Advice for dealing with addicts?

[garnetgirl29]

I'm in a detox clinic & this is my first nursing job & first experience in addictions. We have standing PRN orders for 25 mg Vistaril Q6H PRN, Phenergan (must see vomit),75-150mg Trazodone for sleep or 50mg Benadryl for sleep. My clients want the vistaril like it's candy, and are lining up at the nurses station every 6 hrs (or less) to get it. It's ridiculous, but it's that addicted mentality, I know. I'm trying to be as therapeutic as I can & try to tell them that they do not need another vistaril just because the 6 hours is up. Some walk away, but others are VERY adamant. I had 4 argue with me last night because I would not give trazodone & vistaril or benadryl & vistaril at the same time at bedtime. I tried to explain that trazodone also helps with anxiety & they don't need both or that benadryl & vistaril are both antihistamines and I cannot give that much at once. Now, my standing orders do not say anything about giving meds together, but my gut and nursing judgement tell me that's just too much. Also, they beg me for phenergan all the time, and I have two whom I'm sure are making themselves vomit to get it. One (heroin addict) was begging my for phenergan IM. I offered mylanta and that really ****** her off or phenergan suppository, but she said she had diarrhea & couldn't do that.

So, can anyone give me some advice on handling these situations? I'm often the only nurse on & don't have anyone to back me up. I don't feel that handing out meds every time they ask is doing them any good. It gets exhausting when they are constantly knocking on my door and shouting out med orders while I am delivering scheduled meds to others. (I ignore the shouts because that's just rude and I am no one's servant).

These people are here to detox and learn coping skill (well, not everyone has good intentions), but I want to know that I'm doing right by not handing out a med when I don't think it's legitimately needed.

Now, some of these people who are demanding Vistaril from me are already on Buspar or other anti anxiety meds. How do you handle drug seekers?

Sometimes I wish we didn't have Vistaril or Phenergan to offer.

Also, a few weeks ago, we had a client who was soliciting others to get Vistarils for him cuz he wanted to snort them. What wold be the effects of snorting a vistaril? (this client was kicked out)

[subee, MSN, CRNA]

PsychRNXXX said:

Amen! 100% agree. Hands down. Vistaril 25mg is a joke. Even for me. Benadryl 50mg is nothing to them. I can even take that. People using heroine and other hard drugs aren't going to be affected by vistaril and Benadryl, or phenergan for that matter. Trazodone too. People unfamiliar with addiction and such may not know that. They don't teach thorough enough info in psych rotations etc. so for new grads it's hard. There's not time to change their entire life. Active detox - they can't think about that. Give them what eases their anxieties sometimes. Encourage group and learning coping strategies but ...🤷🏼‍♀️ they need to be comfortable doing so. Physically and otherwise. It takes along time to change addiction mentality usually. I could continue but I just agree with this one 100. So there LOL. 

Just to LOL even more, sometimes trying to get them to sleep is like anesthetized an elephant or a gorilla!  The well is verrrry deep!  

[PsychRNXXX, BSN]

subee said:

Just to LOL even more, sometimes trying to get them to sleep is like anesthetized an elephant or a gorilla!  The well is verrrry deep!  

You are not dang wrong. I've given so much medicine before - B52s, Thorazine later, Zyprexa.... Will NOT calm down. Whew. It's amazing. IDK another word LOL. 

[Luke79AU]

PsychRNXXX said:

You are not dang wrong. I've given so much medicine before - B52s, Thorazine later, Zyprexa.... Will NOT calm down. Whew. It's amazing. IDK another word LOL. 

It's like pain. 7.5mg of slow push IV morphine can depress respiration to a dangerous degree in some patients. Others might need 30mg to settle pain. Observe your patient always

Also, diphenhydramine exerts clinically significant serotonergic effects. Combine that with another serotonergic drug, and agitation could increase. Ask the next doctor you see about that. Many will not be able to answer satisfactorily.

 

[Luke79AU]

For those not in Australia, a B52 is this, correct? Are the meds all given orally, including the haloperidol? 
Why are first generation antihistamines used off label for sedation? There are many risks in this. If serious harm in the patient results, medical will also have to explain the use of a H1 antagonist for sedation. I'd rather not be trying to explain that to the coroner.

• Benadryl 50 mg (Diphenhydramine) 
• 5 mg Haldol (Haloperidol) 
• 2 mg Ativan (Lorazepam)

We use IMI midazolam and haloperidol. That chills the ED out nicely 

[Luke79AU]

nolongeranurse said:

After reading some of the comments on this thread I can see that the nursing profession has a long way to go in the care and treatment of people who use substances.

One person actually made the comments that drug users were monsters. Monsters? Really?

Other statements made on this thread described drug users as manipulative, rude, draining, disrespectful, unable to cope, weak, like a two  year old, liars. One person stated that she just thanked God she wasn't like them and another nurse said they aren't like normal people.

One nurse said when patients asked for medication she tells them, "We don't want you to suffer, but unfortunately detox isn't pain-free. We're trying to help you learn to live without these meds." The other nurse agreed, "That's good. I'll have to use that one" Another nurses posted that she thought it was a good idea for the patient to be uncomfortable because maybe they "wouldn't do that to their body again".

Nursing is a caring profession. Those comments were made by those who lack the necessary compassion, ethics, and integrity to earn a place at the table.

[Luke79AU]

PsychRNXXX said:

...I'm generally sympathetic but we got a lot of "repeat" patients. So each patient has a different story or a different game they are playing with you and the docs. There are people truly physically suffering from detox who are there for their first time. Then there are others who have been there 7 times and think it's a joke. So they are treated differently based on needs...

Repeat patients? Like a chronic asthmatic who has sometimes poor adherence to ICS and LABA preventer inhalers? 

[hppygr8ful, ASN, RN, EMT-I]

Luke79AU said:

Nursing is a caring profession. Those comments were made by those who lack the necessary compassion, ethics, and integrity to earn a place at the table.

Bravo: It pays to remember that "There but for the grace of my higher power go I." I oncw read a quote and I don't know who said it but it stuck with me  "Addicts are not bad people, they are desperately sick people who need to get well. "

Hppy

[PsychRNXXX, BSN]

Luke79AU said:

For those not in Australia, a B52 is this, correct? Are the meds all given orally, including the haloperidol? 
Why are first generation antihistamines used off label for sedation? There are many risks in this. If serious harm in the patient results, medical will also have to explain the use of a H1 antagonist for sedation. I'd rather not be trying to explain that to the coroner.

• Benadryl 50 mg (Diphenhydramine) 
• 5 mg Haldol (Haloperidol) 
• 2 mg Ativan (Lorazepam)

We use IMI midazolam and haloperidol. That chills the ED out nicely 

Im not in Australia LOL. We give them IM usually for "psych emergency"

[PsychRNXXX, BSN]

Luke79AU said:

Repeat patients? Like a chronic asthmatic who has sometimes poor adherence to ICS and LABA preventer inhalers? 

Right 🙄 we have different terms. Was the best I could think of at that moment. 

[hppygr8ful, ASN, RN, EMT-I]

PsychRNXXX said:

Im not in Australia LOL. We give them IM usually for "psych emergency"

I'm in California and rather than a B52 we call this a Cocktail. CA law states we must offer the medication by mouth and if the patient refuses we go with the IM.

[Luke79AU]

PsychRNXXX said:

Maybe I didn't word it very well. All patients are treated appropriately. A lot of the repeaters come for different reasons - homeless, cold, avoiding court or warrants - but we know why they come. You get to know those repeating patients more than the others at this place because it's for acute episodes   No long term inpatient care. So you can address more of a specific problem with them. You also will know who is an extreme drug seeker, those borderline or histrionic patients who do things for attention and do things to get a 1:1 sitter all the time, the ones who are going to lie to the providers for different reasons etc. Each person is just different, yes some with definite need, so you assist them with programming individually. 

And this:
"I'm generally sympathetic but we got a lot of "repeat" patients. So each patient has a different story or a different game they are playing with you and the docs. There are people truly physically suffering from detox who are there for their first time. Then there are others who have been there 7 times and think it's a joke. So they are treated differently based on needs. "

I'm exiting this thread now, but honestly your comments reflect a few things:
- An alarming deficit of knowledge of addiction science and pharmacology.
- A "health professional" that treats patients according to her or his personal moral beliefs, preconceptions, and biases. 
- A belief that you are to "correct" and "teach" people, as though they are young children, or you work in a prison system.
- Detox is a medical environment. It's not AA/NA or a strict long term rehab. You are there to detox.

If there is any compassion in there, the most humane and professional thing you could do is resign from detox.