gone off the unit. He returns for his meals and his MS04, then off he goes again. If he is sleeping during the night,obviously he can't be in that much pain. When he wakes up, the first thing he asks for is MS04 and gets angry when staff dosen't wake him up for it and of course we explain that we won't wake him up to give him a prn med. He must ask for it. The only weaning of this medication since his arrival was changing the time from q6hrs to q7hrs. His pain level is always a 10, and has always been a "10" since the surgery. Should he have been weaned from this alot sooner, say like a week after the surgery??? He was admitted directly from the hospital where he stayed for 4 months and received all of this MS04. Now he's with us in LTC where the Dr. continues to give him this drug, but only one hour later. His history shows that he's been in and out of the Psych Unit for flashbacks of vietnam, hearing voices telling him to "hurt other people" which he says that he would never act upon, he's been admitted in detox for alcohol abuse. He is presently on Clonazepam, Resperdol, Zoloft, Nph insulin with coverage, and a few others that I can't even remember. He knows that as long as he has MS04 ordered, he is allowed to have it. Now I ask you all...Is he a "drug seeker," or someone who is just in alot of pain? Pain from post-op surgery or pain from being delt a bad hand in life and would rather be "numb" to all of it??? Eventually he wants to be d/c'd and go back to his apartment. Then what? If he continues to receive MS04 in some shape or form AND starts to drink again, he'll probably kill himself! I feel so frustrated on why his real problems aren't being addressed. Now social service is trying to get him an electric w/c to go home with. Sometimes it sucks being a nurse when you don't have any answers...
May 20, '01Nightowl, your alcohol abusing/addicted client is likely cross addicted to the morphine you're giving him. Now, I don't know the patient and there is alot I don't know about the situation so _my first statement is very brazen_, but nurses need to be aware of the risk of cross addiction to other substances. That means that when an addict's chemical of choice is not available they will use other chemicals and become addicted to other chemicals.
A consult by a physician who specializes in pain management and has experience in working with addicts would be useful. I think there are many relevant perspectives here. Does the client and/or his family WANT the addiction addressed? How do you folks feel about professional enabling? Are you willing to treat this as a harm reduction situation? (In face of the fact that no one is willing to address the addiction, are you willing to help him use his chemical in the least harmful/safest way?) The latter question may be your best case framework for the whole situation. I personally would be reluctant to enter into a power struggle with a patient when no one else (the patient, his family, his doctor) was concerned about his usage. You could get real tired.
This is a real life incident of you can run but you cannot hide from addiction problems in your nursing practice. If addicts have learned that cutting themself to put blood in their urine and acting like a kidney stone will get them a single shot of morphine, do you think they can fail to learn that replying "10" to a pain scale will get them a shot of morphine? I am not saying he doesn't have pain. But I am very concerned that their is a co-existing addiction problem here.
May 20, '01Molly, Thank you first of all for responding to my post. This senario is a tricky one I must admit. This particular client has family, but they are not supportive in his care at all. As a matter of fact, they haven't had any contact with him in over a year.
Most nurses on our unit would rather just give him the medication because as they state,"who wants to hear him." It would be a very exhausting experience to try to wean him off at this point especially since he has not expressed his desire to do so. He becomes extremely agitated when he doesn't receive the morphine on time even though it is a prn order and yes it becomes a power struggle!
I'm sure that he has a certain amount of pain, but in my opinion, alot of it is coming from within and morphine is helping him to numb that pain just like alcohol did before he had the surgery for hydradenitis.
At this point he needs alot of intervention from a psychiatrist, a pain management physician, his physician, the staff and probably needs to be on a unit that manages drug addiction because a nursing home is not a place for that kind of intervention.
If and when they decide to discharge him and it is in the making, my best bet is that he'll either be admitted to the detox unit for alcohol abuse like he has so many times in the past, or to the county morgue for morphine overdose. I would love to help this man, but his problems are much deeper than I can handle and it seems that no one else is willing to give me or him the support that he really needs. It's a real shame...
May 24, '01Originally posted by night owl:
<STRONG>...At this point he needs alot of intervention from a psychiatrist, a pain management physician, his physician, the staff and probably needs to be on a unit that manages drug addiction because a nursing home is not a place for that kind of intervention.
If and when they decide to discharge him and it is in the making, my best bet is that he'll either be admitted to the detox unit for alcohol abuse like he has so many times in the past, or to the county morgue for morphine overdose. I would love to help this man, but his problems are much deeper than I can handle and it seems that no one else is willing to give me or him the support that he really needs. It's a real shame...</STRONG>
This man has little to lose. He's lost his family. There is no job waiting in the wings for when he gets better. Right now, he's getting a warm, dry bed, meals and a nice, pure drug that is administered in a safe way. Of course, there is the question of what will happen when his wound improves and he leaves.
You may or may not be able to make a difference with this man by getting to know him, hearing him talk about his life and getting him to express what he sees will happen when he is discharged. the above 3 phrases may take a while to accomplish. A week? Two? More? depends on your time and his and he's actively using. Insight, when it comes, may come in a flash and leave that fast. If he talks about the wreckage of his life, you can ask, "how has alcohol or other drugs fit into this picture?" If he trusts you enough, you may start to hear that he recognizes that there is some good and not so good aspects to his usage. If you know him and like him well enough you can make a genuine statement about your worries for him after discharge. Try to echo worries _he himself has stated_. If he says something like, "After I get outta here, I'll probably go back to my apartment and go back to my routine. I know that my drinking makes it hard for me to buy food. And I forget to keep my leg clean when I drink." He may talk for a while about other issues. As a summary to your conversation, these are the statements you want to echo though. You can say something like, "I'm hearing you say that drinking lets you get together with your friends, but it makes hard to buy the food you need to stay well and hard to keep your wound area clean. I worry that it might be easy for that wound to re-occur and you were very sick with it this last time." Make enough eye contact with him to let him know that you find this is a genuine worry. If he let's you know his other worries, over time you can discuss with him what he has done to reduce his use in the past: AA, treatment, using alcohol subs (some are dangerous). There is no road map. Listen. Be genuine. Let him know you are concerned and willing to help him find more resources for this as he faces discharge IF HE IS INTERESTED. You may not even get to first base with this but you extend the concerned hand; HE MUST DECIDE TO TAKE IT.
Try to get a glimpse of the person that is not the obnoxious guy in MS withdrawal clamoring for his drugs that refuses to do what it takes to be sober and responsible. That guy is hard to like or even suffer in silence. Try to find the other person that is in there. Ultimately, you can offer the hand, he has to decide to take it.
[ May 24, 2001: Message edited by: MollyJ ]
May 26, '01WOW- I can't believe all the commets and suggestions I have recieved. This is a real issue and I think we have all come to realize that many people in the healthcare profession don't treat it as one. After thinking about this I have come to the conclusion that there are drug seeking patients out there but as patient advocates we need to help these patients and not put them off or call them pains. I think we could start by giving them the pain med that they want/have ordered and not chastize them. This will start somewhat of a trusting relationship and from there we could move on to the "real problem" and find some means of helping them get of the drugs we are giving them. I think that by using services that many hospitals have such as discharge planning, social services, etc. we can work together to help this group of patients. I also firmly believe that what a pt tells me about their pain is so subjective that I have no right to decide if what they are telling me is true, so until the day that the pain monitor is made I will continue to medicate.
Thank you all for all your input and let's keep working on this one!
May 27, '01I am shocked by those of you who think the term "drug seeking" is invalid!
Tonight @ work, a 12 yr old went through her usual night time ritual. Beginning @ bedtime, she asks for her Benadryl for "itching"; within an hour, she's screaming and crying in pain. I gave her Loratab. One hour later, screaming, kicking and crying in pain. I enter the room, she's hysterical..yet she can answer my questions in a calm voice. I indicate to her that if she's truly not in pain she doesn't need to act as if she is. This remark by me sends her back into her crying, kicking, screaming tantrum. I tell her I will go get her pain med. Immediately (before I can leave the room), she quit crying and quietens. We've done this same ritual for a week. Last night I gave her Vitamin C, she thought it was Lortab. It relieved her "pain". Tonight, I flushed her IV with NS, she thought it was Demerol. Again, immediate relief.
So, my point is..this child is obviously not in pain, "attention seeking" is my guess. However, by most of your philosophy, I should medicate this child anyway, because she SAYS she's in pain. Sure, I'll do it your way and a few years from now she'll be on your unit seeking drugs. Or another alternative is to get a psych consult and find out the real problem. Before I get attacked, the Grandmother (guardian) was aware of what I was doing as were the MD's.
I'm a very big patient advocate. Just as it is my job to control my patient's pain, it is also my job to find out the source of the "pain", be it physical or psychological. It'd be alot easier for me to give a narcotic, knock the patient out and not have to deal with her/him for another couple hours. With that, if pain is not the problem, then I'm only adding to an already sad situation.
Second concern of mine relates to the amount of pain adults generally have VS infants/children. It's a fact that the older we get, the more pain we have. A 2 year old has a T&A, requires moderate pain intervention. An 18yr old, same surgery, requires scheduled narcotics. This is just an example. Generally this is the case with any surgery. Is this because as we get older we learn to EXPECT pain?
Again, I'm pediatric post surgical. In six years, I've probably suspected 4-5 "seekers" at the most. I agree that the majority of pain is "real", but that does not change the fact that we have a responsiblity to the patient to treat the WHOLE patient. That includes any chemical or psychological dependancy.
Now with that said, I am a big advocate of keeping my patients pain free. Rarely, thank God, do I have to even consider if a patient is "seeking". The biggest problem I have is parents wishing to keep patient sedated so they WON'T hurt, or so they will sleep through night.
[ May 27, 2001: Message edited by: nurs4kids ]
Jun 6, '01This is a tough issue that can get very personal. I've had lots of experience working on Chemical Dependency and Psych units and spent more time than I like to think about sometimes with people who are recovering from drug and alcohol addictions. One of their favorite games is Doctor shopping to find the one that will give them exactly what they want (now it seems to be Vicodin and Oxycodone) and laughing behind their backs at nurses they can manipulate. I'd never question someone that is post surgical or only in for a few days every now and then. On the other hand, the frequent flyers that anyone who has worked in ER settings see will be enough to open the eyes of anyone who cares to see. Now I work in a Corrections facility where we don't allow narcotics *period*. Occasionally, someone will get some Darvocet for 2-3 days after a bad tooth pulling but other than that it's Motrin and very few Ultram for serious pain. Guess what? They make it. They aren't happy about it, but they make it just fine and many of them manage to work as trustees to boot. We've successfully gotten people off of a wide variety of prescription drugs in a very short time (including Methadone) and watched their temperaments as well as their bodys respond favorably. Not to mention that probably 75% of them are incarcerated for drug related convictions. I've learned to trust my gut (and vital signs and behavioral observations) before feeding into one more soul's destruction by continuing an active addiction. Most of them end up thanking me for it before they leave and I point them to the nearest AA or NA meetings to help them maintain a clean and sober lifestyle. Many of them verbalize their anger at Doctors and Nurses for not ever telling them the truth. "Why didn't someone tell me what was happening to me?" is a common thread among people who are serious about avoiding a life of addiction. Those of us that are secure enough and have enough understanding to 'tell the truth' may end up saving someones life.
Jun 8, '01When I suspect a patient is drug seeking (usually once or maybe twice a year) I provide the pain meds, but document behavior before and after the med, as well as when the patient is aware of being observed vrs not. Some patients get buzzed on a narcotic and move excepionally well when engaged in conversation but can barely lift an arm when requested to hold their own drink or stand to transfer to a commode. That all gets documented. I also ask for pain scale ratings before and after med admin. I find that they may report mild relief with the initial dose of med, and then no relief with the next dose even if the second and subsequent doses are doubled- because they are milking for the next, possibly better drug. If a patient has been observed and their responses have been documented over time I have also said to them that if they are not getting relief with any med, even after increasing the doseage, then the risks of taking it outweigh the benefits. I usually notice a marked decrease of request for drugs on my shift, and an increase during the next shift. Perhaps that is something to track-do pain med requests go up or down depending on the nurse assigned to the patient? Not sure how that study could be done without a lot of confounding factors, anyone have any ideas?
Jun 9, '01I do almost the exact same thing as the poster above. When >>>I<<< suspect someone is seeking--- and there are drug seekers--- I am very aggressive in finding out EXACT data from and about the patient so I can document it. I also let the patient know what I am doing. It is no secret.
I like to know why they are seeking. The high, pain, withdrawal.
I think it is just a matter of setting limits and conditions on their behavior.
However, having said that I find sometimes nurses can be pretty quick to say someone is seeking. If someone has a drug issue in the community, it is going to take MORE meds to efffectively deal with their pain,,,,,bottom line. Giving someone less pain med because they have a drug tolerance is torture and just bad nursing. We are not there to make judgement calls on how people live their lives we are there to treat them for the condition they came in for.
Jun 9, '01I have a question...If a pt has been getting morphine 30mg IM Q6h PRN around the clock, does there come a time when he feels that the dosage isn't enough anymore? In other words, after almost six months of receiving this med does he build up a tolerance to it and starts to need more for his addiction? His wounds are just about healed. Wouldn't you think his pain level would be decreased by now? At this point, our pt now wants to see the syringe to make sure he's getting 2cc(30mg) of MSO4. Had a nurse float to our unit the other day. He argued with her that he should be getting 3cc! Stated,"Everyone else gives me 3cc!!!" Nurse went back to double check the order and he gets 2cc, just like everyone else has been giving him. I feel he was trying to pull the wool over her eyes so that she would give him that extra cc. How long should a pt receive IM morphine? As long as the Doctor lets him??? He's manipulated the doctor to change the order back from q7h PRN to q6h PRN since my last post in May. At this point in time, I feel (and I know that I'll get blasted for this one)that we are just feeding his addiction. The doctor has given no indication in trying to ween him off. Nurses assigned to him have asked other nurses to give him his MSO4 because they say it goes against eveything they believe in nursing. One nurse in particular is a recovering alcoholic and has been sober for 18 years and still attends AA meetings when she feels she needs to. She feels so uncomfortable giving him his MSO4 because it goes completely against EVERYTHING she believes in not only as a nurse, but for her continued battle with alcoholism. This pt is becoming increasingly nasty to the nurses and two of them flat out refuse to take care of him. He verbally abuses them when his demand for the drug isn't met fast enough for him. He made it a point to verbally assault one of the sweetest nurses I work with at the nurses station, on a Sunday afternoon in front of many visitors. I'm just afraid that he may physically hurt one of us for this med. He is schizophrenic and has heard voices tell him to "hurt people" in the past, but said that he would never act upon it. Yeah, and that was before he was addicted to morphine! God knows what he may do now...Nurse manager says he has a right to the pain medication and there's nothing that we can do about it. Maybe she and the Doctor WILL after someone gets hurt! She used to be in psych nursing & worked with drug addicts??? Even I know that if an addict doesn't get his drugs or money for his drugs, he'll KILL for them if he has to in a heartbeat and think nothing of it. That I learned from the news broadcasts on TV, not sitting in a classroom learning about, "The addict, and his deadly potentials..."
Jun 9, '01Hi Night Owl, Sounds like you are still struggling with this very difficult circumstance with very little will to change from the patient or the doctor (or the family based on prev posts).
I have mentioned Least Harm Interventions before and I think that this re-frame is the best you are going to do here. Least Harm is a public health concept where you switch a patient to an intervention that is designed to reduce the harm associated with a behavior they have since they are unwilling to entirely stop the behavior. Alan Marlatt is a psychologist who has studied and worked with Least Harm extensively and written about it. Handing condoms to teens who are having sex is a least harm intervention, as is giving them birth control. Needles exchange programs are least harm interventions.
Here is a cutting from Dr. Robert Westermeyer's web site from a web article called _Harm Reducation and Illicit Drug Abuse_. Of course your patient is not abusing (at this time) illicit drugs; he is abusing prescription drugs with the assistance of a doc who is reluctant to confront. Here is the link to the whole site: http://www.cts.com/crash/habtsmrt.drugs.html
"Working with addicts, from a harm reduction perspective, involves accepting that some people simply are not going to give up drugs at this time. Offering them services nonetheless, opens the door to helping these people reduce harm in some way--even an infinitesimal way--that wouldn’t otherwise occur. Small reductions of harm are better than no reduction (and definitely better than exacerbation). An open door policy can result in a harm reduction snowball effect: small improvement can pave the path for further reduction of drug use and an improved lifestyle in other ways. This snowball effect can continue, eventually to the point of abstinence.
So how do you help an addict who doesn’t wish to quit:
1. determine if the patient’s use patterns could be altered to reduce harm.
2. determine whether other aspects of their lives could be focused on to improve health and enhance likelihood of abstinence.(therapy for depression, anxiety, referral for medication for psychiatric disorder or for a pain-causing medical disorder)
3. Motivational interviewing to help patients tip the scale of ambivalence in favor of change.
4. discussion of switching substances to one with less associated harm.
5. discussion of gradual reduction toward abstinence as an alternative to cold turkey."
You know, unless this doctor intends to dismiss this man on injectable MS, he is setting him up for MS withdrawal at some point when he is discharged. Again, consult with a pain management doc and addictionologist and someone who is experienced in DUAL DIAGNOSIS patients would be helpful here. If he is nearing discharge, make contact with his mental health services case worker, if he had one, and get him one if he didn't.
If I were able to assemble the team that I mentioned (his primary doc, mental health caseworker, dual dx expert/addictionologist, pain management person) the question I would have at this point include: Can we start switching him to methadone with other non-addicting pain adjuncts (ie TENS)? Can we start him on a pain management contract using less addicting meds? Are his schizophrenia care needs being addressed in this time of additional stress (Dual DX expert)? Especially critical that discharge planning start on this guy 4 to 6 weeks before anticipated discharge.
Your colleague who is in AA will be very conflicted by him as are all of you. This is a prime example of what happens when addiction is tacitly ignored by all. Like the AA prototype, it becomes the big, smelly, poop dropping pink elephant that sits on the couch in the family living room that NO ONE TALKS ABOUT. Obviously, you and your colleagues are way past discussing whether or not legal drug abuse exists. But you may feel dirty and used, and that gets old. BTW, some people would be very comfortable with what the doc is doing: he is providing the patient a legal drug in a controlled and safe setting and that is harm reduction. However, you are getting caught in his desire for escalation of his use (increasing tolerance). The man is also not being asked to look at anything about what is happening, either, as Westermeyer suggests they should be.
One last note: AA is not really into Harm Reduction. To me, it is really hard for people to have a really functional life if they keep using. But we may be able to make him MORE FUNCTIONAL if we don't keep feeding that MS addiction. I think he may need methadone maint or something like it after discharge (if he's willing to comply with it).
Good luck. Complex case, difficult situation for staff.
Jun 9, '01The problem continues and your objectivity is out the window. TV is not the place to learn how to treat addictions. You don't have to worry about his killing anyone unless he doesn't get his drugs. So-o-o, give him his drugs, and then work on how to get him into the appropriate program. Your facility is not the place for him at this point in time. MollyJ has taken the time to write you a plan. Make a copy. Take it to the doctor. Present your case logically and rationally. Please - refrain from preaching. Good luck!
[ June 09, 2001: Message edited by: mustangsheba ]