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.

[Tex.]

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.

That nurse should have her license revoked.

[Postpartum RN]

I HATE when nurses at the nursing station or during report make comments about patients being drug seeking or addicts of some sort. Addiction is a disease. Do we judge pts and talk bad about them because they have cancer? Or a stroke? Heart attack? Arthritis? Etc etc etc.

I get annoyed with nurses who complain about pts and judge them so harshly. Who are WE to judge them, when we only see a snippet of their life for our 12 or 8 hr shift? After all, people do not come to the hospital for fun. Being in the hospital is usually a traumatic event for a person. Even if it's something minor, think about all the things they have to change or rearrange in their current life or schedules (work, family, kids, dependent parents or adults they care for, school, etc) while they are confined in that hospital bed.

To the OP, you shouldn't feel "dirty" giving a pt their narcotics. Maybe with more time and experience that feeling will pass.

[APRN., DNP, RN, APRN, NP]

Drug Seeking.

How's come we have to change the name of every single other label, except for this one?

How about "Narcotic Challenged"?

Until I work in Psyche and have a focus to rehab someone's addictive behavior, I'm going to assume that pain is present and medicate them.

[heron, ASN, RN]

To postpartum et al: I gotta repeat that it is entirely normal to have a negative emotional reaction to being subjected to active addicts' games. It's unhealthy to pretend otherwise. I can even make a case for venting at work but away from patients.

What some of us have a problem with is imposing inaccurate stereotypes on anyone who complains of pain the nurse doesn't believe in, due to inadequate assessment and a poor understanding of chronic pain.

IOW: we're not talking about Cruella Deville, here. We're discussing professional skills and knowledge base. So, easy on the character assassination and guilt-tripping, y'all.

[Guest219794]

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.)

Shame on you for being judgmental and not believing the patient. Have you not gotten the memo? PAIN IS WHAT THE PATIENT SAYS IT IS. From what I am reading here, it is inappropriate to to take into account objective signs, PT's culture, HX, etc...

On the other hand, maybe sometimes pain is not what the patient says it is. Thank god we don't simply rely on self reporting, then find the med/dose that corresponds with the number.

Do folks on this board have any idea of what an ER would look like if we actually medicated patients according to their report of pain? I was injured once to the point that I could not walk, or sit up. I figured that was about a 3/10, as I could easily think of another 7 steps of pain. And sure, I guess somebody can be on the outer fringes of human endurance- 10/10 pain, and be eating Cheese Doodles and talking on the phone, but.....

If we believed that pain is what the patient says it is, it is all we would do. Seriously. We would have every dental pain and chronic low back pain hooked up to IV's monitors, etc. People would move to be close to the hospital and come in every time their dog knocked their Oxy's into the toilet.

If an ER subscribed to this ridiculous notion that "pain is what the patient says it is", it would cease to function. Why would addicts and abusers not come in on a daily basis with 10/10 pain?

Drug abusers would no longer call it the ER, it would be referred to as "heaven". As in, "Dude, I just checked their web site- door to doc time of three minutes. Want to go to Heaven for a few hours?"

On the plus side: In this imaginary world, where pain is what the patient says it is, there would once again be a nursing shortage. Staffing the narcotic dispensaries would be an entire field needing millions of new nurses. This would up the pay for all of us.

The only reason this does not happen is because we use judgement.

BTW- Self report of pain is not the only thing we don't accept at face value. We are skeptical about diet, exercise, alcohol intake, medication compliance......

We actually use training and judgement in everything we do.

[traumaRUs, MSN, APRN]

Several posts have been deleted. This is not a thread about grammar or spelling. It is also not a poster-bashing thread. Please be respectful and adhere to the terms of service. Thank you.

[Guest219794]

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

Gooch-

What field of nursing is your specialty?

You voice some strong opinions, and it would be helpful to know the perspective.

[heron, ASN, RN]

W@hhern: have you read the whole thread or just posts that tick you off? Judgement - or rather the lack of it - is exactly what we're calling for.

I'm truly wearied by those who insist that I'm trying to deny that recreational drug-seekers exist or that they're fiendishly awful to deal with. I know it's fun to let the sarcasm fly unrestrained and engage in a little in-group kvetching about how nobody knows the trouble you've seen, but enough already!

I get that:

a. The ED is not an appropriate place to address chronic pain.

b. The ED is flooded on a regular basis with lying hustlers looking to score the good stuff. In the process they waste your time, energy, and goodwill. Not to mention our money. They suck resources away from people who are sometimes dangerously ill and should be a higher priority.

c. Oftentimes chronic pain sufferers are addicts and/or exhibit behaviors that are virtually indistinguishable from recreational drug-seeking.

d. You don't have the luxury of doing an exhaustive, nuanced assessment on every complaint of pain.

e. I may never have worked in the ED, but I'm not stupid, uninformed, or lacking in fairly extensive experience of my own.

What we're asking you to get is this:

a. There's more than one kind of pain.

b. The classic signs and symptoms of severe pain apply pretty much to only one type.

c. Dismissing patients who don't fit the picture of severe, acute, recent onset pain as recreational drug-seekers is careless. It makes about as much clinical sense as insisting that a woman who's sweaty, vomiting and complaining of back pain couldn't possibly be having an MI. The harm done by such a misdiagnosis can be serious, even lethal.

I agree with you about this: there's a lot of self-righteous preaching here, on both sides of the discussion.

[Guest219794]

W@hhern: have you read the whole thread or just posts that tick you off? Judgement - or rather the lack of it - is exactly what we're calling for.

I'm truly wearied by those who insist that I'm trying to deny that recreational drug-seekers exist or that they're fiendishly awful to deal with. I know it's fun to let the sarcasm fly unrestrained and engage in a little in-group kvetching about how nobody knows the trouble you've seen, but enough already!

I get that:

a. The ED is not an appropriate place to address chronic pain.

b. The ED is flooded on a regular basis with lying hustlers looking to score the good stuff. In the process they waste your time, energy, and goodwill. Not to mention our money. They suck resources away from people who are sometimes dangerously ill and should be a higher priority.

c. Oftentimes chronic pain sufferers are addicts and/or exhibit behaviors that are virtually indistinguishable from recreational drug-seeking.

d. You don't have the luxury of doing an exhaustive, nuanced assessment on every complaint of pain.

e. I may never have worked in the ED, but I'm not stupid, uninformed, or lacking in fairly extensive experience of my own.

What we're asking you to get is this:

a. There's more than one kind of pain.

b. The classic signs and symptoms of severe pain apply pretty much to only one type.

c. Dismissing patients who don't fit the picture of severe, acute, recent onset pain as recreational drug-seekers is careless. It makes about as much clinical sense as insisting that a woman who's sweaty, vomiting and complaining of back pain couldn't possibly be having an MI. The harm done by such a misdiagnosis can be serious, even lethal.

I agree with you about this: there's a lot of self-righteous preaching here, on both sides of the discussion.

I am pretty sure I have read the whole thread- could have missed a post or 2.

I agree with all your points above. I definitely don't insist that you are trying to deny that recreational drug-seekers exist or that they're fiendishly awful to deal with.

I am writing primarily from my experience in the ER, though I do have a couple years ICU as well.

Pain management requires a nuanced approach taking into account a wide range of variables.

My objection is to ANY simplistic approach. And, when the subject comes up, people often bring out the "pain is what the.....", which is incredibly simplistic. And, not especially helpful. It's a catchy phrase, otherwise useless.

BTW- When meds are ordered, I generally give them liberally. When I know somebody has an abuse history, I generally go to the high end of the dose range, and the early side of the time range- as long as my priorities allow. While I may object strongly to our role in creating the problem, copping an attitude toward the patient won't help anything.

I m far more frustrated with the system that created this problem than the individuals enmeshed within it.

It is a pretty weird field when you think about it. Pain management is a specialty with experts who rely on evidence based practice, not unlike cardiology or nephrology. But, if you look at the pain management practices in many environments, this expertise is ignored, unlike cardiology or nephrology. We certainly don't follow it in the ER.

[Horseshoe, BSN, RN]

It seems to me that SOME distinction should be made between ER issues and those which occur with admitted patients. Of course we know that the ERs get inundated with people hoping to score opiates because they are addicted and need these drugs to feel normal vs. being in pain. Of course, the ER also gets people who are addicted but are also truly in pain. As well, they see patients who are there for valid acute onset pain issues. Distinguishing between these patients and coming up with good plans on how to address them could be a whole specialty unto itself, it seems.

The rest of us who are caring for patients who have been seen by an MD and admitted need to either talk to the MD ordering the pain meds if there is an issue with them, or give the meds as ordered. What should NOT be happening is withholding meds, purposely delaying a response to the patient's request as a passive aggressive display of personal power, evaluating the patient in chronic pain using assessment criteria more appropriate to acute onset pain, projecting one's own biases on any patient who dares ask for pain medicine on schedule, or diagnosing patients as addicts. All of those actions are unprofessional, inappropriate, and in some cases, just extremely ugly behavior unbecoming of a licensed nurse.

Legitimate issues of pain which are not being adequately addressed are certainly challenging. It's not our place to take our frustrations out on the patient. Address it with the physician if it's getting out of hand. Otherwise, give the patient the relief to which they are entitled.

[ixchel]

I HATE when nurses at the nursing station or during report make comments about patients being drug seeking or addicts of some sort. Addiction is a disease. Do we judge pts and talk bad about them because they have cancer? Or a stroke? Heart attack? Arthritis? Etc etc etc.

I get annoyed with nurses who complain about pts and judge them so harshly. Who are WE to judge them, when we only see a snippet of their life for our 12 or 8 hr shift? After all, people do not come to the hospital for fun. Being in the hospital is usually a traumatic event for a person. Even if it's something minor, think about all the things they have to change or rearrange in their current life or schedules (work, family, kids, dependent parents or adults they care for, school, etc) while they are confined in that hospital bed.

To the OP, you shouldn't feel "dirty" giving a pt their narcotics. Maybe with more time and experience that feeling will pass.

On the other hand, I've given report to include seeking because I've genuinely felt a person was at risk for withdrawal. Or, they already were in withdrawal and the MD was choosing not to treat it.

[Postpartum RN]

On the other hand, I've given report to include seeking because I've genuinely felt a person was at risk for withdrawal. Or, they already were in withdrawal and the MD was choosing not to treat it.

Yes I agree that is important information to pass along in report of course. What I meant was nurses gossiping about pts or complaining about pts because they are addicts or drug seeking. I get a lot of this on my unit