Dealing with drug seekers without alienating them

NICUmiiki, DNP, NP · Jan 13, 2015

I don't think it's your responsibility to determine whether someone is a drug seeker or not. You can't decide whether someone has pain or not. Ask anyone who has chronic pain (or a Fundamentals book)... People with chronic pain don't always show the same physiological responses as people with acute pain.

I think it would be worse to deny someone who is in pain medication than it would be to give a (suspected) drug seeker a dose of pain meds (as long as it's safe).

LadyFree28, BSN, LPN, RN · Jan 13, 2015

I don't think it's your responsibility to determine whether someone is a drug seeker or not. You can't decide whether someone has pain or not. Ask anyone who has chronic pain (or a Fundamentals book)... People with chronic pain don't always show the same physiological responses as people with acute pain.
I think it would be worse to deny someone who is in pain medication than it would be to give a (suspected) drug seeker a dose of pain meds (as long as it's safe).

THIS.

In all my years of nursing, I have seen many pts with documented addictions, chronic pain, and in between; I manage their pain, and if possible, will collaborate to see if they would try something for chronic pain or long acting medication along with fast acting pain medications until the pain is tolerable; if possible, I would get pain management involved or suggest it to my pts to make sure they are aware of the choices they have in managing pain; I also support them emotionally because some people use drug seeking behaviors as a way to cope, and we have to be cognizant of that as well-we treat pts holistically, including psychosocial and emotional factors, and we can't abandon those aspects when we are managing the physiological aspects.

As someone who has aura migraines and a pain syndrome, I am glad that if and went I make an ER visit, that my symptoms are treated expeditiously and no one with holds or tries to minimize my pain; I know what works for me and there is collaboration involved when I need treatment; it hasn't always been that way, but I have seen better ways if collaborating with my health for the past 7 years I've had my condition, and better treatment of migraines in the past 10 years out of the 20-plus years I've had migraines (developed them at the age of 9).

We have to be cognizant of how we would want to be treated if we were in the same situation; we never know when we would be in our own situation and we would want someone to respect how we feel and what we need, even if the person involved in our care doesn't agree with it, we would want then to respect it, wouldn't we?

RNperdiem, RN · Jan 13, 2015

You still have a healthy fear of what narcotics can do to a person.

If you have ever called a rapid response for a person who is breathing 5 times a minute, is gray and going downhill quickly, you will never forget it.

Your patient probably does not have that same caution. They have always survived, right? It is hard to educate someone with a different worldview.

Libby1987 · Jan 13, 2015

I don't think the sedation/somnolence is an indication of lack of pain in of itself.

A simple example, think of the terminal patients who would suffer their undeniable pain than be "over medicated" and not able to stay alert enough to be aware of their loved ones' presence.

We don't usually put chronic pain in the same class as terminal pain but years of severe chronic pain with ever increasing narcotic tolerance doesn't sound like a picnic either. Not adequately treating one legitimate pain in an effort to not treat a drug seeker isn't worth it. I don't how a hospitalist or shift nurse can really know and judge chronic pain, I'd rather see that left to the patient's PCP or better, their pain specialist.

Emergent, RN · Jan 13, 2015

I am sometimes annoyed with drug seekers. But, I never show it. I had a patient the other day whom we were holding in the ER because no beds. He was asking for pain meds again, he was a young guy whom I suspect was seeking drugs with his general complaints of pain. I called the admitting doc for orders. He ordered every 3 hours morphine.

I laid it out straight for the patient, you can have morphine every three hrs. I gave him his dose and told him when his next one was due. Yes, he called me on the dot. The crusty old nurse I was working with criticized me for telling the pt how often he can have the drugs.

Yet, because I informed the pt when his dose was due, he stuck to that and didn't pester me in between doses. I see no reason not to inform the patient what his order is and have him/her keep track of it. So what is the pt watches the clock. So what if the patient has a drug craving. You're not going to change that in one shift by going to war with them, or getting annoyed. Just follow the doctor's orders.

Meriwhen, ASN, BSN, MSN, RN · Jan 13, 2015

I don't think it's your responsibility to determine whether someone is a drug seeker or not. You can't decide whether someone has pain or not. Ask anyone who has chronic pain (or a Fundamentals book)... People with chronic pain don't always show the same physiological responses as people with acute pain.
I think it would be worse to deny someone who is in pain medication than it would be to give a (suspected) drug seeker a dose of pain meds (as long as it's safe).

Agreed. It's not the nurse's place to decide who should or shouldn't have meds. That is the decision of the prescriber.

Please don't fall into the trap that some nurses do and play God with a patient's medications. Pain is whatever the patient says it is. Some patients with chronic pain come off looking like drug seekers because they're not rocking in bed wailing, or because they're very specific about what drugs do and don't work for them. Yes, some patients do exaggerate or lie in order to get more medications--I won't deny that. And there are a fair share of addicts out there who see you as the supplier of their next fix. But it is not for you to decide if they're in pain and/or really need the medication. And if they're an addict not ready for recovery, you're not going to make them see the light and have them running to NA by denying them medication.

If you truly feel that the patient shouldn't have a specific medication, then by all means voice your concerns to the prescriber. And objectively (key word) document what the patient says, how they are behaving, etc. and let the prescriber decide how to proceed. Otherwise, if it's ordered and appropriate to give at the time, then you should give it.

Here.I.Stand, BSN, RN · Jan 13, 2015

I would rather give 1000 drug seekers their fix, than deny relief to one person in pain.

So did he set the alarm and ask for his prn when it went off, and you denied him? Or did he expect you to hear the alarm and bring the meds? I've mentioned this before, but as a postpartum patient I had a lot of pain. I delivered with no drugs with FOUR of my five children, but post-partum I had pain so bad it made me nauseated. The pain was especially bad when breastfeeding--being able to relax is very important when trying to breastfeed. The pain kept me awake at night, even when the baby was sleeping and when I NEEDED to be sleeping. Guess what...I watched the clock. It's not the nurse's job to bring me my prn's every 4 hrs and 6 hrs respectively, on the dot. They are prn. So four hours after taking Percocet, I requested more Percocet. Six hours after taking ibuprofen, I requested more ibuprofen.

What kind of drugs are you talking about? You are not going to over-sedate the opioid tolerant person with reasonably dosed prn's. Falling asleep isn't a sign of being over-narcotized. Even someone who just had thoracic surgery on NO pain meds at all, they would be in agony but given a few days would fall asleep. It doesn't mean they are finally comfortable, it means that their hypothalamus finally took over. If you wait until someone is wide awake before treating their pain, you are not going to be able to control it effectively.

Someone who is in chronic pain is GOING to look different than someone who is typically healthy but in acute pain. They have gotten accustomed to it and won't be writhing around in bed with elevated BP and grimacing.

No expression.

Flat affect is not a sign of a drug seeker. It's a sign that he's lived with it long enough that he can control his face. It could even be a sign that he's depressed...being in pain all the time can do that to a person.

You weren't objective from what I can tell...you decided that he was a drug seeker, you were critical of him knowing and working with his prn schedule, stated that he wasn't reporting to you adequately--

Talking about schedules. Setting alarms for his next dose...No expression.

Even were suspicious about his ability to do ADLs.--

Yet he was getting up to the bathroom, even showering.

What was he supposed to do, pee the bed? Be stinky? Maybe he actually got some relief in the shower. Moist heat is a non-pharmacological pain intervention and can be a good adjunct to meds.

Does your hospital have a pain management service? Maybe you should meet w/ their RN for some education in this area. Or look for some pain management CEUs.

caliotter3 · Jan 13, 2015

Don't read too much into the situation. You took appropriate action according to what you stated in your OP.

macawake, MSN · Jan 13, 2015

if i found him asleep i knew his pain was controlled and refused to give him meds when his alarm went off. I waited usually until he was alert.

As others have said, people who suffers from chronic pain don't always have the same physiological response as someone with acute pain. It is perfectly possible to sleep despite having even severe pain. People who suffer from chronic pain don't stay awake for a week or two months... They sleep despite their pain. A person can have

a normal respiratory rate, heart rate and blood pressure, have a neutral facial expression, have conversations or watch TV (or whatever) and still be experiencing a significant amount of pain.

I felt as though i was objective about his pain

I don't believe that that's even possible.

Here's a definition of the word "pain" (from IASP).

"An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".

IASP Taxonomy - IASP

You cannot objectively judge another person's pain.

Pain is always subjective.

I never said he wasnt in pain because he did have a medical reason for having pain. I do think he had pain. Simply that he wasnt reporting it to me adequately.

Are you really comfortable deciding to withhold pain medication from a human being who you know has a medical reason for having pain, if their vital signs permit administration of said pain medication? Are you that confident that your interpretation of how it feels to live in that person's body is accurate?

I've written this in previous posts, I'd rather "over-medicate" ten or even a hundred "drug seekers", than run the risk of not providing pain relief for a single patient who genuinely needs it.

Talking about schedules. Setting alarms for his next dose.

This behavior doesn't in any way rule out a genuine pain condition. I've met many terminal cancer patients who do this, and I'm sure that you agree that they aren't faking their pain.

The doctor cut his drugs and he was ****** with me because of it. No explanation was good for him.

This also adequately describes the reaction of a person who suffers genuine pain. Knowing that pain medication will be administered on a regular basis provides psychological comfort and can in turn provide some relief of the pain. The opposite is also true. Feeling stressed out and worried that one won't get medication for pain relief when needed will likely aggravate the patient's pain/perception of.

ArtClassRN, ADN, RN · Jan 13, 2015

You don't give meds to someone who appears oversedated. Period.

You also don't pretend someone is oversedated in an excuse to not give them pain meds.

Your description of the events is a little sketchy. "I do think he had pain. Simply that he wasnt reporting it to me adequately" This sounds a little like you are playing gotcha games with the patient. I would advise you not do that.

Fiona59 · Jan 13, 2015

I was taught that pain is what the patient states it to be.

The 1-10 score is a joke to me. People don't understand it. Worst pain ever? You get the full dose.

I've learnt over the years to save my energy and just give them what they want. My hospital is in the inner city and my pain seekers/addicts just go outside and get a fix if they don't think they are getting enough inside. I'd rather know what's in them than try and figure if they've been shopping outdoors.