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]

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

...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.

Are you entirely sure about that?

Complications of Uncontrolled, Persistent Pain

Consequences of Inadequate Postoperative Pain Relief and Chronic Persistent Postoperative Pain - ResearchGate

postoperative pain assessment and management

» Consequences of unrelieved chronic pain ? PHARMACIST STEVE

Besides, we weren't discussing acute pain. We were discussing the misdiagnosis by nurses of chronic severe pain vs. recreational drug-seeking.

[ftmrn]

I think it's important to realize that a patient may be seeking, may be drug-dependent, may be addicted, may be a chronic pain sufferer, may have an acute-on-chronic exacerbation for which their current regimen is ineffective, may have had poor experiences with providers, may have unaddressed psychological issues such as unresolved trauma, depression, anxiety, etc. etc. etc.

These things can and do occur in combination. A patient may have legitimate pain and may also be manipulative. Having one characteristic does not preclude another. It is our job as nurses to determine best course of action for our patients. We have all medicated and rolled our eyes (to ourselves) at the dramatics. We have also compassionately medicated when our patient appears to be in real pain. Whether addicted, dependent, or opioid-naive, ALL our patients needing and/or wanting this class of medications are in some kind of pain.

And we are human, as nurses. It does not make us bad people or unsympathetic when we apply our critical thinking skills and judgement to these situations.

Great topic, OP--thanks for bringing this up.

Please let's be kind to one another, as well.

[TheGooch]

Great topic, OP--thanks for bringing this up.

.

Yeah, like it's never been brought up before.

[heron, ASN, RN]

@ftmrn: just the point many of us have been trying to make! The issue is dismissing patients as recreational seekers because they don't fit the picture of acute, recent-onset pain.

Challenging that assumption is not unkind.

[Nurse3000]

leave it to the docs and say what you think it might be, i.e. drug seeking, and tell your team, hand over. and keep on promoting that health.

[DuniganRN]

Our job is to assess, NOT to judge....

[SleeepyRN]

So it's okay for you to "delay" the medication for a patient in pain if you have other priorities.

Pot meet kettle?

As you seem to not know the definition of priority or the difference between a higher priority and other things that must be done as well, I have uploaded the definition for you.

If I have a HIGHER priority at that very moment such as my patient with dysphagia vomiting or an agitated patient at danger to himself or herself and in need of ativan, I WILL, with a VERY clear conscience, tend to those patients FIRST.

You clearly have not read all of my posts on this thread. I specifically stated how terrible it is to punish a patient requesting pain meds by delaying administration of pain medication.

I admitted that BELIGERENCE gets under my skin. But I am a professional and keep that inside and do my job. Drug seeker or any patient with any condition.

I have zero problem with addicts. I feel very bad for people addicted to meds. That must be a terrible life to live. Who says to themselves, "You know what? I want to be addicted to meds when I grow up and overdose and continuously go through terrible withdrawals. Yep. That sounds good. That's what I want to be."

Come at ME again with that attitude....Yeah, you hit a RAW nerve, as I know addiction all too well.

Beligerence is my problem. Not the people addicted to meds. And I NEVER would withhold care to anyone.

[SleeepyRN]

I certainly do not believe in punishing patients by withholding medication or being rude to a patient. And I know that the drug seeker label DOES get thrown around too much. I also believe that if it is ordered and the patient is stable, I will give the medication. It just makes things easier and practical. However, I do not have to like having my time wasted by people who not only ask for pain meds, but demand snacks every 15 minutes, toiletries, want to be bathed when they can walk to the toilet. That takes valuable time away from my other patients who can't walk, are non-verbal, or cannot advocate for their wellbeing.

THANK you. Yes. We judge people. We are human. However, it doesn't mean we withhold care. We prioritize. I get annoyed on the inside, act professionally outwardly, then get it off my chest when I come home and complain to husband. Then move on.

I *usually* don't judge whether someone is in pain or not. Having such intense personal experience with chronic, untreated pain, yet show no outwardly signs to anyone other than my family until it hits at least an 8, I give most the benefit of the doubt.

But I'm not going to lie and say that I feel I KNOW a couple true addicts at my facility. One if them is SO beligerent. He drives me nuts on the inside. But I do my job. I give him his meds showing no outwardly signs of my annoyance of being yelled at.

The other is not rude or mean, so I have NO problem with him.

[SleeepyRN]

I think I've read most of the posts in this thread & haven't really seen this addressed-

When I did bedside nursing I did more than my share of Dilaudid pushes. And yes, quite a few were on pts that I felt were 'drug seeking'. But as has been stated- if VS were WNL & it was at the appropriate intervals- I gave it- and no matter how I felt about it I did my best not to show that to the pt. To maintain a professional & compassionate demeanor.

But what I did mind was the behaviors that accompanied some of the worst of those pts. No matter how many times you told them at what times their meds were available- they tried to get them early. They usually had other meds ordered & wanted them in between. IV Benadryl or Phenergan were giveaways. I had one ask " is there any pill I can have? Protonix? Anything?"

Or, a perpetual favorite: " if you ain't giving me Dilaudid- gimme some ice".

They call constantly for ice, jello, popsicles, etc. They call & when bell is answered- they stutter because they don't really want anything.

Or how about the ones that refuse to take their regular meds unless you give them their pain meds?

My personal favorite, the guy that had a hold of his temp dialysis cath in his chest, threatening to pull it out if I didn't bring his Dilaudid an hour early.

No, giving pain meds- no matter if I think the pt really needs it or not isn't a problem for me if the pt is not manipulative & acting like an entitled brat.

I can't like this enough.

[nurselady77872]

For me it's a double edged sword. A nurse that suffers from chronic severe pain. Obviously I'm addicted to pain meds because I've been taking them for so long. For true pain relief to be achieved, pain medication needs to be taken before you get to 10/10. Yes it is a conundrum as their are many patients that have no pain and just want the Opiate. It's not our job to judge we assess, administer and assess again. Hopefully with accurate assessments on the Nurses part will help physicians weed out drug seekers. If we automatically assume patients are drug seekers, we jeopardize the care of the patients that truly need pain meds.

[moriahcat]

Re: ETOH, my neighbor had to have an overnight at the heart hospital in our state, and he jokingly asked a nurse for a beer with dinner. His doctor had already written it into the orders if he requested, since he had been honest about drinking a six pack or two a week. They explained about being there to treat heart issues, not alcohol detox, and so he went ahead and drank the beer. Then kept the can, filled it with water, and freaked out his daughter the next day. Gotta love the kidders

I doubt all cases of "red flag behavior" fall neatly into either "horrible manipulative addict with no real pain whatsoever trying to get high" or "saintly misunderstood chronic pain patient with no other choice than going to the ER/hospital for relief and being perfectly polite".

Current and former addicts in real pain, in emotional pain that might be affecting their perception of their physical pain, people who really need to be on longer-acting meds who aren't going to get them in an ER or hospital unless already ordered either, people who refuse meds because of real or imagined worries about addiction (I was scared the only time my situation has ever warranted IV narcs, and asked the nurse to *not* give me too much too fast, but I have never had a problem myself... family history, tho)... people who are worried about seeming like a seeker, people who project previous interactions with other health care providers on us...

The problem is that while all of them need compassionate care, as ER or medsurg nurses we simply aren't capable of giving them the care they really need to address the root problems -- whether it's rehab, outpatient pain management, counseling, whatever. This isn't a judgment on nurses or patients. It's just the truth.

So the only thing I can see to do is to try to get these patients flagged for a social worker to offer assistance in discharge planning if inpatient, or see if the ER discharge desk can offer daytime callback from someone who can help them get the referrals they need, and then give medications as ordered if VS are good while they are our patients.

[moriahcat]

My grandmother was afraid of meds, because her family had alcoholics and her husband was dependent on Empirin-4s for spasmodic torticollis pre-botox. When she broke her hip, she thought the PCA after the pinning surgery was giving her a base amount already, and in quite a bit of pain but refusing to hit the button when I came to visit (and not complaining either, it was just obvious) I had her nurse confirm that it was only giving her meds when she pushed the button, and she felt better when she did hit it. I explained that they are safer if the patient controls it themselves, because you can't hit the button if you're asleep, and it wouldn't let you hit it too much awake. It made sense then, but she thought she was just being a wimp before she understood how it worked.

So when, a few years later, she was crying from pain and we took her to the ER, we knew she was a tough lady and if she was crying it was serious. (Shingles.)