Dealing w/ difficult/drug seeking pts...

Blindsided · Jul 17, 2010

Yes...I feel your pain! Don't forget all the heartbeats spent on sched. their expensive tests, which come back negative, sched. their physical therapy evals for which they never show. They manage to doctor hop through all the different docs in the practice and/or the town trying to get their fix, then show up in ER after their suicide "attempt" and positive drug screens, even though the doc didn't prescribe any narcotics. Oh, and don't forget their complaints to medicaid for not prescribing their favorite narcotics, which starts the ball rolling for a medicaid audit...more heartbeats we'll never get back! Oh yes, and those that sell the drugs on the street which they do manage to obtain, and occassionally get caught, then end up in "a special shelter for women and/or men" for six months or so before making their way back to the practice to try again. Uh, it's called JAIL, and it's our buck paying for it all! So what keeps me going? The only saving grace is my observation of these people. I have decided that it must be the most miserable, miserable existence. So miserable, lying and all consuming, that my overwhelming fatigue in having to deal with these misfits cannot compare in misery to the going no where life they are living. I despise them, yet pity them at the same time, all the while treating them with respect, because I know that they know that WE know how bogus their complaints are, and the heartbeats that THEY spend doing this, they will never get back either.

heron, ASN, RN · Jul 17, 2010

This subject is controversial and tends to trigger intense discussion. There are several terrific threads on the issue. Search under addict, drug-seeking ... stuff like that.

Another good way to learn more about addiction is to cruise the Nurses in Recovery forum ... good info there, too.

What you won't find is easy answers to this. There aren't any.

Have never worked in ED, but I worked with actively addicted patients with end-stage AIDS for eleven years. PM if you want.

If it's making it hard to work, maybe there's a local al-anon meeting that might help. I've never tried it, but it works for a lot of folks. I've often thought that such a resource for nurses would make a world of difference.

Do you have access to a good psych nurse? They have a lot of skills that can help ... as do many social workers. The more of these skills you can pick up, the better you can deal with these complicated patients. It's never gonna be easy, though. Take care.

NocturneRN · Jul 17, 2010

I love my job, and feel that on most days, I make a difference for the pts/families that I care for. Lately, though, I am getting more and more annoyed with difficult pts--those who complain about every little thing, and pts who are strictly drug seeking and have no interest in complying w/ care plans, interventions and treatments. I come home angry, frustrated and not looking forward to my next shift.
Any suggestions for dealing w/ these pts?

I have a few suggestions, that have worked for me since my days of working in the addictions field. They sound like a bunch of Nursing 101 textbook BS, but they really do help.

First thing: remember that patients who "drug seek" are usually either chemically dependent (psychological or physical or both), or are having more pain than is apparent. (I think most nurses have an embarrassing story about a patient they once dismissed as a whiner, who turned out to have a painful underlying medical problem. Once the problem was detected and treated, the whining stopped. So you can't completely rule out that possibility, when someone is constantly asking for more and stronger medication.)

If the patient does have an addiction, it's important to keep reminding yourself that irritability, dishonesty, lack of trust and unwillingness to follow a regimen are features of the disease. So is manipulation. These patients are going to do everything in their power to get more drugs, and you just happen to be the one who dispenses drugs, so they target YOU. Some use flattery ("you're my favorite nurse"), some use staff splitting ("But the other nurse didn't give me all this hassle when I asked for a pain pill!"), some use abuse or threats ("Get your fat a** out there and get me my @#$%&@#%@*$# shot, or I'll call my doctor and get your a** fired!"), and some just try to wear you down (asking, "But WHY can't I have my shot now?" for the 10th time in 20 minutes). Whatever you do, don't take it personally. It's not about you (whether or not you have a fat behind). It's about their addiction.

Another thing: choose your battles. Resist the temptation to get into power struggles over things that don't really matter: if the call light goes on and you can manage the time to answer it, do so. If you said s/he could have her medication at 10, then give it at 10. (I've seen some nurses try to get back at these patients by deliberately making them wait longer than necessary. That's just feeding right into the battle.) If the patient keeps asking you for dumb little things, like moving a Kleenex box two inches on the night stand, say something like, "I have a couple of minutes before I go do some dressing changes. Do you want me to bring you anything, rearrange anything, help you with anything now?" Do everything you can to show that your primary goal is the patient's well-being, not payback for being a jerk.

Remember, too, that you're not going to fix someone's drug problem during an unrelated hospital stay, and it's unlikely that withholding medication is going to teach them anything (except not to trust nurses). If a medication is ordered for the patient, and s/he feels s/he needs it, it should be given as ordered, or clarified with the doctor.

It's also appropriate to confront patients at times, customer satisfaction surveys or no customer satisfaction surveys, if you catch them being dishonest. I've done this at times: pulled up a chair, looked the patient in the eye and said, "I'm getting the impression that you're not being honest with me about (insert lie here)." Of course, they'll usually deny whatever it is that you bring up, but it does convey two important things: (1) you're not easily fooled, and (2) it's their behavior, not them personally, that you're against.

If all else fails, I believe in sharing the wealth. In the ER, whenever certain names appear on our tracker screen, whoever hasn't had that patient in a while gets him/her. ;>)

donsterRN, ASN, BSN · Jul 17, 2010

Yes...I feel your pain! Don't forget all the heartbeats spent on sched. their expensive tests, which come back negative, sched. their physical therapy evals for which they never show. They manage to doctor hop through all the different docs in the practice and/or the town trying to get their fix, then show up in ER after their suicide "attempt" and positive drug screens, even though the doc didn't prescribe any narcotics. Oh, and don't forget their complaints to medicaid for not prescribing their favorite narcotics, which starts the ball rolling for a medicaid audit...more heartbeats we'll never get back! Oh yes, and those that sell the drugs on the street which they do manage to obtain, and occassionally get caught, then end up in "a special shelter for women and/or men" for six months or so before making their way back to the practice to try again. Uh, it's called JAIL, and it's our buck paying for it all! So what keeps me going? The only saving grace is my observation of these people. I have decided that it must be the most miserable, miserable existence. So miserable, lying and all consuming, that my overwhelming fatigue in having to deal with these misfits cannot compare in misery to the going no where life they are living. I despise them, yet pity them at the same time, all the while treating them with respect, because I know that they know that WE know how bogus their complaints are, and the heartbeats that THEY spend doing this, they will never get back either.

This is an excellent post, and I completely agree.

It's incredibly frustrating, but you know, it's not my life that they're living. I can't imagine what hell their lives must be like. Whether or not it's of their own making, it's still a hellish existence. I try to treat them with respect, and if the pain med is ordered, I give it like I would any other medication.

classicdame, MSN, EdD · Jul 19, 2010

drug seeking or not (and how can you really tell for sure?) these people are in pain. Could be emotional, not physical. I treat them like pysch patients. Funny, but when I lowered my expectations I was not as frequently disappointed.

HOWEVER, do not put yourself in jeopardy. Be wary. Document carefully. Bring another person in the room to witness when needed.

noreenl · Jul 19, 2010

My husband has been on pain medications for over 14 yrs and has built up a tolerance for some meds. What upsets him most is when a; as he puts it, "so called medical professional" assumes his RX (Oxycontin 160mg q 6 hrs w/Oxy IR caps 15mg po prn breakthrough pain) means he is an addict. Lately he has been having multiple horrific muscle spasms in his back that make him curl into the fetal position and scream in pain. His IR was increased and IM Toradol was added and the pharmacist refused to fill it. the pharmacist told my husband he didnt need them and the toradol would be hell on his stomach. I can't tell you how upset he was! The pharm REFUSED to call the MD and just said I wont fill this. my husband left the drugstore embarrassed because multiple pts heard this exchange(HIPAA anyone?) and one of them followed him outside to try to get my husband to sell his Oxycontin!!!! I can't belive how ignorant some people can be!!!!!!!!!

pawashrn · Jul 20, 2010

Most drug addicts and alcoholics are base line manipulators. Kindly and firmly, let them know the schedule of medications and treatments and if they buck you. Notify the physician and let them get so pestered by this patient that they discharge them from the hospital and usually won't re-admit. remember manipulators are only children who have never been told "no" and we are starting to see alot of these people in our society as a whole.

kayern · Jul 31, 2010

You don't state what the primary diagnosis is. Remember pain is subjective and if a patient states he's in pain its not up to us, as nurses, to judge his pain. As M/S nurses we're not going to cure someones "pain medication addiction". Treat the pain as ordered, do not get into a debate with the patient. If what is ordered isn't doing what its supposed to do, advocate for the patient, get a pain management consult, suggest to the attending PCA. Get Psyc, Care Management and Social Work involved and as soon as the patient is medically stable get him/her to a drug rehab program.

wibilly · Mar 26, 2013

I just don't understand why you all think you can somehow judge a person by first impressions! How are you going to tell someone that they're pain is real or not? Have you ever had a back injury, multiple herniated disc, do you understand how much pain that could put a person in? Because the way you all are talking it seems as if you think that the pain would be minor to mild but never severe! I myself have 3 herniated, bulging ruptured discs whatever you'd like to call it and for some reason I get looked at like I'm just shopping around for pain meds even though I have the MRI's to prove it! You all walk around like you S**t don't stink and act like you understand what the patients are going through but you don't really. I know a couple of addicts and I feel horrible for them because withdrawals from opiods is the worst type of sickness, pain and mental stress you could imagine! You cannot possibly understand an addict unless you were once one! An addict will continue to be an addict whether or not you give them the medication they will just go find them else where or go on to another drug like heroin or cocaine and possibly overdose. Not saying that you made them go do that but you did put them into a position that made them feel like there was no other way except buying the meds off the street. I am just trying to share their point of view because it seems no one else has! Also to the lady with the husband who was denied his prescriptions I personally would have filed a lawsuit against that pharmacy for sure!