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.

[FineAgain]

How about PRN fentanyl as per protocol. 20mcg Q3Min

Yeah, because THAT'S what I want to do all night.

[SleeepyRN]

Raises hand.

Me too.

Yep, same here

[SmilingBluEyes]

Nurses definitely need more education on drug tolerance, dependence and addiction. They are all different things.

[SleeepyRN]

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.

So, try telling me again what addiction is. Because below us the Ultimate source.

" DSM-IV Substance Dependence Criteria

Addiction (termed substance dependence by the American Psychiatric Association) is

defined as a maladaptive pattern of substance use leading to clinically significant impairment

or distress, as manifested by three (or more) of the following, occurring any time in the same

12-month period:

1. Tolerance, as defined by either of the following:

(a) A need for markedly increased amounts of the substance to achieve intoxication or

the desired effect

or

(b) Markedly diminished effect with continued use of the same amount of the substance.

2. Withdrawal, as manifested by either of the following:

(a) The characteristic withdrawal syndrome for the substance

or

(b) The same (or closely related) substance is taken to relieve or avoid withdrawal

symptoms.

3. The substance is often taken in larger amounts or over a longer period than intended.

4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

5. A great deal of time is spent in activities necessary to obtain the substance (such as

visiting multiple doctors or driving long distances), use the substance (for example,

chain-smoking), or recover from its effects.

6. Important social, occupational, or recreational activities are given up or reduced because

of substance use.

7. The substance use is continued despite knowledge of having a persistent physical or

psychological problem that is likely to have been caused or exacerbated by the

substance (for example, current cocaine use despite recognition of cocaine-induced

depression or continued drinking despite recognition that an ulcer was made worse by

alcohol consumption).

DSM-IV criteria for substance dependence include several specifiers, one of which outlines

whether substance dependence is with physiologic dependence (evidence of tolerance or

withdrawal) or without physiologic dependence (no evidence of tolerance or withdrawal). In

addition, remission categories are classified into four subtypes: (1) full, (2) early partial, (3)

sustained, and (4) sustained partial; on the basis of whether any of the criteria for abuse or

dependence have been met and over what time frame. The remission category can also be

used for patients receiving agonist therapy (such as methadone maintenance) or for those

living in a controlled, drug-free environment."

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders. Fourth Edition. Washington, DC: American Psychiatric Association, 2000.

[SleeepyRN]

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.

I think the problem is the STIGMA to addiction. Chronic use of narcotics leading to addiction is not the patient's fault, and we should not make them feel bad about it. I'm a pain patient. Always in bad pain.

But once again, I have to disagree at the definition of addiction.

DSM-IV Substance Dependence Criteria

Addiction (termed substance dependence by the American Psychiatric Association) is

defined as a maladaptive pattern of substance use leading to clinically significant impairment

or distress, as manifested by three (or more) of the following, occurring any time in the same

12-month period:

1. Tolerance, as defined by either of the following:

(a) A need for markedly increased amounts of the substance to achieve intoxication or

the desired effect

or

(b) Markedly diminished effect with continued use of the same amount of the substance.

2. Withdrawal, as manifested by either of the following:

(a) The characteristic withdrawal syndrome for the substance

or

(b) The same (or closely related) substance is taken to relieve or avoid withdrawal

symptoms.

3. The substance is often taken in larger amounts or over a longer period than intended.

4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

5. A great deal of time is spent in activities necessary to obtain the substance (such as

visiting multiple doctors or driving long distances), use the substance (for example,

chain-smoking), or recover from its effects.

6. Important social, occupational, or recreational activities are given up or reduced because

of substance use.

7. The substance use is continued despite knowledge of having a persistent physical or

psychological problem that is likely to have been caused or exacerbated by the

substance (for example, current cocaine use despite recognition of cocaine-induced

depression or continued drinking despite recognition that an ulcer was made worse by

alcohol consumption).

DSM-IV criteria for substance dependence include several specifiers, one of which outlines

whether substance dependence is with physiologic dependence (evidence of tolerance or

withdrawal) or without physiologic dependence (no evidence of tolerance or withdrawal). In

addition, remission categories are classified into four subtypes: (1) full, (2) early partial, (3)

sustained, and (4) sustained partial; on the basis of whether any of the criteria for abuse or

dependence have been met and over what time frame. The remission category can also be

used for patients receiving agonist therapy (such as methadone maintenance) or for those

living in a controlled, drug-free environment.

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders. Fourth Edition. Washington, DC: American Psychiatric Association, 2000.

[SmilingBluEyes]

I just don't get feeling "Dirty" taking care of such people. They are PEOPLE and if they are ADDICTS, they are still deserving of the best care we can give them. 10 percent of the US population is classified as "drug or alcoholic addicted". Yes, that is a lot of people. But pain is not just limited to non-addicts and the trick for all health care providers is to provide pain relief to true addicts/folks with high tolerances. It's not for me to judge or qualify who is whom. It is for me to render my best care in any circumstance, however challenging it may be.

[SleeepyRN]

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.

I understand being irritable by addicts behavior, but with this post, you have to get off your high horse.

You have NO clue what they are feeling. God forbid someday you fall off a ladder, completely crush your legs and end up in physical therapy. One Norco 10-325 may help for a week, but your body builds a tolerance, and soon it's two 10-325's then oxycontin, then fentanyl patches....our bodies develope tolerances. I'll tell you right now that one Norco 10-325 won't do squat for me anymore. And that's after just having 1 pill after 3 months of not having it. My body STILL had a tolerance to it. And guess what? I talked on my phone. Had visitors, laughed....it was DISTRACTION for the pain, and a front.

[Been there,done that, ASN, RN]

That was not a gentleman;) Could have been worse, he could have called your phone 15 minutes before the dose was due.

This is NOT your battle. The physician has ordered the medication, it is your nursing responsibility to administer it. You will not effect a change during a hospital admission.

You could order a pain management consultation, for whatever that may be worth.

[NOADLS]

I've seen a lot of these threads and haven't really contributed my 2 cents.

If a drug seeker has an order for a narcotic and the dose of the drug ordered isn't going to harm the patient seeking it, withholding the drug is a losing battle for you. The patient can continue to ring and complain until they get it. At the very least, by giving it to them, there is a minimum period of time before they can bother you again.

If the drug seeker is always "on the dot" when requesting their drug at every possible interval, just wait a few minutes to respond to their bell and then take another 15-20 minutes to get the drug to them. Explain to the patient that requests are responded to based on urgency if they act up over the short delay. If they continue to persist, explain to the patient that you are okay with giving them their drugs, but they might not be so fortunate with other nurses who will ask a barrage of questions each time the patient requests their PRN. Basically, sell them that the short delay is better than nothing.

[sissiesmama, ASN, 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.

This!!

I can remember how I felt when I was 19 and admitted to the hospital with abd pain - finally got a diagnosis of pancreatitis. I was stuck in the hospital for weeks at a time waiting for my enzymes to go back down - I had stones lodged in my duct and had scope after scope before my surgeon took me to the OR for my choley.

I never imagined something something that hurt so much - I was in pre-nursing classes at the time and worked in medical records at the hospital where I was as a patient - my director stopped by my room one afternoon and started bringing d/ced charts for me to work on.

Anne, RNC

[joanna73, BSN, RN]

Provided the patient is not going into respiratory depression, why should I care if they want their PRN pain meds as ordered? Pain is subjective and we aren't there to make a moral judgment.

[SleeepyRN]

If the drug seeker is always "on the dot" when requesting their drug at every possible interval, just wait a few minutes to respond to their bell and then take another 15-20 minutes to get the drug to them.

So you are promoting punishing a patient for certain behaviors. WOW