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.

[heron, ASN, RN]

So, LadysSolo, as an np dealing with drug contracts, you must be familiar with the concept of differential diagnosis. So how do you differentiate between an addict actively trying to force you into enabling his habit, from a chronic sufferer of severe pain who may have developed dysfunctional behaviors in an effort to get relief?

[LadysSolo]

Someone trying to get relief does not lie to me about their 3-year-old daughter dumping their pills into the toilet, someone picking their purse in a restaurant, (see previous post,) is not in the parking lot selling their pills from the prescription they just got filled. You distinguish by history and physical, just like any other diagnosis. And I am not cruel - work with me people! I am not above titrating up, but I am going to do it slowly, and above all, DO NOT LIE TO ME!!! And do not insult my intelligence, I am not stupid! TALK to me - tell me what is going on in your life. Be open to alternative treatments also - try physical therapy, counseling (if you are in chronic pain, you are bound to have some depression,) etc. If you refuse to try alternative treatments, I am not going to be as willing to increase your medications - you have to try too. I also loo up on the drug monitoring tool in the state, if you have been to multiple providers, every ER in the state, etc, I am going to be suspicious.....

[ixchel]

Couldnt agree with you more and I hope my previous post did not come across that I believe that there aren't drug seekers out there. I know there are. I should have used the quote feature but I was addressing your previous question about what kind of biases those with a history of chronic pain might bring with them. (Post #176).

ETA: OK, reading the post below mine I see now what you were addressing. Sorry, been a long couple of days with very little sleep...gotta love insomnia...I'm a little on the slow side tonight. Ignore me.

No worries, love. I should have used quote as well!

[heron, ASN, RN]

Great answer, LadysSolo. I noticed that you never mentioned "clock-watching" or failure to exhibit the same s/s as someone having acute short-term pain. Which is what many of us have been trying to point out.

It has nothing to do with being "saintly". It has to do with the dangers of dismissing certain patients' complaints and the over-simplified assumption that failure to fit a certain inappropriate profile always equates to them lying or manipulating to get stoned.

I still believe that insisting on treating all chronic pain sufferers as active addicts causes significant harm. I believe that avoiding that harm is more important than showing a junkie who's boss.

[russianbear]

It seems like a lot of people here are confusing true sufferers of chronic pain with addicts. I worked in a place where a patient went outside and injected heroin into a PICC line. Wanna tell me he was a chronic pain sufferer? There is a difference.

[heron, ASN, RN]

Of course there's a difference. The question is whether you know how to tell the difference. It was not apparent from your OP that you can.

[Horseshoe, BSN, RN]

WKShadowRN, I am not saying you are naïve, but I am saying that a lot of posters on this thread have been attacking (politely) those of us who see manipulative addicts as manipulative addicts and judging us for not buying into their behaviors. I will help to keep people from withdrawing by providing their opioids as long as they follow the rules they have agreed to, but I never "buy" their stories. Some of the posters here like to try to get us to believe they are saints, and never get annoyed by manipulative behaviors.

If they are being "polite," then they are merely disagreeing, not "attacking."

[Horseshoe, BSN, RN]

Ain't nobody got time to deal with a withdrawing patient. Let's be real - these patients don't plan to stop outside of the hospital, so it's stupid to make them detox just for the fun of it. It's like the alcoholics they put on CIWA protocol and whatnot - it's a heck of a lot kinder, and makes a heck of a lot more sense, just to give them a beer with every meal tray. It's not like they're going to stop taking the substance at home just because they missed it for a week or two in the hospital. Who suffers from the forced withdrawal anyway? Well, yes, the patient suffers, but guess what? You do too, because you have to deal with the patient's symptoms, symptoms that you may have caused as a nurse that withheld pain medicine/benzos/whatever.

Forget about the patient for a second - why exactly does anyone want to make their day/night MORE difficult than it already is?

I once had a patient in horrible DTs. I couldn't give her enough meds to calm her down. An elephant would have OD'd with the amount of stuff we threw at her. That day was such a nightmare. The resident working the case heard me out at the end of my shift and said, "Well what would YOU suggest we give her?" I said "An alcohol drip-please. When I get here in the morning, I want that lady on an alcohol drip!"

Guess what that patient was on when I got to work the next morning? An ALCOHOL DRIP. I had been being facetious. I didn't dream he would take me literally.

My patient was a kitten that day. And when I left that evening, it was with a smile on my face. Selfish, I know, but after the day from hell the prior day, I felt I'd earned a little bit of self indulgence.

[Horseshoe, BSN, RN]

Politely attacking?

I would say "disagreement".

Oops, I posted before I read your post. You beat me to it.

[Tenebrae, BSN, RN]

HOW in heck, does one "politely attack" anyone else?

Wait, what was the subject again????

I will say again, nurses, doctors, and other health care providers need a lot of substance abuse education. So many misunderstandings here.

...

:yes:well said

[calivianya, BSN, RN]

Wanted to say, that story about the ICU nurse leaving a patient helpless, call light out of reach and shutting his door, while he was in pain, is horrific. I agree with those who say such a nurse is a "monster". How awful. And if I knew who that was, or worked with that person, I would definitely report it.

I've got to say I've never done it, but I totally understand why it happened.

I am thinking about one particular night a couple weeks back - one patient had a BP of 50s/20s and was a full code, the second patient had taken off her nonrebreather and was satting 62% (also a full code), and my third patient was riding the call bell for pain medication. I got an earful from that family about letting that patient be in pain once I finally made it into the room, of course, and the urge to kick the family out and take that patient's call bell away was strong.

I am quite sure if that patient came in here right now, she'd talk about that horrible ICU nurse that let her be in pain all night long, and how that nurse needed to be reported and fired.

Pain sucks, and I'm all about keeping the patient pain free, but if I have called the physician twice and they have refused to order more pain medicine, I'm at the limit of what I can do, and my other people are *actually* dying so I don't have time to sit there and do guided imagery or a massage or whatever, and we are total care so I can't delegate a CNA to do it either. Pain never killed anybody. Maybe it was so bad the person wanted to die, but they don't actually die from it. I have seen BPs in the 50s/20s kill people and O2 sats in the 60s cause people to brady down and die, too. I have never seen anybody die of acute pain.

People awake and alert enough to be asking for pain medicine are the healthiest patients on the unit. The healthiest patients on the unit don't get priority. I do the best I can, and I am definitely giving that nurse the benefit of the doubt, too, because what she did was awful but we don't know what her assignment looked like that night. We only know her (likely) healthiest patient's story.

[nurse2be13]

I don't care. If there is an order for you to receive iv pain medications I will write the next time that you can receive it on the board. Don't ask for it any sooner (this just applies to drug seekers). It's not my place to determine whether you actually deserve it or not.