Drug seeking patients?

Nurses Safety

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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 in pain. On the other hand, though, they are usually patients who are hospitalized frequently but may not have any medical reason to be there besides pain. What are your thoughts?

I 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..."

Hi 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.

The 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 ]

Preaching? I'm sorry if I sounded like I was preaching I certainly didn't want to make anyone uncomfortable with my and my staffs problem. I planned on taking a copy of MollyJ's plan to work and maybe I can get the doctor to start helping this man instead of doing nothing with him...Thank you Molly J for your advice

:) ~nightowl~

I didn't mean to imply that you were preaching to us, Honey. Just not to sound that way when approaching the doc. Probably didn't need to say that, did I? Sorry.

I know that we all have heard the term "drug seeking patient". Until Nov. of last year, I had never had myself or family treated like a drug seeker. My sister age 36 had been fighting breast cancer for 4 years. I won't go into details. She was supposedly in remission when she started haveing sever headaches and vomiting. Was hospitalized for a week on morphin IV. All scans wee neg. Spinal fluid neg. except for very high pressure. Dc'd home. We made it for 4 days. Pain became worse. Went to ED at a regional size hospital. She had never ben through the ED befor. The nurses drug their feet. I could tell by their atitude what they were thinking. I had to stay on them to get her meds all the while my sis is crying and begging for a shot. Scans still neg. Admitted and put on morphin PCA pump.. The next night, while she was sleeping we went for dinner. When we returned, kThe neurologist had dc'd her pump because of change in level of consciouness. We could here her screaming when we got off the elevator. We found out that there were Ca cells in her spinal fluid. She was confused and disoriented. Pulling at everything. A "nurse" was telling her to quit pulling at things. We finally got morphine restarted several hours later. Do you have any idea how difficult is is to watch your sis screaming and crying in pain? Karla died 18 hours later. I have never been so disappointed and disgusted by some of my fellow nurses. I hope never to see that again. My point is to be very careful how you treat patients. One day you or someone you love may be in that situation. Tricia

Tricia: I am so sorry your sister suffered. One more case history to support the argument for treating pain as reported by the patient. It is better to medicate an addict than to NOT medicate a patient who is suffering. The picture of a loved one suffering stays with us forever.

A difficult situation and we are sorry for you, your sister and her family. Again, the problem of the severe pain vs drug seeking dilemma is that these are not black and white situations and being with people that are in unalleviated pain is very difficult for those that have to be there.

I am sorry.

Hello yall,

I find the discussion about pain management very interesting. Pain is indeed the 5th vital sign and I have always acted as patient advocate even before it was mandated by any of our governing commissions. :D

We have all had those patients who seem to be seeking instant gratification from our pharmceutical resources and we have seen the suffering of those who have had less than adequate pain management.

This past weekend I was a pt in the ED where I work. I had fallen and twisted my foot. I could not touch my foot to the floor without screaming with pain nor could I even take the bumps in the road on the ride to the hospital due to the agony it caused. The wait was not long in actual time however my foot told me we had been there a week or more!!!!!!

My foot was x-rayed and luckily there were no fractures. I was seen by a P.A. and in his opinion and past experiences "sprains don't hurt that bad"...I described the pain on a scale of 1-10 as a 10 consistently...told him that I was having muscle spasms and if he didn't believe me all he had to do was look at my toes flexing and twitching...the vascular system of my foot was visibly throbbing. He gave me a prescription for an NSAID and would not listen to me when I tried to tell him that I have a sensitive GI system,in fact he just walked away from me. My husband asked for me to be given something for the pain and the P.A. raised his voice and said "we don't give narcotics for sprains".

Well...then he turned on his heels and said "you're welcome"

:o The next 36 hours were horrible and I experienced a lot of pain ....a LOT of pain. Oh yes,I applied ice packs and elevated the extremity and did all of the pallative measures I knew to do.

I cannot really express how this experience has made me feel.

No,I did not have cancer! No,I did not have a GSW! BUT...I was having pain...I presented with "10" and I left with the same "10"!!!

No medication was given to me for pain control in the ED. The prescription he gave me caused nausea and vomiting.

I feel the pain management guidelines and assessment tools are a farce until there is a seminar that dwells on the meaning of the word "subjective".

My health care plan does not pay a lot when used at another facility...HOWEVER.......due to the fact that I was not treated as a human being, I will not subject myself to this inhumane person who rates pain on his "personal experience" of pain. I will gladly pay 80% of the costs if I can find a facility that has personell who use the JCAOH mandated subjectivity to any discomfort or injury I may have.

Thank you for letting me vent...the shoe was really"on the other foot"this weekend and I have been livid that I recieved less than adequate care where I work. Geesh!!!!!!!!!

I have filed a complaint through the proper channels. We shall see what the outcome may be.

Gimpily your colleague!!!!!!

suzannasue

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

Hi y'all? Hey another southerner? Wow. I'm not usually in this forum, but boy a nerve got tweaked when I saw this thread.

Most of my career has been in adult orthopaedics in a major teaching hospital. Our patients had PAIN!!!! Try having the top part of your femur sawed off and a new hip pounded in there!

On the other hand, because we were so skilled in pain med management and epidural and PCA management, we got many, many sickle cell crisis patients. Have you ever SEEN what SSC does to a person? It is agonizing. It's a constant TEN . Unfortunately the meds that make it bearable also make for addiction.

Our folks were "frequent flyers," but I seriously doubt they sold their pills after discharge. A slight change in the weather, a gals period, or even stress could set off a vaso-occlusive crisis. They asked, I gave. Most of the time it was for agonizing pain. Let me tell you a "10" can't usually do anything but scream!

Now *I* became a pain patient myself after my work injury. I can't say that I had a 10 with the herniated disks, but I surely had a "9." I finally went to a pain management doctor because......yes *I* was drug seeking! I was IN PAIN!!!! Fortunately he believed me and gave me a short course of narcotics including fentanyl patches. Only 3 weeks to get me out of pain so I could cooperate in therapy.

You say that folks walking and talking and laughing CAN'T be in pain? Haven't y'all heard of DISTRACTION?? I would get up at night and walk and lean on walls to try to forget about my leg that was on fire. I said I had PAIN. The doc believed me. The pharmacist even delivered the med to me.

Believe me. PAIN should be the FIRST vital sign! BTW I still hurt some, but not like before. I still get up at night. I am never going to be able to work as a hospital nurse again. But if I went back, I tell you now that when someone SAYS they have pain, it's not going to be ME who denies them the med.

And I have lost family members to alcohol and drugs too so I am not immune to what that feels like. I also watched my sister in law with terminal diabetic kidney disease and pathological fractures NOT be prescribed anything but Tylenol because the renologist didn't want her to get ADDICTED!! She died at age 34!!

OH and just because someone OD's and has oxycodone in their blood, it doesn't mean that Oxycontin is to blame. There are at least 10 other meds that have the same ingredient. The same company that makes Oxy tried to get a sustained release Dilaudid on the market....guess what.....nope, no can do.....because of the Oxy stories. It's OK in most of the world, and available right there in Canada though.

Very interesting thread we have going here...

I, too, believe it is better to medicate a addict than to not medicate a pt in pain. Pain is very subjective. What's a 10 for me maybe a 8-9 to you.

But sometimes I do not feel comfortable giving the desired (by pt and MD) dosages. For example, right now there is a pt where I work that has been with us for 3 wk almost 4. She is in with sickle cell crisis. I know she is hurting. Her expressions, verbal and nonverbal, indicate pain as do her lab values. She is receiving 150mg Demerol q2h scheduled. And it is proven that >800mg/day can cause renal failure and/or seizures. She is getting 1800mg/day and has been for 3 wks now. Now that her labs are resolving her pain is still a 10, and I believe her but I also believe she is addicted. One of the few reasons I think she is addicted is because she demands that you give it IV push through her femoral TLC, a nurse tried to use the syringe as a secondary on the IV pump because she had 6 other pt to get meds to. The pt yelled and cursed so loud she was scaring other pts, so she demands the push. The 'Pain management doctors' refuse to see her anymore because they do not believe she is in pain, and her doctors will not attempt to taper the dosage at all.

I just hope she does not seiz and code from all the Demerol she is

I hate the term "drug seekers" because it implies that the person who is seeking pain relief is addicted or abuses drug in one form or another.

I do know that some people do seek drugs for recreational use, and I hate that, it gives people who suffer from Migraines, back pain or any other form of chronic pain a bad name.

The whole oxycontin thing is terrible. The people who have misused this drug have taken a very useful, safe and effective medication and gave it a bad name, and that stinks. I work in an emergency room and I (almost) always refuse to give out oxycintin to patients, I will give them an alternative to take home (if ordered by the Doctor) with them until they can get a refill of their oxy from their PCP, but I have refused to send people home with the med. The reason I do this is because, unless the person has a well documented reason for taking the medication on file, I tend to think that if someone comes in to the ER and asks for oxy there is a very good possibility that they are either abusing it themselves, or want to sell it.

On another point, I have a tendacy to twist and sprain my right ankle periodically and I usually live with it. However one time I sprained it so bad that the size doubled immediately and the pain was excrutiating, like nothing I ever felt before, a definate 10. The doctor in the ER gave me Torodol IM and sent me home on Vicodin and the torodol worked better than the vicodin, but I doubt very much that Ibuprofen would have even touched it. So, to anyone who has never experienced a real bad sprain, they are very painful. I broke my elbow a few years ago and that pain was nothing compared to the sprain.

People who seek drugs, do so for many reasons. They may be seeking because they have real pain, emotional pain that it showing itself as physical pain, they may be afraid that they are not going to have enough pain meds and in fear that the pain may come back, or the may be addicted ( which is, by the way 1% of patients who take narcotics). They may have become tolerant and need more meds more frequently to control the pain, tolerance does not equal addiction.

I also want to add that there is a big difference between physical dependancy, addiction, and abuse.

Also, just because someone asks for pain at the exact time they can get it does not mean that they are "seeking" as many people think of seeking, they are probably seeking pain control and maybe augmenting the percoset (or whatever) with ibuprofen or another NSAID, antidepressants, anticonvulsants or other classes would be more useful, I have found this to be very useful with my pain, as I then have to take less of the narcotics. One other thing I try to do is to get the person off IM,SC, or IV meds ASAP and go the oral route. I simply explain to the patient that the oral meds work longer and that one of the goals of pain control is to get them to take only oral medications.

A suggestion for the man in the LTC facility would be a transdermal fentanyl patch or MS contin or even oxycontin with something oral for breakthrough. I would have a tendancy to stay away from the oxy with him though because of the risks for abuse.

I don't think we can exclusively judge someones pain by how they are acting, but when I have suspicions, I document their behavior before and after the medication administration, I use quotes alot. For example I had a patient come in the other day with chest pain, stated she was allergic to all nsaids and such and NTG was not working for her pain, then she had a HA after the NTG. Refused an IV, wanted IM meds, when I told her I could not give her anything IM with chest pain, she then wanted the IV. With the chest pain better, wanted something for her HA, MD ordered Tylenol. Pt made the statement "If all you will give me is tylenol, I will go home then". Pt checked out AMA. I documented this in quotes, along with other statements she had made. If the doctor would have ordered a narcotic for the meds after she threatened to go home (which he didn't) I would have had her rate the pain given her the med and documented the conversations with her and the reaction of the patient. I will not refuse to give pain meds, but I will document when I have suspisions of seeking behavior.

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