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.

[russianbear]

1. I do not believe I have a problem with addicts. I treat addicts every day. We have tons of overdose patients on our floor. My problem is with the waste and the contributing to the problem. If you take what we are doing out of the hospital context then we are what you would call in AA enablers. Plain and simple. 2. As nurses our duty is not only to help restore health when it has been reduced as in the case of disease, but to encourage wellness. Contributing to creating and maintaining drug addiction is not encouraging health. I'm in no way advocating refusing to give or delaying administering the medication. I'm talking about a flawed system that perhaps should be looked at. I am a compassionate person and I do not want anyone to suffer, but are we really helping in some cases?

[emtpbill, ASN, RN, EMT-P]

I agree, it's the waste of resources that gets on my nerves. I would be cooler with someone coming in and saying, "Hey, I'm an addict, I need my Dilaudid so I don't go into withdrawal," than I am with someone complaining of "chest pain." And "belly pain." And "back pain." Or whatever the complaint du jour is.

You know these people aren't paying their hospital bills. So, that multi-thousand dollar abdominal CT? Yep, we're eating that. And, in the long run, what does the hospital paying out millions in unreimbursed tests due to their budget? Where do they make the cuts to still come out positive? Oh yeah, it's usually the nurse staffing budget that's hit first when the hospital needs to free up some extra change.

That being said, I never withhold narcs and I give them as soon as the patient can have them. The patients are with me to have their acute, life threatening problems treated, not their chronic ones. The patients' addictions are not my problem. I am not addressing that.

In a perfect world...........

I am referencing this as a pre-hospital provider as I am currently in nursing school.

I would love it if people would be honest. Tell me they are in withdrawal rather than telling me they are having chest pain but are allergic to nitro and aspirin. It would save time, resources, and money. Would I give a patient Morphine just because they are in the throes of withdrawal , no, but atleast I can give an accurate concise report to the ER Doctor when I arrive with the patient.

[bloatedputti, MSN, RN]

I agree with you. This is however a very complex problem. The system supports it. Illegal drug smuggling and manufacturing, doctors over prescribing, mental illness, crime, abuse,poverty, all of these things can lead to drug abuse. It's up to the physician or pain management team to nip this in the bud. Limits need to be established. They can offer him other non- opioid drugs and sedatives. They usually give an end point and make it clear. the patient usually walks at this point. Will this cure the person of his addiction? maybe and probably not, but it will save the hospital millions of dollars and wasted resources for people such as you described. I agree with one post, don't make yourself crazy over this. its wasted energy.

[Ruby Vee, BSN]

If you're only having to give him IV Dilaudid Q6H you are so fortunate as many of my pts get it ordered Q1H PRN. And let me tell you, if it's ordered and they claim to have pain and have decent blood pressure and are easily arousable with good O2 sats you pretty much don't have a choice but to give it to 'em. Sad but true. It's hard. I know. It makes you want to scream. But it's called PATIENT SATISFACTION.

Patient satisfaction is a dangerous thing.

[iluvivt, BSN, RN]

Why is the I man in the hospital..I am certain they do not admit him for the Dilaudud.Does he take a po narcotic at home for pain? I agree with the others that said just give it as long as it is a safe dosage and your assement and sedation parameters are OK. The clock watchers do not bother me AT ALL .As a matter of fact I try to beat them to it if I know they will ask. I may or may not discuss with MD..it depends on a lot of factors but this is a small dose of Dilaudid and I can tell you from many surgeries it wore off in 1.5 hours for me when I had it IV and I had 4 mgs! I was right back in agony!

[typoagain]

1 milligram every 6 hours. I would never question it. In fact I'm wondering why so far between doses? Is it an elderly patient or do they have some disease that will keep them from metabolising the drug. Do they even stock vials of 1 milligram dilaudid? The smallest I've ever seen was 2 mg.

[russianbear]

The dose was scheduled every six hours to appease the patient. He threw a fit that they were not giving it to him more frequently. He stop complaining when they said you could have it every six hours.

[~PedsRN~, BSN, RN]

I think we have all had those patients that clock watch for their next pain med, all while joking and having a great time in the room with their friends, texting on their cell phone, etc. Pain is so subjective though, so if a patient states that they are in pain, I medicate that pain. To not medicate it would be unethical.

I do think one of the most.... not dangerous, but maybe harmful? things that we have to be careful about doing with our patients is to stigmatize narcotic pain relievers. If a person is in pain, a dose of dilaudid or morphine or percoset or lortab does not the addict make. The acute care healthcare workers are not just creating droves of addicts with our IVP narcotics, but this is a myth that is perpetuated in society. I see it all the time. I will have parents refuse ordered pain medication and opt for tylenol or motrin for their children, even after seriously complex and terrible surgery - just because they "don't want them to get addicted to that kind of stuff." I have watched children suffer in the bed because of misinformation. I think it's important we don't portray negative attitudes towards these medications, because honestly - they do a job, and it's an important one.

Even if we do have those occasional guys who enjoy it a little too much.

That's not our place to say, or our job to diagnose them as addicts.

[sjalv]

You are not going to solve someone's narcotic addiction during the course of their hospitalization, nor are you likely trained in rehabilitation services. Just give the opioid; it is not up to you to decide if the patient is faking his pain or not. Even if you are 99% certain that he is, just give the med and leave it at that. Perhaps I am too apathetic but who cares? You are not going to change them.

[txredapple79, BSN]

I was taught the pain someone claims to be in; is the pain they have, and it is not for me to judge. The only side note is based on making sure all vitials are stable prior to giving the medication ordered.

[michlynn, BSN, RN]

1 milligram every 6 hours. I would never question it. In fact I'm wondering why so far between doses? Is it an elderly patient or do they have some disease that will keep them from metabolising the drug. Do they even stock vials of 1 milligram dilaudid? The smallest I've ever seen was 2 mg.

Yes, most hospitals stock 0.5mg vials as well.

[Lev, MSN, RN, NP]

My ER is "dilaudid free." This is what we tell patients. It is available, but only from pharmacy and providers rarely order it. Even if they do order it, it may be a little while before your nurse actually has time to take a trip to pharmacy.

But seriously people, take the time to push dilaudid slowly or if you have a bolus of fluids running at the time wide open (as common in the ER), inject it into the highest port. This is what I do with my morphine (which we have been giving much more now that we said bye bye to dilaudid). I think this will partially deter drug seekers who want your to "push it fast" to get that rush.