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 sick of the self righteousness I see here regarding this topic. Just give the damn medication as prescribed. Just because someone doesn't act the way YOU think they should while in pain doesn't negate what they are feeling. Chronic pain sufferers learn to deal with it in their own way like I have. I might be smiling and laughing but I can guarantee you that my lower back or knees hurt like hell. I've just learned how to cope with it the best way that I can.

As a chronic migraine patient, I can't like this enough.

[BostonFNP, APRN]

I had a nurse-patient issue last week that made me think of this thread.

In short this was a chronic opioid user/abuser that has been hospitalized many times, has been spoken to be me and several other providers for asking nurses to "push it fast", always wants IV benadryl with his dialudid, etc. I think we all know this kind of patient. He was admitted to the hospital via the ED where he got some dilaudid. I admitted the patient, discussed with him that we know he has an problem with narcotics (which he acknowledged), and made a plan that I would give him appropriate narcotics in the hospital to get him to a tolerable level of pain while diagnostics were run, but he would not be discharged with any narcotics. I wrote an order for 1mg dilaudid q3h and went to clinic for the day.

Five hours later at my office I get a phone call from the patient (from his room phone) irate that he did not get his medication and he was in pain and refused to go to CT without it; again we discussed the plan. I call the attending RN and ask about his ordered/scheduled dose, which was now missing x2. The RN tells me she didn't feel comfortable giving the medication; so I have her go through the vitals with me and her assessment (which were essential normal other than a pain rating of 10/10 (probably told her 100/10), for the past two checks). So I ask her why she didn't feel comfortable given the ordered med: "because he's a drug addict".

I did my best to remain calm and professional, provide education, and the nurse did give the med. As I look back on it, I get more and more upset at the situation. In my opinion, the RN did not have reasonable objections to carrying out the order, interrupted an established plan of care, delayed the patient's CT scan, and didn't report that a med was held twice. I understand her concern, but on the other hand, I didn't feel that I this case it was her concern to have as I can assumed that concern.

[chevygirl1987]

I had a nurse-patient issue last week that made me think of this thread.

In short this was a chronic opioid user/abuser that has been hospitalized many times, has been spoken to be me and several other providers for asking nurses to "push it fast", always wants IV benadryl with his dialudid, etc. I think we all know this kind of patient. He was admitted to the hospital via the ED where he got some dilaudid. I admitted the patient, discussed with him that we know he has an problem with narcotics (which he acknowledged), and made a plan that I would give him appropriate narcotics in the hospital to get him to a tolerable level of pain while diagnostics were run, but he would not be discharged with any narcotics. I wrote an order for 1mg dilaudid q3h and went to clinic for the day.

Five hours later at my office I get a phone call from the patient (from his room phone) irate that he did not get his medication and he was in pain and refused to go to CT without it; again we discussed the plan. I call the attending RN and ask about his ordered/scheduled dose, which was now missing x2. The RN tells me she didn't feel comfortable giving the medication; so I have her go through the vitals with me and her assessment (which were essential normal other than a pain rating of 10/10 (probably told her 100/10), for the past two checks). So I ask her why she didn't feel comfortable given the ordered med: "because he's a drug addict".

I did my best to remain calm and professional, provide education, and the nurse did give the med. As I look back on it, I get more and more upset at the situation. In my opinion, the RN did not have reasonable objections to carrying out the order, interrupted an established plan of care, delayed the patient's CT scan, and didn't report that a med was held twice. I understand her concern, but on the other hand, I didn't feel that I this case it was her concern to have as I can assumed that concern.

Can you contact the unit manager or nursing Ed for that facility? Not only did she delay care, but if he's a chronic user/opioid dependent/addicted she was risking putting him through withdrawal and the

discomfort associated with that.

My unit recently had a presentation about CIWA because nurses weren't comfortable giving the benzos.

[BostonFNP, APRN]

Can you contact the unit manager or nursing Ed for that facility? Not only did she delay care, but if he's a chronic user/opioid dependent/addicted she was risking putting him through withdrawal and the

discomfort associated with that.

I had a detailed discussion with the RN and left it there. In retrospect I should have also spoken to the supervisor but I felt that I had handled it sufficiently with the RN at the time. If I was the supervisor I think I would want to know.

[chevygirl1987]

I had a detailed discussion with the RN and left it there. In retrospect I should have also spoken to the supervisor but I felt that I had handled it sufficiently with the RN at the time. If I was the supervisor I think I would want to know.

I'm not even thinking getting anyone in trouble; people need to be educated.

I do stepdown nursing so I'm thinking of all the times nurses hold the diuretic in a pt with little LVEF because the SBP is 96 or don't give the beta blocker to an MI pt with HR 59 without telling anyone. Our job is to clarify questionable orders not to just hold meds indefinitely.

[BostonFNP, APRN]

I'm not even thinking getting anyone in trouble; people need to be educated.

I do stepdown nursing so I'm thinking of all the times nurses hold the diuretic in a pt with little LVEF because the SBP is 96 or don't give the beta blocker to an MI pt with HR 59 without telling anyone. Our job is to clarify questionable orders not to just hold meds indefinitely.

This is a huge problem, we see it all the time in rehab/skilled facilities and with VNA. I have a lot of cirrhotic patients on lactulose that had it held for loose stools.

Absolutely right that it's an education issue.

[chevygirl1987]

This is a huge problem, we see it all the time in rehab/skilled facilities and with VNA. I have a lot of cirrhotic patients on lactulose that had it held for loose stools.

Absolutely right that it's an education issue.

Sorry, but I'm LOLing. I just had this conversation with someone last week. Her pt was getting more confused and the ammonia was increasing but she was holding lactulose for loose stools.

Sigh.

To weigh in on topic. I have only ever taken care of around 5 people that I think of as "drug seekers". I did give the meds as ordered, but drew the line at letting one apply an extra fentanyl patch from home. If you are questioning an order, call for clarification.

If the vitals are normal for the patient. Just give it. Sometimes it is annoying to be called just for a reminder that the PRN med is "due" in 10 minutes and you may feel like you are being lied to in regards to pain level, but it is subjective. And it's really not your job to be judgmental.

If your patient is a drug user outside of the hospital, they may require more, not less, opioids while admitted for acute pain.

[poppycat, ADN, BSN]

I had a nurse-patient issue last week that made me think of this thread.

In short this was a chronic opioid user/abuser that has been hospitalized many times, has been spoken to be me and several other providers for asking nurses to "push it fast", always wants IV benadryl with his dialudid, etc. I think we all know this kind of patient. He was admitted to the hospital via the ED where he got some dilaudid. I admitted the patient, discussed with him that we know he has an problem with narcotics (which he acknowledged), and made a plan that I would give him appropriate narcotics in the hospital to get him to a tolerable level of pain while diagnostics were run, but he would not be discharged with any narcotics. I wrote an order for 1mg dilaudid q3h and went to clinic for the day.

Five hours later at my office I get a phone call from the patient (from his room phone) irate that he did not get his medication and he was in pain and refused to go to CT without it; again we discussed the plan. I call the attending RN and ask about his ordered/scheduled dose, which was now missing x2. The RN tells me she didn't feel comfortable giving the medication; so I have her go through the vitals with me and her assessment (which were essential normal other than a pain rating of 10/10 (probably told her 100/10), for the past two checks). So I ask her why she didn't feel comfortable given the ordered med: "because he's a drug addict".

I did my best to remain calm and professional, provide education, and the nurse did give the med. As I look back on it, I get more and more upset at the situation. In my opinion, the RN did not have reasonable objections to carrying out the order, interrupted an established plan of care, delayed the patient's CT scan, and didn't report that a med was held twice. I understand her concern, but on the other hand, I didn't feel that I this case it was her concern to have as I can assumed that concern.

This reminds me of when my dad was in hospice a few years ago. He had morphine ordered with a dose range & he needed the highest dose in the range. One of the night nurses refused to give any more than the lowest dose because "it's against my personal beliefs". I lost it when she said that & told her my dad's care had nothing to do with her personal beliefs. She needed to give him what HE needed.

[Horseshoe, BSN, RN]

This reminds me of when my dad was in hospice a few years ago. He had morphine ordered with a dose range & he needed the highest dose in the range. One of the night nurses refused to give any more than the lowest dose because "it's against my personal beliefs". I lost it when she said that & told her my dad's care had nothing to do with her personal beliefs. She needed to give him what HE needed.

So did she? Any hospice nurse with "personal beliefs" against narcotics needs to be shown the door ASAP. WTH.

[poppycat, ADN, BSN]

So did she? Any hospice nurse with "personal beliefs" against narcotics needs to be shown the door ASAP. WTH.

That was the whole problem. The nurses in that unit were not trained in hospice. There were no full time hospice nurses there because they didn't always have patients in the inpatient unit. The nurses were all floated from med/surg & had zero training in hospice philosophy. The only actual hospice nurse they had was in the corporate office & only available on day shift. We had to have the hospital administrator on call contact the hospice physician at 1 in the morning & he ordered a morphine drip. He also had a long talk (on the phone) with the night nurse& made it clear she was to titrate the drip to my dad's comfort & not to withhold it.

Had we known all this before he was admitted there, we would have chosen a different hospice. It was a horrible experience!

[Big Blondie, ASN, BSN, MSN, APRN]

This thread has become annoying...

[heron, ASN, RN]

Yeah, but they crop up once a year or so, along with the "entitled patients" and the threads mocking people on welfare. Seems to be an unrecognized phase of professional development - somewhere between "beginner" and "novice".