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.

[SleeepyRN]

I mistyped, I meant to type "drug-seeking." So, a person who is sitting in bed, on the phone, laughing, BP is great, HR is great, snacking on chips is truly experiencing 10/10 pain. Doesn't add up to me I guess. This particular patient has a history, based on his physician notes, of "numerable admissions complaining of vague pain, then becoming angry demanding IV Dilaudid." He is a non-compliant in his medication regime for diabetes, does not take his HIV meds, etc. This admission was for chest pain. All markers were negative, etc. Not only was he getting Dilaudid, he was getting Percocet along with it. Administered together.

I get it OP. And you clearly stated in your original post that you are talking about, in your words, the rare times people really are drug seeking.

I have a patient who drives me up the wall with his drug seeking behavior. I'm not going to get into details about how I know he is addicted. I just do. (Not his fault. He is in rehab recovering from serious painful injuries. After months, of COURSE his body is addicted to it.

But his BEHAVIOR quite honestly angers me.

The other day he bugged me because he said his Q4 hr PRN Norco was "late." I had popped my head in his room exactly 4 hours after I had administered his last Norco. I let him know I was across the hall in the middle of something and would be with him in 10 minutes for his Norco. He said, "ok, good. No problem."

10 minutes later, Norco in hand, I entered his room. At this point it had been 4 hours and 10 minutes since his last dose. He had the nerve to tell me I was LATE with his pain medication. Ummmm no. It is a PRN med, not a scheduled med. He proceeded to tell me that because I was late he was going to have to pay the price of not being able to get his next dose until 12:10am instead of 12:00 am

Sigh

[SleeepyRN]

Many healthcare professionals opinions on pain make me so angry. I have interstitial cystitis. My bladder constantly burns, the muscles around my bladder are always spasming or completely clenching up and so on and so on.

I'm in a good 6-7 amount of pain at any given time. You would NEVER know it. I've dealt with this for 9 years and simply refuse to show my pain to the world on a regular basis.

I'm at work, smiling, just working away. Meanwhile my bladder is screaming at me, "What are you doing to me!"

I try not to even show it to my husband anymore. Until it's an 8 and I'm just laying in bed crying with an ice pack or heat pack.

At my norm of 6-7, you will see me smiling, talking to people...but it's a front. Many chronic pain sufferers are good at putting on a front.

And believe me. I'm not being a baby by saying I live my life at a 6-7 (8 during weeks of flares.)

A 9 for me is a stuck kidney stone just slowwwly digging it's edged into my abnormally small ureters, with writhing and vomiting requiring surgical removal.

[heron, ASN, RN]

Don't let it come as a shock to y'all, but needing narcotics for a long enough period to develop physiological dependence is not - repeat NOT - the definition of addiction.

[Tridoral]

I think I'll just stick with pain being whatever the patient states, its what my instructor had always emphasized.

[iluvivt, BSN, RN]

Bless you Heron...you are 100 percent right on.It is dependence not addiction and those in chronic pain have better lives when their pain is controlled.If you have not experienced pain non-stop for 3 mos or greater it is impossible for you to understand how DEVASTATING is to every aspect of your life and how you just pray for a few good hours so you can do your laundry, take a bath, or just read.Its a viscous cycle of pain,fatigue, stress and more fatigue.

[jadelpn, LPN, EMT-B]

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?

A nurse needs to step back and truly erase his or her personal beliefs or opinions away from the bedside. I can not stress this enough.

When one uses terms such as "enabling" this is taking personal emotion and placing it at work.

A nurse can encourage health and wellness, not force it. HIV in itself (and diabetes) is a complex, multi faceted, multi discipline process. With very expensive treatment options.

One of the most horrifying things I have witnessed is back in the day when HIV/AIDS was so very painful that the only thing the patient could do is cry. You could not give them enough pain medication. And you are speaking, OP, of a patient who is non-compliant with treatment--which to me suggests that this now chronic illness is not manageable, therefore, continues untreated. Which is very painful.

Which brings us to his diabetes. Which I would also assume was largely untreated. Which then causes complications, one of which is nerve pain.

Then, as I mentioned in a pp, there is the behavioral aspects of HIV, (and the psychological pain of HIV) which is organic in nature, and can cause acting out behaviors. As well as complications from diabetes--most notably in my experience with kidney malfunction, which can cause all sorts of behavioral outbursts.

If can be a frustrating process to be giving 5mg of dilaudid every 1 hour and 58 seconds all shift. To someone who perhaps doesn't present like they are in 10 out of 10 pain. But in this instance, you have a patient with significant and largely untreated disease processes. And to be perfectly blunt, if I had an HIV/diabetes combo that is now complicated by years of non-compliance, I would be wanting a heckuva lot more than a couple of Percocet and 1ml of Dilaudid every 6 hours.

So again, a plan needs to be put into place. Help with medication payments as well. If no one knows "what to do" with this patient, that is concerning. The flaw in the system is that patients such as the ones you describe are not given options, discharge plans that work, outside referrals, and the support they need to function.

A compassionate nurse and a compassionate person should be 2 entirely different things. As a compassionate nurse who doesn't want to see anyone suffer, advocate for something different for this patient. Promote a plan for wellness (or in this instance as well as he can be going forward).

This patient doesn't come across to me as a "drug seeker" rather a largely untreated patient with difficult dynamics and chronic disease.

[jadelpn, LPN, EMT-B]

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.

And rightly so. You are talking about a patient who is chronically ill. AND with untreated HIV/AIDS. Seriously, 1mg every 6 hours is crazy.

Take yourself away from how the patient "acts" and look at this realistically.

[ClaraRedheart, BSN, RN]

Glad to see I'm not the only one who feels this way. I have patient's who have developed a genuine dependency to opioids due to long term use for legitimate cause. I work 4 days, 5 patients per day, I'd say I run into to 1-2 of them per week.

I HAVE recently had a Munchausens patient. Not certified yet, because he turns away psych consults, however, mysterious abd pain is of completely unknown cause despite multiple colonoscopies, EGD's, etc's. Demands more pain medication constantly. Throws fit's when doctor tries to taper it off. Unfortunately, his family seems to be completely sympathetic and enabling, and will demand more pain medication for him when he feels that his opinion alone is not obvious enough. This led to Q2 dilaudid pushes for awhile, and more recently, lots of fits and demonstrations of outrage because the doctor is tapering to hopefully discharge, since there is no medical reason to keep this patient as an admit. I don't mind doing my job, and.. honestly, I realize that pain is subjective, and if they have pain meds and their systolic is over 90 and their O2 sat over 95, I'll just give it. However, when I have patients this manipulative and demanding that are calling constantly when I am trying to care for truly sick patients who are in a life or death situation, I have NO patience for this. They are a distraction and a danger to others.

[heron, ASN, RN]

It's perfectly normal to have an emotional reaction to being bullied or manipulated. Having worked for 11 years exclusively with AIDS in-patients, most of whom were active addicts and/or newly-released inmates, I'm well acquainted with that particular black hole.

The point that some of us have tried to make is that anger and frustration does not justify poorly informed and over-simplified stereotyping of patients experiencing pain. We're human, yes - but we're supposed to be professionals, too.

[JoseQuinones]

When the devastating earthquake hit Haiti a few years back I went over with a group from Puerto Rico to offer help. The smell. The carnage. The sheer size of the need. After the only thing you can offer to a young mother with two little ones and a shattered pelvis is a Tylenol, the drug seekers back in our reality seem less important. Give them what they want and get them out of your hair so you can help others who do need you.

[lsvgsdawn]

I agree it's easier to give the pain meds when they are due or needed. I also agree with the op. The system is broken. There is a huge heroin addiction problem in the United States in areas of the Country that are considered middle class and not the typical " drug addict" stereotype. Many of these people were once prescribed pain meds from their doctors and then because prescription pain medication has become an issue they are being more controlled to prescribe in many states. These people are turning to heroin, because the dr is no longer prescribing. Dilaudid should not be the go to medication for pain... It is very addicting. I have had PTs and many of you have that not only want their dilaudid but want a cocktail of dilaudid, benedryl, phenergan, all pushed in a certain order etc. I have seen patients flat out lie to the doctors saying they can't hold any food down cause of abdominal pain but have friends and family bring them McDonald's. And the doctor is aware. Dilaudid shouldn't be the one pain med we seem to give. It's very potent and I even had a patient admit to me that they can't live without it IV because it feels so good. And they get sent home after months yes months of refusing to be discharged or having new symptoms when she knows she is being discharged and then they finally discharge her and they are right back in the ER in a few days... I hope she doesn't eventually turn to heroin or something that isn't monitored in a hospital setting, but I do know that I spoke with the dr and he says she is having abdominal pain... That's that. We all know what's right, unfortunately there is nothing we as bedside nurses can do in three shifts per week.

[malestunurse]

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.

How about PRN fentanyl as per protocol. 20mcg Q3Min for as long as their resp rate is over 10.