not comfortable with giving narcotic injection due to street drug interaction

[Sarge_BSN_RN]

Hi all

I'm in an outpatient center. I had an order to give a narcotic pain relieve via injection.. As a standard precaution, I performed a UDT which tested positive for two illicit substances. Patient reports using substances the previous evening. I informed the ordering physician of the results. I was directed that the patient is in pain and that I should go ahead and give the shot. It has been drilled into my head that pain is what the patient says it is and I'm a firm believer in that. However, I did not feel comfortable in giving the injection due to fear of potential interaction and harm to the patient. I explained this to the provider which was not taken well. I'm just curious if my actions were appropriate and acceptable or am I being overly cautious. Has anyone else dealt with this?

[blondy2061h, MSN, RN]

You do a urine drug screen on any patient requiring pain medication? I'm wondering what kind of clinic this is that you're giving IV pain medication.

When you say "illicit substances" that could mean a wide range of things, so it's hard to make a judgement call on that alone. If the patient is having pain and they have strong, appropriate respirations, and they're alert, coherent, and speaking appropriately, and they were going to be monitored after the injection, and things like narcan and oxygen were available, I'd be okay with it.

If someone smoking pot got in an automobile accident and had a bilateral traumatic leg amputation would you deny them pain medication? There are lots of situations where it may not be ideal, but it's appropriate to medicate for pain despite other drug use.

[Tenebrae, BSN, RN]

What was the illcit substance, and what likelyhood was their for interaction?

Bear in mind that a person who abuses heroin will be more opiate tolerant than someone who doesnt?

Its hard to comment without knowing the ordered med and the illcity substances they tested positive for

[MunoRN, RN]

I wouldn't do a UDS as a "standard precaution", but if I was aware the patient used opiates due to a UDS the only way that would figure in to my decision making is that it would tell me the patient will likely require more opiates for pain control than is typical, I definitely would not use that as a reason to withhold pain meds all together.

[Pangea Reunited, ASN, RN]

Those patients are the most tolerant and the most difficult to accidentally harm. Assuming the situation was as uncomplicated as it seems, I would have been fine with administering the clinic-ordered medication.

[TheCommuter, BSN, RN]

I'm just curious if my actions were appropriate and acceptable or am I being overly cautious.

I think you may have been too cautious in this situation. As long as the patient's respiratory rate and systolic blood pressure were within normal limits, I would have administered the medication.

As others have previously mentioned, harming a potential illicit substance abuser with injectable narcotic pain medication is immensely difficult because these patients need more pain medication than usual to experience untoward effects.

In addition, just because a patient has a positive urine drug screen, this does not necessarily mean the person has used illicit drugs that same day depending on one's metabolism. For instance, my father used to abuse cocaine many years ago. He once tested positive for cocaine on a urine drug screen even though he had not used in three days. The illicit substance was in his system 72 hours after the last use.

[Altra, BSN, RN]

Can you tell us more about this protocol in your clinic, to do a urine drug screen before administering opioids?

And when you say you were concerned about "interaction" between the med you were giving and other substances used by the patient ... can you be more specific about what worried you physiologically? Respiratory depression? Was there any compromise in the patient's respiratory status? If your discussion with the provider consisted of "worried about interaction" I can bet that it was not received well.

[Karou]

What were the illicit substances? What was the narcotic?

Was your patient stable?

I would have given the narcotic. Especially after you already discussed it with the physician. I probably would have given he physician a heads up about the UDS (since that's your policy to do one) but I wouldn't question the narcotic very much.

[cayenne06, MSN, CNM]

Were you giving a med with a strong opioid antag potential to a patient with an opioid dependence? I am having trouble thinking of other potentially dangerous interactions.

[Jules A, MSN]

I think you used good judgement by running it by the provider first since it made you uncomfortable however if the doc ok'd it I would have just given it and documented very clearly that I had double checked secondary to concerns of drug:drug interaction.

[KelRN215, BSN, RN]

I, too, am curious about the whole doing a UDS as a "standard precaution" thing. If the patient used an illicit substance the night before, he's unlikely still under the influence of anything and I'm curious as to what kind of reactions you'd be expecting. People on PCAs get narcotics q 7 min.

[Jules A, MSN]

I'm in psych and inpatient we pee test everyone so I don't find it all that unusual that it would be ordered. Outpatient I do it at my own discretion.