Narcotics administration

[schoolmack]

I work on a med-Surg floor where dilaudid is prescribed excessively. Especially to chronic drug seeking pts. We have joked that we think some of the pts are setting an alarm to wake themselves up so the can request more IV medication "when it is due" (actually when the time is up and they can get it again) Anyway, we have confirmed this as fact, and I have a problem administering pain medication to someone who is setting a clock to receive it, not because they are genuinely in pain.

What do you think? How would you handle it? These are frequent fliers and this is a very constant issue!

[BertinaRN, ASN, RN]

I work in Med/Surg in an area that has a high volume of drug addicted, ETHO, suicidal,mental illness and so on type patients. We do not have the resources in this community to fix or help these patients. I always review previous admission documentation, H&P, discharge summaries, I verify the home medications as best I can with the information they provide. If the MD prescribes the narcotic and the patient states they are having pain, I give the medication as prescribed. I know that I can not fix them, I always hope that they are quickly discharged, but while in my care I make the best of the worst.

[Esme12, ASN, BSN, RN]

I think that the medical profession in general have become too judgemental of the chronically ill in our society. The ill and disabled are far too often treated as disposable insignificant humans. I think that there should be a lot less judging and a lot more tolerance toward the chronically ill.

Of course there are those frequent flyers who we ALL know are seeking meds for the meds.....but we, as nurses need to be very careful to understand that the chronic nature if someones pain does not signify addiction and "seeking" behavior. I have a family member with metastatic CA to the bone......everywhere and a nurse recently worried about addiction to the pain meds.

My response to her was.....yes he maybe addicted to the meds and he will take that addiction to the grave with him!!! Of all the crazy things to say!!!!

This is a hot topic amongst nurses and MDs about the use of emergency rooms for pain.....pain clinics.......but my expereince has been that pain is way under treated due tothe assumption that someones pain isn't that bad and they are seeking.

It has no bearing on race and I think it is a reflectionof society itself on the uselessness of the chronically ill..

But we need to stick to the topic and not call each other names. We can agree to disagree without being disagreeable(Gerald Ford).

A reminder to everyone!!!!

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Lets please keep to topic.

[Cold Stethoscope]

This is how I view drug seekers: I don't care about them. I don't care about their health. I don't care if they die an early death.

Really? Then I don't see how you can ethically remain as their nurse.

That is not a popular opinion as a nurse, but drug addiction IS A CHOICE...bottom line.

Once you're addicted, it's a choice? That raises some interesting questions about free will.

Biology is not best understood through moral reductionism.

Pain is what the patient says it is and until someone comes up with a pain test, I'm not putting my license or job at risk for a drug seeker.

In fact, there are heroin addicts who have traumatic accidents and surgery who feel pain the way everyone else does. The difference is that they've built up a tolerance to opioids. And unlike other most (but not all) other patients, they are subject to withdrawal symptoms, which can be severe.

So, if they have loaded up on herion before they come in, lied about it, we can't see evidence of it and we give them something else and they drop dead? One less drug seeker as far as I'm concerned.

I'm not sure that you should be treating anyone addicted to drugs. Apparently you'd just as soon see them dead.

These people generally don't work, they mostly live on state assistance and they neglect their children and give birth to drug addicted infants. They are the lowest of the low and IT IS A CHOICE.

These people?

I don't think you know much of anything about the epidemiology or physiology of opiate addiction. There are normal-looking and normal-functioning people all around you who are hooked on opioid pain killers, and have been for years, sometimes decades.

You might want to explore what is at the root of your intense bitterness toward drug abusers. Really, there are bigger fish to fry for a nurse than to obsess over whether a patient is getting more Dilaudid than he really needs.

[leyaussie LPN]

Pain med administration, OH what a subject.

Having been a nurse for 38 years it is quite clear, if it's ordered by the physican, the pt. c/o pain, the proper nursing assesment is made and vitials are WNL I administer the medication as prescribed leaving all personal judgements about addiction aside. It is not or has never been my job to prescribe the medication, therefore I administer as ordered and requested by the patient. If a pt's need for pain medication is questioned, as many times myself and my co-workers have discussed, assessment and documentation are a must.

Many times a pt. will request increasing or decreasing a prescribed dose. As we all know we can educate the pt. reguarding pain med administration and titration then document our findings, this will ultimetly assist the physician in making the decision in what is best for the patient. That is what we all want as medical professionals, that which is best for our patients. For me personally the comfort of my patients is a primary concern, especially in an area of rehab. The more comfortable and pain controlled the patient is, the greater cooperation and recovery. I have even encouraged a pt. to take his/her prescribed pain meds to enhance their participation in therapy, therefore many times expiditing their recovery.

On the other hand I have seen aquaintences, Dr. shop or make unnecessary trips to the ER to obtain pain meds. This ticks me off. Not only are they wasting the medical staffs precious time, but they totally make fools of themselves. The ER staff pretty much know who the frequent flyers are and those who are only there to seek pain meds. I have seen many a pt. leave the ER in a huff when they are not given the meds they wanted when they came in. When the so called patient is in the ER, VS WNL, sitting up, asking for food because they have been there for hours and not given anything to eat then when asked what their pain is on a scale of 1-10, and it is "10" I have to laugh to myself.

But then too communication and documentation is key. The look on their face when nothing is found and they leave the ER with a recommendation for APAP q4 or a script for Motrin is PRICELESS.

In any event, as much as we all hate all the documentation we have to do it and do it well...documentation is our friend, and can protect us in questionable situations!

[CarryThatWeight, BSN]

I agree with most of the replies in this thread. If a patient complains of pain, and the med is due and safe to give, we have to give it. On the other hand, after a few years in mental health, I understand that as nurses, our deep resistance to giving people meds when we know they are drug seekers comes from an aversion to being an enabler. We don't want to enable addicts because we know that is not helping them. Unfortunately, we can't judge a patient's true pain level, so we have to medicate everyone who complains to avoid missing the patient that has true pain that may not be obvious. And for the Press Gainey scores ;-) Sometimes we have to enable peopled with addictions. No way around it.

[8jimi8ICURN]

i dont care how much they want. i give it . if they want it more often give them a pca. if the doc prescribed it they can have it. push it fast, sure. if they are trying to get high i document their request and notify the md.

[FMF Corpsman, MSN, RN]

Pain, is pain whether it is real or imagined it is still pain. Think about it, Pain is subjective, we ask our patients to give us a number from 1-10 on how much it hurts, we ask them to describe the pain, we ask them how much pain they are willing to live with.

Taking on this 1-10 scale, is all very subjective, and if you have a patient who suffers from Chronic Pain and also Chronic Depression, each diagnosis is fighting the other at times and at others synergizing it, and it isn’t unusual at all, to see such concomitant diagnosis.

While it may seem to the Nursing staff as drug seeking behavior to set ones phone alarm to request the next dose, it can also be explained as keeping on top of the pain margins. If a chronic pain patient does not receive their routine dose of medication at the prescribed time and their pain makes a headway, it goes from extremely difficult to impossible to get their pain back under control, and you may be talking about a patient who has worked for years to achieve just a modicum of control over their pain. Pain control is indeed a funny, and no, I do not mean in the laughable sense, science. Migraines seem to like Nurses, anyone of you suffer from migraine headaches? Then you might have an idea what your patient endures on a daily basis, if they don’t get their medication.

I’ll take it one-step farther, those of you who have had the blessing of childbirth. The pain you went through. How do I know? I’ve had the distinct pleasure of OB/GYN numerous times during all of my licensure pursuits. The main thing I learned during my time there was why G*d chose women for childbirth, if He had left it up to the men, it would have been a one child per family deal, because men are not going to put themselves through that pain and excruciation more than once.

At any rate, my point being, I remember hearing the OB/GYN telling the mothers that they should get ahead of the pain, and take the epidural now or whatever pain control they were going to use, before the pain got too intense, or they would have to use much stronger meds and "ruin the birthing experience." I remember thinking those were a strange choice of words, but to each his own I guess. Being much older now, I can understand where he was coming from, but it would still be that one kid per family deal as far as I'm concerned.

It isn’t up to us as Nurses to second-guess the Physicians ordering the pain control regimen for his or her Patients. If your patient shows mild to moderate s/s of excessive sedation from the medication, you should obviously chart your observation in your notes, and bring it up in your EOS report. That is something that needs to be observed and maybe the meds need to be held or if allowed, modified the next time.

If you are the Nurse Manager for the Pain Control Unit, you already know what you are doing, but it sounds as if some of your staff could use some freshening up. Give your Patients their meds as long as they are due and they don’t show any adverse s/s. At least with all of those I-Phones and Androids going off, your meds will always be on time.

[beachluvva]

Pain is subjective, therefor, it is hard to say who is really in pain, and who is just med-seeking. That being said, there are people who sincerely need their medication "around-the-clock" so that it stays on board & they arent caught in a situation where they waited too long & get no relief from the med. I have known patients to set alarms for this reason as if they sleep until they awaken (in pain) then the pain is such that the med is ineffective...if I were in the same situation I would prefer the patient to set the alarm than risk having them in pain that I cant relieve with medication, thus also setting myself and my staff up for possible complaints from family members, etc. I am aware that there are those who may not even need the med but use it for habitual purposes, but I am in no position to judge or determine whether someone is having chronic pain or drug-seeking...

[dudette10, MSN, RN]

I wonder how the difference in attitude relates to having been the patient. I have been in severe pain many times with a flare up of a chronic condition and have been eternally grateful to the nurses who were agressive with pain care.

I think being a patient helps nurses. Not just the relative of a patient...the actual patient. I know that my current and continuing experience has informed my practice immensely.

[dudette10, MSN, RN]

I just doubt that a patient's pain is 9/10 when they are eating chips and chatting on their cell phones. I understand that pain is subjective, but seriously, if your pain is so bad, you'd show it. You wouldn't desire to eat fried foods and text message your friends. Isn't that an assessment? I've charted it before. "Pt reports pain 9/10. Requests medication and a snack. Patient currently watching television and talking on the phone. No guarding noted...." blah blah.

This is only anecdotal evidence, I know, but I'm gonna give it anyway.

I am opioid naive. I underwent a 5-hour surgery. Your body WANTS food after surgery (I'm still eating like a pig). I was higher than a kite (brain felt REALLY fuzzy) between the anesthesia still in my body and the pain meds. I was ravenous, and I was on the phone talking to my husband and kids, but I didn't remember much of the conversation until the fuzziness went away and I asked them about it. I still felt pain.

I am not saying that there aren't drug seekers out there. Often, however, patients have a verifiable source of pain r/t hospitalization or r/t medical history, and we still wonder about their pain. I have encountered only one drug-seeking patient in my short stint (+1 year) as a nurse. He wasn't on his phone, didn't eat much, and he acted the part as a pain sufferer. It was verified that he was a drug seeker because of his chest pain admissions with normal diagnostics at multiple hospitals over the past year.

I am also not saying that we don't need to think therapeutically toward discharge. Weaning off the PCA, weaning down the extra meds to match what they normally take at home. That's just common sense and good medical/nursing practice.

[rn undisclosed name]

I have a hard time with the drug seekers like a lot of other nurses. Some things that help me out:

If it is ordered and the patient is requesting it they get it IF it is due. I always go over the pain scale with patients. If they tell me their pain is a 10/10 I correlate that with mild, moderate, severely, extremely severe. I had a patient who kept telling me her pain was a 4 and it turns out she was actually experiencing mild pain. Well that would be a 2 or 3 so it required reeducation on the pain scale.

If a patient has norco and iv pain meds ordered and they are refusing the po I tell the doc. A lot of times that will have the doctor getting rid of the dilaudid/morphine.

If you are taking vicodin/norco at home and you are not in the hospital for an exacerbation of a pain crisis I really don't understand why you are requiring dilaudid just because you are in the hospital. If your pain is at the level it is when it is at home and you are at your goal we are all good.

People who have chronic pain do cry when their pain is so out of control. People who say that doesn't happen...well everyone is different.

Many (not all) patients with chronic pain need limits so they are not monopolizing all of your time. I let them know when there next meds are due. I find it extremely frustrating when they go on the call light 1 hour or more before they know their next pain med is due. I don't understand why they do it and there is nothing I can do about the timing of the pain medication. It is ordered by the doctor and If they are getting their dilaudid every 3 hours well I don't need you to start calling me 1 hour, 45 minutes, 30 minutes, 15 minutes before you can have your dose. I will give it to you 3 hours after you had your last dose because that is then it is ordered. Many of these patients have an extensive psych history and are on multiple psych meds. Sorry but these are things that make me go hmmm. These people need to find other methods of pain control besides iv narcotics. They really need to open their minds to other methods of pain relief.

I believe we as nurses should second guess a pain regimen with a doctor. As nurses we receive much more education than they do. Ordering morphine/dilaudid q6h is ridiculous when it has a short half life. I recently went to a conference and learned doctors are lucky if they get 1 hour of pain education in school.

[JMBnurse]

I think nurses need a lot more education regarding pain management and addiction. We recently had a class on this where I work a couple of months ago and it was very helpful. I was an Oncology and Hospice nurse for many years, so I have given a lot of pain medication to patients in my time. I agree, if it's ordered and safe, just give it and withhold the judgement. I have been on the other side, too. I have a history of diverticulosis, first diagnosed about 6 years ago. The first 3 years after I was diagnosed, I had several episodes of diverticulitis, involving pain, fever and very elevated WBC count. I have since learned how to manage the condition and reduce the episodes with diet and early detection of a flare. The last episode I had was 3 yrs ago. I went to an urgent care clinic, seeking antibiotics, nothing else. I told them my history and my symptoms. I told them I was having LLQ abd. pain because that is part of the symptoms of the condition. I was not crying. I did not ask for anything for pain or a prescription for pain meds. I never mentioned pain, other than to tell them that the abd. pain was one of my tell-tale symptoms. I wanted a script for Levaquin or Cipro and then to go home and take care of myself. After examining me, the NP said, "You know, I can't give you anything for pain." I said, "Yes, I know, but you can give me a prescription for an antibiotic, right?" "Yes", he said. I felt like a skid row bum. It's sad when people now are treated like drug seekers when they don't even ask for pain medication, but just admit they have some pain. Pain is part of this condition, but not the biggest part. The biggest part is the 102 fever and 20,000+ wbc count and the possibility that my colon may rupture. That's the part that worries me. People should not be afraid to say they are in pain for fear of being labeled as a drug seeker or an addict.