Drug seekers

[russianbear]

I'm sure this has been posted before and I would appreciate any links to good threads on the topic. I am a new nurse and struggle with giving strong opiates like Dilaudid, etc to people who are clearly pain seeking. I feel dirty. Yesterday I had a gentleman who was ordered 1mg Q6. He was a clock watcher. As soon as that six hours was up, he was on the light. The reason he was getting this is because during the previous shift he threw such a fit yelling, screaming etc to have it the physician ordered it. Looking through his history, this is his pattern. Usually in the ER he yells and screams and demands IV Dilaudid. In this country there are a lot of people addicted to opiates because they are often over prescribed and these types of things feeds into that. As a nurse, one of our responsibilities is to encourage health and I feel more like I am contributing to a societal problem than helping a patient in situations such as this.

I don't want this to be a "pain is what the patient says it is" argument. I am talking about the rare instances where someone is clearly a drug-seeker.

[joanna73, BSN, RN]

If the medication is ordered and I know the resident has chronic pain, I administer the drug. No questions asked.

I have other things to concern myself with than if the patient is drug seeking. You are not going to modify their behaviour in one hospital stay. That's a losing battle.

[Tenebrae, BSN, RN]

Diabetes and HIV can cause a great deal of pain. And 1mg every 6 hours is not an over abundance of pain medication even with the Percocet. Knowing that you are not going to get pain relief for 6 hours, and one needs to do something to get their minds off of it.

.

I had cellulitis in my middle toe last week, and it hurt like hell.

[iluvivt, BSN, RN]

Opioids: Addiction vs. Dependence

Most chronic pain patients who take opioids on a long-term basis will become physically dependent on them, very few will ever become addicted to them. The rare few who do develop a problem are often found to be highly susceptible to addiction due to a genetic predisposition.

Addicts

Addicts take drugs to get high and avoid life

Addicts isolate themselves and become lost to their families.

Addicts are unable to interact appropriately with society.

Addicts are eventually unable to hold down a job.

The life on an addict is a continuous downward spiral.

Pain Patients

Pain patients take drugs to function normally and get on with life.

When pain patients get adequate relief, they become active members of their families.

When pain patients get adequate relief, they interact with and make positive contributions to society.

When pain patients get adequate relief, they are often able to go back to work.

When a pain patient gets adequate relief, their life progresses in a positive, upward direction.

I liked this chart because it will help clarify for some the difference. Anyone that has lived with crippling chronic pain and has safely taken their medications and followed medical advice and the prescription as written do not take kindly to being called addicts. They do not have a craving for the narcotic nor do they generally feel high. Many on po regimes are managed on long acting narcotics and have a shorter acting narcotic for breakthrough pain. Anyone that has suffered for a long time without relief or that has endured surgeries and procedures and doctor visit after doctor visit are so relieved to get any significant pain relief they will take all the mislabels and it even if they are labeled as addicts so they can live a more noram life and be a contributing member to society.

Although some think they are "impaired",it is not true! It is the opposite, rather they are impaired and crippled by their pain. When you suffer in pain you all you can think about is getting some relief and if you don't you get fatigued from fighting then super irritable. So you are actually functional and sharp since your focus if off the pain and agony you are enduring!

[Tenebrae, BSN, RN]

I'll never forget the time I ended up in the ED with terrible pelvic and back pain. I couldn't walk and I had no idea what was wrong with me. The first time they treated me like dirt and sent me home with nothing in an ambulance, even though I never even asked for pain meds. When they got me home I could not get out of the ambulance so they brought me back to the hospital where the nurses, including the charge nurse, ridiculed me and made me feel like an inconvenience. Several years later it happened again after a long time of mysterious pain. I went to the ED again straight from work because I could not stand. They gave me Dialudid and I had an MRI which came back negative. Immediately the tone changed and I was treated like absolute dirt. I will never forget that feeling of utter shame, even though again I never asked for any pain meds. I was disgusted and told the nurse in charge how I was made to feel. Months later I was diagnosed with Stage 4 endometriosis with deep infiltrating disease that I needed 3 surgeries for. I still need narcotics and I still work full time. Someone's pain is NOT your decision. Someone's addiction is NOT your concern. Do your job, act like a professional and be an advocate for the patient and try to have some compassion about what people have to go through. I hope it never happens to you so you never get to experience it first hand. Since then I have made it a point of never leaving my patients in pain for any length of time. I make it a priority to give patients their pain meds and if I see someone procrastinating for no good reason I'll give them hell. I do not want to see what happened to me happen to anyone else.

You are awesome.....

[jadelpn, LPN, EMT-B]

My father was a long-term drug addict who became infected with HIV from sharing needles. He preferred uppers, so usually didn't use emergency facilities for getting high.

That being said, remember that HIV can cause all sorts of other issues, and the meds aren't easily tolerated. Many patients who are noncompliant with HIV medication are also suffering from depression or other issues related to a terminal diagnosis -- some have essentially chosen to die faster rather than slower. Depending on how long they've been sick and their current immune status, they could have many quality of life issues, including severe gastrointestinal distress that opiates may help and opiate withdrawal is certainly going to exacerbate.

You aren't going to fix a patient like my father in one stay. Dad was on methadone in his later years when he had to have a hip replacement and started rapidly developing other symptoms of degenerative joint diseases -- but he refused to have other scans that might have found the tumor sucking calcium out of his bones, until the high calcium itself caused an admission. The tumor had metastasized and one was already quite large. That's not an uncommon end for average 17-year diagnosed patient. It's amazing he lived that long, given his lack of compliance. But as his kid, I saw a little more to see why he was such a frustration to his doctors.

If you have the ability to notify a unit social worker about such a patient, finding an advocate to help them get care outside the ER and hospital to address their health without taking up resources and getting them better quality of life would be my suggestion.

But remember, this patient is terminal. Is addiction his biggest problem?

If I could like this x1000 I would.

Food for thought for sure. Thank you so much for sharing your Dad's story.

[jadelpn, LPN, EMT-B]

I guess my father was lucky. Since his drug of choice was amphetamine, it wasn't something he could "score" easily from physicians. But any addict has a similar rep when it comes to seeking, and for good reason -- even if it's not the high they prefer, narcs are still quite capable of giving them *a* high.

Dad had been able to work with a physician outside of the hospital for his pain management, and that's what this patient really needs, from everything that has been said. But just based on my Dad's experience, a request for an opioid and becoming hostile, but then accepting a dosing schedule that isn't going to address pain (Dilaudid is an ugly opioid because the short action makes it far more addictive, and every six hours is still not often enough), makes me wonder about extremely loose stool being an issue he's dealing with but unwilling to discuss. That regimen might not address chronic pain effectively, but might be helpful with fecal incontinence from unhappy gut flora. Dad said that was the most embarrassing part of his illness.

Interestingly, I have had patients who attempted to crush up popular allergy medications to push in their IV's.

So we needed to be mindful, especially if you are giving an antihistamine for itching.

I think chronic pain is largely misunderstood. And by the time the patient is in a place that they need medication at larger and more frequent levels to function, the frustration level is so high that to communicate other options is not well received.

I am oh so curious if the OP was homework, trolling.....as we have not heard from the OP for a bit.

But as indicated before, people who have chronic illness/disease that has gone largely untreated or other chronic conditions that cause malfunction/inability to function need to be treated accordingly. When a nurse starts getting emotionally invested in the labelling is when this turns into some kind of passive-aggressive struggle. That just shouldn't be happening.

[SleeepyRN]

I'm a nurse with a bad back. With the help of different docs - ortho, neuro, pain management - I used conservitive medical management for years. Then...I hit the point where the pain was getting worse and worse -- and when I finally developed foot drop, I admitted that I was at a point where that surgery I'd been avoiding for 20 years was necessary.

I'd been on fentanyl patches at home - but they were no longer helping - and got admitted for intractable pain. In the hospital, I was on what - to me, anyway - were huge doses of IV dilaudid. I was conformable and functioning. It was several days before there was an opening in the OR schedule, so I used that time to prepare my students' assignments & set up my office so my assistant could manage while I was out.

As one of the NP's noted, my back was split open in the OR. And while I'd planned for post op care with my docs (who ordered a PCA pump for me post op) and the Pain Service NP --- I thought I had covered all the bases.

I didn't count on one of the ICU nurses - who I had never met - and who admitted she didn't know me - deciding that I was 'drug-seeking'. I have no idea where that came from or what she saw that gave her that idea.....but there it was.

And apparently, she convinced the ICU intensivist that I was a major drug seeker. He cancelled my PCA and ordered 1 mg of dilaudid IV every 4 hours. That was a fraction of the dose I was on preop. No surprise - I was asking for pain meds all the time. In addition, while my docs had clearly told me they wanted me to stand at the bedside that first night- she refused to let me do that - actually yelled at me.

And the final horror: my repeated requests for pain meds led to her taking my call light away - and closing the sliding glass door to my ICU room.

So - I now know what it feels like to be a supposed 'drug seeker' - and what it feels like to hit a pain level of 10 --- and have no relief for over 9 hours - and to feel abandoned by my nurse.

I'm not saying your patient isn't inappropriately drug seeking - you were there and you assessed him. But, I can tell you that not all patients that repeatedly ask for pain meds are inappropriately drug seeking. When my PCA was reordered at 7:30 -- and the pain nurse had it on by 7:45 ----and gave me several boluses, until my pain level was below a 4....then I stopped asking for pain meds.

I did ask to speak to the unit's director tho.....and discussed with her what I went through over the night shift in the Surgical ICU - truly one of the most horrible nights of my life.

Omg. How incredibly horrific. I have no words. I wouldn't typically admit this on here, but I guess I will.

I've been suicidal in the past from my chronic pain. I get no pain medication. The only treatment my urologist will do for my interstitial cystitis is weekly bladder installations of steroids. I did one round of 8 weeks, and it brought my daily usual pain (when not in a 3 month flare) from a 7 to a tolerable 5. That's it. The treatments cost thousands of dollars. I had to borrow a grand from my parents for one round of tx just to be able to function somewhat like a normal person in the world. But I only did the treatments once. It's way too expensive.

After graduating nursing school, I quit my first job after only 3 months. I would come home every night in tears curling up in the bed, not sleeping bc of the pain, and then getting up for work the next day, smiling to my patients, nobody none the wiser.

Finally, I was just SO incredibly depressed, I literally walked off the job and didn't work for almost a year. I laid in bed day and night, didn't leave the house, didn't eat, just wishing I was never born. Months when I had a flare, my pain was an 8. Day after day, week after week. I shut everyone out of my life except my husband, because unlike well known chronic pain conditions, people just don't understand.

I broke down in tears at my urologist's office, literally crying to my clinical nurse specialist telling her I wished I wasn't alive. I WAS begging for SOMETHING. The Dr. ordered one week's worth of flexeril for muscle spasms of the bladder. Does NOTHING for the intense pain of acidic urine eating through the bladder, creating bleeding ulcers.

I've had to accept this as my reality. I only work part time because of it, but I'm NOT letting this keep me from living my life anymore. I HATE HATE HATE people judging the amount of pain anyone is in. I hate those memes where it shows a pt smiling and a cat with bubble over its head saying no dilaudid for you. HATE it.

With known drug seekers, yes, I'm human. Certain people, their beligerence irritates me. But I'm not withholding meds. They might have to wait if someone else takes priority, but beligerence or not, I'm not withholding meds or punishing anybody.

[sarah_smile, BSN, RN]

I mistyped, I meant to type "drug-seeking." So, a person who is sitting in bed, on the phone, laughing, BP is great, HR is great, snacking on chips is truly experiencing 10/10 pain. Doesn't add up to me I guess. This particular patient has a history, based on his physician notes, of "numerable admissions complaining of vague pain, then becoming angry demanding IV Dilaudid." He is a non-compliant in his medication regime for diabetes, does not take his HIV meds, etc. This admission was for chest pain. All markers were negative, etc. Not only was he getting Dilaudid, he was getting Percocet along with it. Administered together.

Pain is subjective. I understand your frustration, but just remember pain is subjective. I can have 8/10 pain and hide it well.

[Rocknurse, MSN, APRN, NP]

Let's frame it like this: a lot of the time addicts originally started off having legit pain and are prescribed a narcotic that they then become addicted to. Would you rather give those people what they need to function or have them out on the street buying heroin? If someone is an addict they probably have a pretty terrible life. If they need to come in to the hospital for some respite, some rest and some care and attention as well as some legit, clean drugs, why not give it to them? If they're not an addict and they are having legit pain, then you got to comfort them and take their pain away. Win, win. The pain meds, by the way, do not come out of your pay check so really...don't concern yourself about who gets it and who doesn't.

[Farawyn]

SleepyRN, I'm so sorry for your pain.

[Dmlref]

RubyVee, That's very insightful and helpful. Do I need to use APA format as well? Where should I put my reference list and table of contents? I did not realize I was being monitored for format. I wasn't posting for you, I was addressing OP. If you cannot read something, then don't read it. Hope those is condensed and well-packaged enough for you to read.

[Been there,done that, ASN, RN]

Ponder this one.

My father and my brother both had huge pain issues. They both had a brain enzyme that interfered with the metabolism of opiates. At the end they both required 80 mg of morphine an hour to control their pain.

Clinicians could NOT understand this concept..both of them suffered greatly , even with me running interference.

The moral of this story is.. medicate without judgement.. you may never know the whole background.