Overuse of opiates?? Opinions?

Katmae RN · Oct 20, 2004

I work in a small rural hospital within 10 miles of the Interstate. We get migraines, severe neck pain, etc. in the middle of the night to our ER. No insurance and just passing thru the state. A few tears and doc orders morphine or demerol and off they go in an hour. Guess a junkie could get quite a night stopping along the interstate hospitals. Especially with HIPPA and not being able to contact the other hospitals about wheither this person has been there tonight. Before HIPPA we found many who had been at the previous hospital on the Interstate. One night a woman came in doubled over,crying with lower back pain. She writhed and carried on so in front of her 15 yr. old daughter. I went to see if the ER nurse needed help and was sucked in by this scene. My heart broke for her and i asked why she(the nurse) hadn't gotten her pain meds ordered. Come to find out she was a monthly visitor with ailments that could never be proven. Once she got admitted for possible kidney stone..she ordered those meds hourly and sat on bed playing cards with her daughter. So druggy she could barely get the words out. Wanted food and to go outside for a cigarette. It made me sick. The next day i found out when she never had a kidney stone the doc she was using for this told her on no uncertain terms was she ever to seek treatment from him again.We were gonna send her to the University hospital as our ER doc at the time was not sure what was going on..they refused to take her with just her name given. Of course HIPPA kept us from knowing why.

stbernardclub · Oct 20, 2004

If the medication is due, and the patient states pain, you need to give the medication...period! If you follow the physicians orders quickly, you won't have all that time lost on judgements. Go have a coffee , and thank god your not in that situation!

PMHNP10 · Oct 20, 2004

I have a confession to make. I am judgemental. One of the patients who frequently visits us does so by swallowing inanimate objects or some other sort of self harm actions. This latest admission, he bit his hand so he could get admitted--this was his suicidal gesture. There is no question he wanted narcotics. There is one specific MD patients love to see because they know they can get narcotics from him. So initially he got roxicodone. Most of the nurses, myself included, protested this order. The logic was that 1 it enables him; 2. it takes away a bed from someone who can benefit from it. Noone was doubting he was in pain, but we weren't going to reward his behavior. When the psychiatrist saw him, all narcotic/benzos were forbidden.

Another patient I have is a paraplegic who is on : diazepam 15mg BID; methadone 20 mg QID; baclofen 20mg BID; methadone 20 mg 1/2 hour before we get him up and into his wheelchair. Is he in pain? No question about it. Is he a drug seeker? No question about it. Do I withold his meds? Never except on one occasion when he was going through septicemia. He was unable to speak an understandable word, produced no urine and barely able to follow the simplest of commands and his vitals were a concern. When I came into his room and assessed him, I would have sworn he was cheeking meds and attempted an OD. I believe medicating him would have been a detriment to my license.

I may be incorrectly interpreting previous posts, but it seems some say that giving pain meds is a black and white situation. I don't believe that is necessarily the case. We do treat for pain based upon what the pt says, or if the pt can't communicate, based on what we assess. We as nurses should give meds whether we feel they need meds or not, unless we feel the medication will further harm the patient. Another thing to note is that when treating previous drug users, often they require many more meds to achieve the same pain relief as someone who has never abused drugs, so that should be taken into consideration.

Katmae RN · Oct 20, 2004

Don't mistake my post..this was an exception and a proven abuser. I am all for pain meds, and believe no one should have to experience it. There are multitudes of meds available, and in my opinion there is no reason for anyone to suffer needlessly. I am quite liberal with prn pain meds. But that situation I described was a woman who should have been applying for an acting job, she surely woulda own the oscar for her performance. It was blatant that she was using the system and us as nurses to get drugs. I resent her taking my time away from my patients that night. I pulled her old chart that night and she had pulled this many times at our hospital. However if she were to seek psychiatric help that would be another story.

JHUBRAIN · Oct 20, 2004

just to clarify, i did say 100mg of demerol every hour. yes. and the most disturbing part of that situation was the fact that the patient wasn't even slighty affected by such a large dose. he was still awake, cursing at the staff, threatening to leave ama if we didn't call the doctor and get him more pain medicine and a diet order that would allow him to eat a cheeseburger. please, if you are in that much real pain, you would not be thinking about a big mac. i agree that there are people who are in real chronic severe pain, i don't doubt that, and i believe many times they fall through the cracks because we are so used to seeing the drug seekers that we become suspicious of everyone, but 9 times out of 10, these patients are just looking for a high and a free meal and the doctors are more than willing to hand it to them. i know my complaint is a waste of breath, i might as well be beating a dead horse, but thanks for letting me vent. :stone :stone :stone

if he was saying he would leave ama over a cheeseburger and higher dose - i think i would get the paperwork ready and remind him he will get the bill for it since he is leaving ama - and let him sign out - wow

ScarlettRN · Oct 20, 2004

I learned cynicism from my drug seekers. I am the first to offer pain meds to patients with genuine pain and a reason for the pain. BUT I learned from folks like Patient X who would be admitted for exacerbation of COPD and get an aminphylline drip...and nubain with phenergan every 4 hours, IV push, for pain. She would walk up to the nurses station 5 min before her dose was due so she could get a cup of coffee and her shot. Then she would proceed to stay awake for days on end, sitting on the side of the bed with her perpetual cup of coffee, swaying drunkenly but refusing to lay down to sleep. It is safe to assume she didn't want to sleep thru a due time for her shot.

This made me cynical. She is just a small sample and not an isolated incident.

My time in the ER has taught me that patients don't understand the pain scale very well and that they think if they report anything less than a 10/10, they won't be treated for pain. I try to qualify the 10 rating by giving an example to women of active labor and to men of having a limb severed, LOL. I don't think people can accurately judge the pain scale until they have experienced a true 10. By the same token, when I know a person has a hx of cancer or some illness/injury that puts a 10/10 rating in perspective, I am VERY likely to take their report of a 6/10 as significant pain in relation to other people....but our profession is not one of concrete one-size-fits-all treatment.

I don't think I have ever refused to give pain meds to a patient before. I think my source of aggravation stems from the ones who stalk you in the hall when their dose is due and you have a full load of patients who need stuff but they are in the halls, following you, standing at the nurses station watching every move you make until you can get to the drug box and draw up their meds.

xmaxiex · Oct 22, 2004

No arguement here just wanted to share something I have been thinking about . I work in LTC and often I wonder about pain meds in the elderly . We have some pts known as clock watchers. I don't judge but oftentimes I worry about the effect some pain meds have on the healing process ( some pts are so "relaxed" they rather sleep than attend therapy) Also I worry about the cognitive effects pain meds have on an unstable elderly resident or those suffering with dementia . I would welcome more education on pain and its management , particularly in the elderly .

leslie :-D · Oct 22, 2004

No arguement here just wanted to share something I have been thinking about . I work in LTC and often I wonder about pain meds in the elderly . We have some pts known as clock watchers. I don't judge but oftentimes I worry about the effect some pain meds have on the healing process ( some pts are so "relaxed" they rather sleep than attend therapy) Also I worry about the cognitive effects pain meds have on an unstable elderly resident or those suffering with dementia . I would welcome more education on pain and its management , particularly in the elderly .

elderly and children are the 2 populations that are typically underserved in terms of pain mgmt.

i've worked w/elderly and have seldom met a clock watcher. most are stoic, deny it and refuse it. that's the way their generation was. and it takes much education and 1:1 to get them to try even tylenol sometimes.

besides, they're elderly. my only concern is their risk for falling if sedated. other than that, with the typical dxs of op, oa, ra, compression fxs, djd....they certainly need and deserve something.

leslie

jennifer0223 · Oct 22, 2004

would like to know what your opinion is on an issue that has bothered me for quite a while. patients being admitted to medical/surgical units with various diagnosis, for instance "abd. pain, nausea, vomitting, " you know the type, frequent flyers who come in every other week with some imaginary ailment, and they always get a bed, and then get obscene doses of narcotics. i mean, 100mg of demerol every hour? or 25 of phenergen on top of the 4mg of dilaudid they are getting every hour via pca pump. is it me, or is there an epidemic of narcotic addicted junkies floating around the healthcare system? and does anyone else feel that the doctors are part of the problem? i'm growing more and more intolerant of this whole horse and pony show. after a night like last night it really makes me think about my career choice. :uhoh3: :uhoh3:

i do not know you. i am new here but i will have to say that alot of the problem are nurses that assume a person is getting to much narcotic or they are addicted. i have a rare bone disease that causes me so much pain i can barely walk. but if i wear 200mcg of fentanyl changed every 3 days plus oxycodone 15mg prn i can walk and move around. now i have been admitted to the hospital 3 times in the last year. once i collapsed from pain and exhaustion, 2nd was surgery, 3rd was a severe eye infection. even with my medical record there showing i do not absorb medication the "normal" way that my body metabolizes it way to fast that the effect is not felt sitting in front of them the doctors would not give me the 'normal" for me doseage. once they finally were told to do so by my specialist the nurse was terrified of giving me what was ordered. which was dilaudid 6mg iv push every 15min until out of pain then every hour prn. now that may seem like alot it does to me even. i have yet to have a pain free day in the past 2 years. i went 8 months without any pain medication while they tried to figure out what was wrong. then started pain meds and they didn't work. finally found the problem so we changed routes. 200mcgs of fent is alot i know this....but guess what i stilll have pain severe pain that wakes me up in themiddle of the night crying.

i guess i learned from spending a month in the hospital the other side of the issue. i found that if a patient says they are in pain 9/10 they are. if they ask you for pain meds and they are ordered you shouldn't think about are they addicted let the doctor. the patient needs us to not judge them. the patient needs to know if they need something for pain they will get it not a look from a nurse thinking god she is a pill junkie. one day it might be you on that bed crying from pain and the nurse saying i already gave you 5mg of such and such. or there is no way you are hurting or no way you are nauseated. visit pain clinic, hospice places where people are using large amounts of pain medication you may find you have a different view.

i do see your point if you are talking about a true needle track junkie or what not. but if i go into the hospital every week for the next 10 weeks for pain and get a bed i surely hope i do not get a fellow nurse that takes the outlook that i am "making things up" or coming up with some misc. ailment etc. i am not writing this as an insult to the originator of this post or anyone else merely giving the "large dose" of drugs prospective. most people that were on 200mcg of fent would be out cold. i still hurt on this amount go figure. this was a very interesting thought brought up and i thank you for the opportunity of sharing my viewpoint.

jennifer0223 · Oct 23, 2004

Sorry,

xmaxiex,

i did not see your post. But if you want to view more about pain in the elderly read about hospice and palliative medicine even though it is about death and dying etc it does have alot to talk about medicating the elderly for pain. Here are a few short articles I found.

http://www.seniors-connection.com/03011999a.html

http://www.stat.washington.edu/TALARIA/LS7.2.html

http://www.painbooks.org/elderly.html

good luck

xmaxiex · Oct 26, 2004

Thanks Jennifer , I am always trying to learn and find new ways to help my pt's great info !

LittledebX2 · Oct 26, 2004

would like to know what your opinion is on an issue that has bothered me for quite a while. patients being admitted to medical/surgical units with various diagnosis, for instance "abd. pain, nausea, vomitting, " you know the type, frequent flyers who come in every other week with some imaginary ailment, and they always get a bed, and then get obscene doses of narcotics. i mean, 100mg of demerol every hour? or 25 of phenergen on top of the 4mg of dilaudid they are getting every hour via pca pump. is it me, or is there an epidemic of narcotic addicted junkies floating around the healthcare system? and does anyone else feel that the doctors are part of the problem? i'm growing more and more intolerant of this whole horse and pony show. after a night like last night it really makes me think about my career choice. :uhoh3: :uhoh3: [/quote
it is so sad to know that there are nurses out there that think anyone who takes a higher than normal dose of a narcotic is just a "narcotic addicted junkie". i pray that you never have a chronic illness that causes you pain, because i think your opinion of these "frequent flyers" is very biased. one thing "abd pain, nausea and vomitting" is not a diagnosis it is a symptom, and doctors are getting a hard time from insurance companies:angryfire for using that terminology.
but just maybe this person really does have pain?:uhoh21: what do you do then when you have already made a decision to label them. to me it seems alot of nurses are backwards in there thinking about narcs and pain. they assume they are guilty (of being an addict) before they assume they are not. there are many studies and surveys out there to show that in fact, nurses and doctors are undermedicating patients:crying2: , not the other way around. undermedicating causes more problems in the long run, (longer stays in the hospital, more complications-like pneumonia because the patients don't want to tcdb, dvt's due to the patient's resistance to get up and move around, ect.)
my suggestion to you about this frequent flyer is to get the doctor involved with your concern, and tell:chuckle them what you are witnessing with this patient, and see if this is cause for the doctor to assess what they are doing with this patient.
i am a chronic pain patient who takes narcotics everyday, and because my illness is not something you can see it does not mean that i don't have very real pain. and if i came to the hospital as a patient, i would need more pain meds than the average patient to get relief, does that make me an addict, absolutely not. so don't be so quick to assume and always treat that person as if were somebody you love and care for dearly.:)