Addicts in the ED

Kooky Korky, BSN, RN · May 31, 2017

I don't pray, just a turn about of Kooky's post. I hope it never happens to anyone, but more often than not, it's poor personal choices that lead people down that road. My sympathy runs pretty low when you're a victim of your own stupid decisions. It's also pretty easy to hate on addicts in the throes of their disease because of their reprehensible behavior: lying, cheating, stealing, murdering.
Again, I'll help those seeking help but if you're trying to throw resources at someone whose literally just seeking a drug fix, you're tying up precious ED time, space and staff. Or is this the touchy-feely rehab forum and I'm turned around?

Have you ever made a stupid decision? If so, did you appreciate the help you, hopefully,

received with regard to it? Or what?

I know ER can be frustrating and some resources do seem to be thrown away/wasted but who the devil do you think you are to decide who is worthy of help and who isn't? Today might be the 40 millionth time a particular addict comes into your ER. And today might be the very day that he will, at long last, "get it". This might be the day he turns around. It does happen, you know.

So don't let frustration or cynicism get the best of you. Just do your level best to help your suffering fellow human who shares this planet with you.

Think of Mother Teresa. She couldn't clean up all of the suffering, cure those who were literally dying in

the streets. But she could and did cradle a dying person until that person passed. So the book says. I

wasn't there, but I think it's believable that this loving and dedicated woman did what good she could

whenever the opportunity presented itself.

Kooky Korky, BSN, RN · May 31, 2017

While I get where you're coming from here, I hope you really don't mean that you hope this person ends up addicted.
I will say this, folks...if substance abuse has not touched you personally via yourself, friends or family, you are blessed.

No, I don't really want him or anyone else to be addicted. I was just angered by his high and mighty-sounding statement.

3ringnursing, BSN · May 31, 2017

I try to keep an open mind when dealing with seeking behavior because I'll never know all the facts. And as an addict 25 years clean and sober I probably garner distain from those never having had the opportunity to have walked in my shoes. I help where I can, and empathize with all the rest. We all bear our own crosses in life, and no one ever promised it would be easy. One day at a time has always worked so far for me.

babychickens · Jun 2, 2017

...well let's just hope you never have get in a car accident or hurt yourself skiing or something, need major surgery, and then become dependent of pain pills. Or God forbid end up with cancer and need then to function. You, sir are a disgraceful human. Not only that...you are not God. Surely your biases are affecting your patient care. If you have any sense of personal nursing ethics you would examine that.

Kooky Korky, BSN, RN · Jun 2, 2017

I hear you, it's really annoying when some malingering junkie is draining resources. I get really pissed off, but I usually fall back on an inkling of compassion that carries me though in order to still attempt to do something positive. I think cutting off the narcotis and/or providing follow up and boundary setting, i.e. care palns and such for possible future visits is necessary. I agree that poor personal choices are definitely at play, I do think that there is a biological component to addiction, so that at a certain point people are no longer making choices. Perhaps there is a small amount of will power and nurses and health care providers can harness that small amount to possibly save their life. Unless I have "walked a mile" in someones shoes, I make every attempt to refrain from judgment. Once we start making judgments and assumptions we miss things and that's not good for an ER nurse.

Suppose the patient is a long-term Pain Management patient. Been on Morphine or Dilaudid or whatever for quite a while (years) for chronic pain. Is also bipolar. Has to go to ER for unrelated reason, like abdominal pain or fracture.

BP is a bit low and patient's mentation is not exactly normal, so they understandably stop the pain Rx and never do get back around to reviewing the meds for the whole day and a half that pt is there, never see what the spouse sees because they are not at the bedside long enough because they have so many other patients, which is the patient tossing and turning uncontrollably and nearly throwing self out of bed due to muscle spasm, severe spasms that are part of going cold turkey.

The cure: restart the pain Rx.

And there needs to be no cold turkey for anyone else, even those doing illegal drugs. It's just plain cruel.

amzyRN · Jun 2, 2017

Suppose the patient is a long-term Pain Management patient. Been on Morphine or Dilaudid or whatever for quite a while (years) for chronic pain. Is also bipolar. Has to go to ER for unrelated reason, like abdominal pain or fracture.
BP is a bit low and patient's mentation is not exactly normal, so they understandably stop the pain Rx and never do get back around to reviewing the meds for the whole day and a half that pt is there, never see what the spouse sees because they are not at the bedside long enough because they have so many other patients, which is the patient tossing and turning uncontrollably and nearly throwing self out of bed due to muscle spasm, severe spasms that are part of going cold turkey.
The cure: restart the pain Rx.
And there needs to be no cold turkey for anyone else, even those doing illegal drugs. It's just plain cruel.

I don't think this thread is referring to chronic pain patients who run out of meds or need a refill or restarting their meds. I believe this thread was referring to malingering drug seekers who use the ER when they run out of their supply and feign illness to obtain narcotics. There is a difference between a chronic pain patient and a drug seeker because the drug seeker is not using narcotics for the intended purpose and/or misusing their pain medications (this can happen to people who are using narcotics for legitimate conditions).

There is also a difference between individual drug seekers, some of them are downright abusive to staff, and other patients in the ED. Abusive behavior is unacceptable in any instance, but particularly appalling if one is lying and manipulating staff for drugs.

I do think withdrawal is probably very unpleasant, and I am not suggesting a chronic pain patient who ran out of meds or had his meds changed abruptly should be put through this. If that was how you read my post, you are misunderstanding.

Do I think cutting off the supply for a drug seeker who has no verifiable illness which requires opioids in an emergency department? Yes, I do. EDs are not detox centers so it is inappropriate to use them as such, especially if the patients is lying and manipulating. If someone comes in with withdrawal symptoms and honestly says they need help and are going into withdrawal is there anything you can do to get me through today until I can get into a program? I think the ED doctor would be way more willing to help an addict who is honest. Clonidine has been used to ease symptoms and the doctor might prescribe that and give other supportive medications that ease symptoms.

It is unrealistic to think that things won't ever be uncomfortable, that pain and distress can be avoided for every condition. I think that this kind of thinking has led to over-prescribing narcotics when there may be other pain management treatments that don't have so many downsides. It is more of a kindness to stop enabling a debilitating addiction.

Kooky Korky, BSN, RN · Jun 4, 2017

I don't think this thread is referring to chronic pain patients who run out of meds or need a refill or restarting their meds. I believe this thread was referring to malingering drug seekers who use the ER when they run out of their supply and feign illness to obtain narcotics. There is a difference between a chronic pain patient and a drug seeker because the drug seeker is not using narcotics for the intended purpose and/or misusing their pain medications (this can happen to people who are using narcotics for legitimate conditions).
There is also a difference between individual drug seekers, some of them are downright abusive to staff, and other patients in the ED. Abusive behavior is unacceptable in any instance, but particularly appalling if one is lying and manipulating staff for drugs.
I do think withdrawal is probably very unpleasant, and I am not suggesting a chronic pain patient who ran out of meds or had his meds changed abruptly should be put through this. If that was how you read my post, you are misunderstanding.
Do I think cutting off the supply for a drug seeker who has no verifiable illness which requires opioids in an emergency department? Yes, I do. EDs are not detox centers so it is inappropriate to use them as such, especially if the patients is lying and manipulating. If someone comes in with withdrawal symptoms and honestly says they need help and are going into withdrawal is there anything you can do to get me through today until I can get into a program? I think the ED doctor would be way more willing to help an addict who is honest. Clonidine has been used to ease symptoms and the doctor might prescribe that and give other supportive medications that ease symptoms.
It is unrealistic to think that things won't ever be uncomfortable, that pain and distress can be avoided for every condition. I think that this kind of thinking has led to over-prescribing narcotics when there may be other pain management treatments that don't have so many downsides. It is more of a kindness to stop enabling a debilitating addiction.

I've seen many patients given Clonidine for withdrawal. It never seems to quite help them enough. At least it is something.

Actually, the OP was asking about referrals for addicts leaving her ER because her ER apparently doesn't do any referring and she would like to help her patients.

She's gotten good advice. Research her community and find those places where addicts can get help. See if Social Services has anything to offer. Be aware that not all detoxing addicts are going to welcome information that she might give them.

I could be wrong, but I don't think most ER docs would give any help to someone detoxing. Maybe the Clonidine if BP is elevated, but nothing that would really help the cramping, the freezing, the itching, the terror. Maybe the doc would admit to help keep an eye on the pt and address other symptoms that arise. And yes I suppose honesty could help. But I've seen plenty of snotty doctors who hate addicts and are as cruel to them as the nurse who posted here earlier who said he does as little as possible to help them and sees them only as a waste of resources. Plenty of physicians are the same way.

LiLev · Jul 16, 2017

We have a packet of resources to give them but more often than not it gets thrown back in our faces. They are usually not ready the moment they find out they are not going to get the dilauded they have been waiting for several hours to get, sometimes they even get violent. If you do come up with resources to give them stand a few feet back when you give it to them.

babychickens · Jul 17, 2017

A couple of days ago I had an experience I hope to never forget: I am a student RN and also volunteer in a busy ED... I was taking vitals for an RN and the pt got very upset that the "pain in her leg was not being taken seriously, and would I tell her nurse that she was about to leave and go to 'x' hospital if she didn't get a new doctor or some pain meds because all they were offering her was freakin' ibuprofen?!" She was covered in tattoos (albeit very nice ones) and she had her daughter and and husband at the bedside. Who knows what sort of things went through the tx team's mind. You know, we all make quick judgements about people in situations. I told her I was very sorry for her experience. She explained that maybe she thought she had a blood clot (young women) and I let it go in one ear and out the other. I relayed her displeasure to her nurse who was pleased the pt was about to leave and I moved on. A short while later I overheard the pt gratefully telling a doctor "let me shake your hand! Thank you for taking me seriously!" I followed him to the pt's nurse and sure enough, he tells her that "she has no pulse in one leg and a bounding pulse in the other!!!" :/ As a student nurse, just finishing up first semester, I practically slapped my forehead in front of everyone. No, she was not my patient, but I wish I would have thought to check her pedal pulses myself. If my nursing professor's said that once, she's said it a thousand times!!! I do not know what ended up happening to that pt but in that instance it could easily have gone badly. She was obviously not drug-seeking and yet that's what almost everyone thought. I'm totally not the judgemental type either, but that situation proved how easily I can get caught up in "group think" mentality, especially as a new nurse, when I need to be thinking for myself.

JKL33 · Jul 17, 2017

I was taking vitals for an RN and the pt got very upset that the "pain in her leg was not being taken seriously, and would I tell her nurse that she was about to leave and go to 'x' hospital if she didn't get a new doctor or some pain meds because all they were offering her was freakin' ibuprofen?!"

That is a good experience - always carry it in your back pocket. Let it remind you to **always**, regardless of any other circumstance, do the darn assessments that are related to the complaint. Always. Rule #1 with regard to this type of situation. The same thing is true for "frequent fliers" - do the assessment. Period. They will be on their way soon enough if nothing is wrong, but sooner or later they WILL come in with something actually going on.

Your story makes me kinda feel :sour: for other reasons too, though....the fact is, the majority of people (in my own experiences) who are concerned about something like a blood clot come in and when you say, "what's going on today?" they say, "something's wrong with my leg" or "gee, I'm concerned about a blood clot" as opposed to spewing threats that involve wanting pain medication seemingly more than they want to find out if something is seriously wrong with them ("give me pain medication or I'll leave"). She also did herself no favors by waiting for a student to arrive and give her extra attention before she would announce her concern. You see, this isn't only about "judging" someone. It's just not. It's also about the fact that, through her behavior, she unknowingly put herself into a category that more often turns out to be something other than "something seriously wrong with leg".

I'm not trying to critique the very useful lesson you learned. I just feel 'blah' about the idea that most people (admin, general public, etc.) don't give credit for the difficult job of sorting - - nor how much more difficult it becomes d/t other societal factors (such as rampant non-urgent use of EDs).

So did she have a blood clot?

babychickens · Jul 18, 2017

Hi JKL33. I completely see your point, and you're right. She acted in such a way that caused staff to likely dismiss her reported symptoms. That's why I was very deliberate in not saying the RN should have taken her pedal pulses or something like that. In fact, she may have. My role as a volunteer supersedes my student nurse title in the ED. In fact, many people don't know I'm in nursing school. It just depends on who's working that day. It's more a matter of taking what I see and using it internally to learn. However it wouldn't have been out of my scope of practice to take some pedal pulses and report them to my RN. I'm a volunteer, but I'm also there as a team member. Truly, it's one of the best places to get experience. Yesterday was one of the craziest days to date... and yet my rock star RN mentors weren't even fazed.

amzyRN · Jul 18, 2017

A short while later I overheard the pt gratefully telling a doctor "let me shake your hand! Thank you for taking me seriously!" I followed him to the pt's nurse and sure enough, he tells her that "she has no pulse in one leg and a bounding pulse in the other!!!" :/ As a student nurse, just finishing up first semester, I practically slapped my forehead in front of everyone. No, she was not my patient, but I wish I would have thought to check her pedal pulses myself. If my nursing professor's said that once, she's said it a thousand times!!! I do not know what ended up happening to that pt but in that instance it could easily have gone badly. She was obviously not drug-seeking and yet that's what almost everyone thought. I'm totally not the judgemental type either, but that situation proved how easily I can get caught up in "group think" mentality, especially as a new nurse, when I need to be thinking for myself.

I'm surprised no one assessed her leg a triage. Every time a patient comes through triage if they have a complaint like leg pain the appropriate thing is to look at the leg, compare it to the other leg and check CSM. The fact that that was not done at that time is kind of troubling. I find it odd that the primary nurse didn't assess the leg when they got to the room unless there was a critical patient that needed to be seen first. Then you get to the room and do a set of vitals but don't check the leg. I'm glad you recognized your mistake and I don't think you should feel bad about it, and as others have said a valuable learning experience.

I think part of the reason this is so troubling is not only that there were assumptions made about the patient, but that people are so busy they are bypassing critical steps in the nursing process, the assessment. I also don't think it's appropriate for the patient to receive pain meds like narcotics until someone assesses her

leg. Most doctors at my hospital never order narcotics unless they assess the patient's condition first. They do this for everyone regardless of if they have tattoos or not. The only time I've ever seen narcotics given for pain without an eval by the MD first is for return patients with conditions like gastroparesis.

In short, I don't think it's wrong that the patient only got ibuprofen until the MD came in but I do think it's a serious mistake that no one checked a pulse on the patient's leg. That could have resulted in the patient losing the leg potentially.