Dealing with drug seekers without alienating them

[Secel]

I am writing this post because I'm feeling guilty on how i dealt with a patient. I apologize this is lengthy

I had a patient who came in for for pain management. Throughout time i had him i was careful not to over drug him. He had signs of being a drug seeker. Talking about schedules. Setting alarms for his next dose. Pain never less than 7. No expression. Yet he was getting up to the bathroom, even showering. 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. He told me he passes out from the pain When he was falling asleep during conversations i told the doctor this. 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. I only said the truwhich is he was sedated. The doctor cut his drugs and he was ****** with me because of it. No explanation was good for him.

I felt as though i was objective about his pain and the meds and i sought other nurses advice and the doctors with my decisions. They backed me up. Where i think i failed however was with communiating to the patient. What ways have you found to explain the risks of these meds or your decisions or that theyre sedated without essentially calling them a drug seeker or alienating them?

[dream'n, BSN, RN]

I have no beef with giving patient's pain medications as ordered, whether my 'antennae' is up that they are a drug seeker or not. Honestly I don't care if they are seeking it's not my issue to handle. My ONLY issue is with the patient's safety. When my patient asks for Ambien, Dilaudid, Percocet, and IV Ativan at 2100, they are not getting it all. Sorry, not doing it. I'll educate them why and give some, but not all the meds. I then inform the patient that I will be monitoring their condition and administer the other medications in a reasonable time frame if still needed. This has irritated a couple of patients, but I'm not going to have to Narcan them on my shift.

So I guess I'm saying I kind of understand the OPs concern. But I only withhold PRNs if safety is an issue, I could care less if they are drug seeking. I will call the Dr. if they are requesting PRN pain medications and I don't feel safe administering more at that time, to report that the ordered medication isn't controlling their pain.

[kanzi monkey]

Dealing with appropriate narcotic prescribing is a terrible burden. It's not yours to bare though. In my opinion, if they report pain and have an order and are not a safety risk, give the med.

Sent from my iPhone.

Yes, but would you be willing to prescribe it? It does take a lot of effort and time to tease out the right treatment for patients with pain who are also opiate addicted (not just tolerant). I think it's irresponsible to say "pain is what the patient says it is" and just give the patient what they want. I do not prescribe that way and I become frustrated when a nurse who is caring for my patient tells me "8 out of ten says he needs more pain medication" without providing assessment details. Setting an alarm or writing down scheduled times meds are "due" are not good techniques in pain management. If a patient is controlling when the next dose is, they are perseverating on the drug, not on how they are feeling. This is an addictive behavior. This is not a judgment--helping people with substance abuse disorders who also have chronic pain is very tricky and requires commitment, time, some compromise, and compassion. And it is an ongoing process.

Giving the drugs just because it is safe in that moment, and the mentality that "there's no way to know WHAT the patient is truly feeling" is not helping these patients.

[heron, ASN, RN]

OP, I was going to suggest that you need further education on pain ... Now I will simply suggest you read - and re-read - previous posts.

Pain and the behaviors associated with it are complex ... Sleeping = no pain = drug seeker is a dangerous oversimplification. Failure to relieve pain has led to substantial legal damages in the past.

[macawake, MSN]

I think it's irresponsible to say "pain is what the patient says it is" and just give the patient what they want.

So what is pain, if it isn't what the patient says it is? Is it what you say it is, is it what I say it is?

[helping people with substance abuse disorders who also have chronic pain is very tricky and requires commitment, time, some compromise, and compassion. And it is an ongoing process.

I absolutely agree with you when we're discussing long-term management of a patient with chronic pain. Pain is extremely complex with physiological, psychological and individual components involved and there's still much research surrounding mechanisms of pain that needs to be done.

In an acute care setting you don't have the luxury of "time". An average nurse's patient load makes it difficult to be a fully functioning member of the "long-term treatment strategy" regarding pain management and possible addiction and rehab

for each individual patient.

If we had a "pain-ometer" that we could stick in the patient's ear and accurately measure the pain the patient is experiencing, a reliable blood test or some imaging/radiological exam that accurately quantifies the individual patient's pain experience than everything would be so much easier. We don't, all we have is the patient's subjective experience of their situation. The patient deserves to be listened to.

How would any of us feel if we suffered serious pain and were denied relief from that pain, simply because the nurse doesn't think that our response to our pain is one that s/he finds credible?

The medical/nursing professions have historically inflicted unnecessary pain on patients through ignorance. I'm convinced it still happens. In my own field, early reports from patients about awareness during surgery/general anesthesia was met with disbelief. Today, we know that it can happen. I can't imagine the how it must feel to first experience something as scary and potentially quite painful, only to be told that it can't happen and that it didn't happen. We need to listen to our patients! In my opinion we need to continuously educate ourselves and keep up to date with the latest research as well as work on our own biases. We'll never be perfect (we are human), but we can at least try

This is why I will chart my observations as objectively as I know how to, chart the patient's description of their pain and medicate as ordered when it's safe to do so.

As I said earlier, we don't have the luxury of time in acute setting. I can often speculate in private if the reason the patient asks for more opioids is due to an increased amount of noxious stimuli (I work PACU and anesthesia so there's no denying that we do cause our patients pain through surgery) an increased opioid tolerance, opioid-induced hyperalgesia or addiction. Or perhaps it's worry about their current condition/surgery, the effect of previous medical interventions or other stressors (more often than not it's probably a combination of several factors), but it doesn't really matter. I medicate when the meds are ordered and safe to give. My goal is to relieve my patient's pain.

When I worked in the ER I had some coworkers whom I consider way too emotionally involved with "drug seekers". They made it personal, a battle of wills and I'm sure I observed a component of moral judgement of choices the individual patient had made. Not wanting to "reward" a drug seeker became a motivating factor. I personally don't approve of this "judgmental/punitive" mindset and I also think it has a detrimental effect on a nurse's wellbeing. These coworkers were angry at the world in general a lot of the time, and angry at some of their patients in particular. I consider it a misallocation of mental energy.

Giving the drugs just because it is safe in that moment, and the mentality that "there's no way to know WHAT the patient is truly feeling" is not helping these patients.

I'm not sure what you consider a viable alternative to be in an acute care setting, that still guarantees that every patient in pain receives high-quality treatment/care?

[Hancock330]

I've seen a lot of pain control issues during my career. A caveat -- the pain scale was created for use in a research project and was not designed or intended for use in the usual patient care situation.

I've seen patients who retreat into sleep to escape their pain -- who awaken and become active after a dose of pain medication -- medication they took only because the prescriber or nurse insisted they try it. I've seen trauma patients who refused pain meds because "it only hurts if I move" who had to be urged to try a dose -- so I could go in later and say things like "Take a deep breath -- how does that feel?" When the patient said "It didn't hurt!" I could say -- "You need to take deep breaths to keep from getting pneumonia and pain meds make that possible. You need to take them at least several times a day."

I've seen the occasional patient who would never understand the pain scale who reported pain of 10 regardless of their actual pain. People who, when given the lowest dose of the prescribed opioid were "out like a light" -- arousing only to painful stimuli -- for hours and hours after the dose -- and who, upon arousing were given another dose of the opioid for the reported pain of 10, passed out for another 10-12 hours -- when given acetaminophen at bedtime, would sleep for 6 to 8 hours, awaken, again report pain of 10, eat breakfast, have a normally active day, etc. etc. Had nurses given even the prescribed opioid the patient could well have died of the hazards of immobility. For that patient, I wished I could have used the "On a scale of 0 to 10 where 0 is no pain and 10 is the being tortured to death with broken bones and with burns all over your body, what is your pain level?" pain scale.

I've seen an adult patient in a sickle cell crisis who, by report, had been awake all of day shift; I worked a double that night and I KNEW she'd been awake, watching TV and talking on the phone, even laughing at stuff, all of evening shift and all of night shift. I KNEW her pain medication wasn't adequately controlling her pain but couldn't get more ordered. No one who's had a lot of pain all day and all evening will be wide awake and doing stuff at 3 am if their pain is adequately controlled.

I've seen a lot of different situations. I've also been a patient where the nurse was sure she knew how much pain medication I needed better than I did, regardless of my knowledge of how MY body handles opioids. Being told "You can have the smaller amount of the oral pain med ordered now -- if, in an hour, you still have post-op pain, you can have the rest of the dose" was irritating. I wanted to take that youngster and shake her for her "One size fits all" approach to pain management.

Occasionally, perhaps rarely, one will also see someone who's "shocky" from uncontrolled pain whose vital signs will improve with an adequate dose of an opioid.

I'm mostly saying that pain management in acute care is FAR more complex than I ever imagined when I was a student and new nurse -- back in the dark ages of the late 60s and in the 70s. I can't say I ever got to the point where I was consistently satisfied with my abilities to assess and manage pain for patients -- but I did get better at how I thought about pain management and about teaching student nurses about pain management. I grew to love patient controlled analgesia machines. The confidence that, if the doses available were adequate to control pain, the patient could get every bit of medication needed but couldn't go into an opioid overdose regardless of how often he/she pushed that button, was wonderful.

Now that I'm fully retired -- I can say to those still in practice -- Best wishes for successful travels across what is occasionally a minefield of risks as you try to help manage your patients' pain.

[lostgirl0815]

I really, really hate that term"drug seekers". I personally know someone who has that on their record, but I also know the true story. They were physically abused by their spouse and because they went to the ER with injuries 6 times in 4 months this is the label they received. They honestly thought she was hurting herself to get meds. I think we should not call anyone this term as we truly can't be 100% sure ever.

You say you feel guilty about this patient, will you should. Who made you God to decide what his pain was? Just remember your oath to"g do no harm" and treat your patient. Please never be my nurse cos I can sleep with pain. I have chronic back pain due to a break with nerve damage, just learned to live with it most of the time. But when I can't take it anymore, I get pain meds. You would never know I was in pain unless I told you. So don't judge people cos they don't "act " the way you think they should if they were in pain.

Getting of my soap box now.

[NurseGirl525, ASN, RN]

A person who has chronic pain learns to adapt. Yes, we can go to the bathroom and shower ourselves. I take my pills on the dot to stay ahead of the pain. Even with the meds, I'm still in pain. It does make it tolerable though. I function normally. By looking at me you would never know the amount of pain I am in. I know right now that even though it won't get better, it won't get worse and that has to be my positive outlook.

I am fortunate to have understanding doctors who want to help me and try to take care of my pain. And that is for my doctor to decide, not the nurse. We are human, we do sleep also. Is my sleep interrupted? Yes. I can remember the last time I slept a full 8 hours. But I do get some in. I'm just having a hard time understanding your justification for this.

It is absolutely not your job to judge. The physician needs to make that assessment. I feel like you were wrong and you need to fully understand what a person in chronic pain is like and what they endure. I most certainly hope you are never in pain and have a nurse up an decide you don't need your meds.

[BostonFNP, APRN]

Yes, but would you be willing to prescribe it? It does take a lot of effort and time to tease out the right treatment for patients with pain who are also opiate addicted (not just tolerant). I think it's irresponsible to say "pain is what the patient says it is" and just give the patient what they want. I do not prescribe that way and I become frustrated when a nurse who is caring for my patient tells me "8 out of ten says he needs more pain medication" without providing assessment details. Setting an alarm or writing down scheduled times meds are "due" are not good techniques in pain management. If a patient is controlling when the next dose is, they are perseverating on the drug, not on how they are feeling. This is an addictive behavior. This is not a judgment--helping people with substance abuse disorders who also have chronic pain is very tricky and requires commitment, time, some compromise, and compassion. And it is an ongoing process.

Giving the drugs just because it is safe in that moment, and the mentality that "there's no way to know WHAT the patient is truly feeling" is not helping these patients.

My prescribing it would be based on my assessment of the patient; it is never easy but I rely on my training and experience and I make the choice I feel is both safe and correct. If I assessed the patient and prescribed it than I would expect that the patient received that medication as prescribed unless there was a safety issue. I have to deal with this issue more than I would like to due to bias of those administering the med.

My patients don't control when the next dose is due I do; I am not sure where that comment is coming from. Perseverating about the next dose isn't necessarily addictive behavior; in my experience it is often a direct result of inappropriate prescribing (under dosing, chronic treatment with short acting agents, etc).

The bottom line is most bedside nurses (or primary clinic nurses, VNAs, etc) lack the training and experience to be deciding what narcotic dose is appropriate for what patient; if they do than that should be addressed with the prescriber/attending provider not just limited or withheld by the attending nurse.

Sent from my iPhone.

[scottaprn]

Between 2007 and 2012, heroin use rose 79 percent nationwide, according to federal data. Within the same period, the data show, 81 percent of first-time heroin users had previously abused prescription drugs.

Experts: Officials missed signs of prescription drug crackdown’s effect on heroin use - The Washington Post

Be part of the solution with helping the patient have a comprehensive pain management program.

[Whispera, MSN, RN]

I have pain all the time. I'd rate it from 6 to 10 every single hour of every single day. No one could tell by looking at me or checking my vitals. I've lived with it so long that my overt behavior that would indicate pain has adjusted. I can sleep--it's a relief! I can bathe, and hot water helps tremendously. In those times my pain is 10 or even 20!, you can be sure that if someone else was giving me medications, I'd be watching the clock, probably come across as drug-seeking, and asking for relief when the time frame allowed.

I understand drug-seeking behavior in the negative sense--it is very irritating and frustrating to caregivers. I also believe, in the depth of my heart, that if someone is drug-seeking, there's a reason, and the reason should be addressed, without withholding what can give the person a bit of relief. Addicts, as well as other people, have pain and get irritated and frustrated by it too. We're not nurses to fix them in the few days they're hospitalized. That's for another type of treatment that can take the time that's needed.

[Sisyphus_01]

I think the best way to approach these situations is to come from a place of "concern" for the patient and deemphasize any type of speech that could be construed as condemnatory or judgmental.

I can understand the patient wanting to make sure they take their meds on time, even if they aren't in pain because once pain starts it can be difficult to make it stop. "Preemptive analgesia... involves the introduction of an analgesic regimen before the onset of noxious stimuli, with the goal of preventing sensitization of the nervous system to subsequent stimuli that could amplify pain" New Concepts In Acute Pain Therapy: Preemptive Analgesia - American Family Physician

I've gotten kidney stones several times and keep a prescription pain medicine on hand, which I will take the minute I get that pain in my gut telling me I have another kidney stone. I've found that once the pain starts ramping up, it feeds on itself. I think it's got something to do with a physiological cascade.

Short of educating the patient and watching for signs of withdrawal or abuse (taking more than prescribed, snorting pills, etc.) there's not much to do, but observe and report.

[Glycerine82, LPN]

*sigh*

I don't know if your patient is a drug seeker or not, and I also don't think there is any way for you to truly tell, either.

I think the only reason you should have notified the MD is if you felt uncomfortable with giving him more meds. I suspect that is not the reason you notified him/her, though.

What if, just what IF that patient truly has a 7/10 pain and is just so used to it that they can function normally? What if their tolerance is so high that they aren't receiving analgesic effects in the same degree they are receiving sedative effects?

Maybe he needs a different med, or maybe he's an addict. I don't know. What I do know, is society needs to change the way they look at addiction.

I would really like to see nurses start being concerned that their patients may have an untreated medical condition (addiction) and stop worrying about whether they're taking meds for fun. Ask them about it, (is that allowed?), call a case manager, tell them it's nothing to be ashamed of if that's indeed what's going on. It's a condition and there are treatments available......

If people weren't made to feel ashamed and wrong for drug addiction, more would seek help.