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.

[RayeAnn Kemp]

Yes, I've sent patients home with no scripts from the doctor, after they were just taken off 3 weeks of round the clock I.V. meds, switched to p.o. for 2 days, then the doctor refuses to write them a script for pain. Wonder what these people do?

[MelissaBarthold]

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.

[Jillnage]

Not my job to be a drug rehab counselor. Yes, we must use judgement. If patient is obviously altered, high...we can refuse to medicate them. Appropriately documented and MD notified. Just because a person has normal bp, doesn't indicate no pain. Pain management is complex. I think people suffer from 'anticipated' pain. They become dependent, and know what's coming without the medications. You just do your best. His docs are probably well aware of his behavior. Just document your observations, without judgement.

[Roy Hanson]

discuss this with your charge nurse OR the doctor. This gentleman may have a LOW pain tolerant. Pain killers are temporary measures. If he needs drugs, under HIS dr order, who are you to be a decision maker. Do your job!

[Dmlref]

This drives me crazy! I have been reading these forums for years and years and have never posted, but I feel compelled to do so now, a nerve has been hit. OP, I think you may have missed the forest for the trees...let me ask OP this: have you ever had pain? Have you ever had chronic pain? Have you ever taken opiates? or have you ever had to take opiates for an extended period of time? Have you ever had an addiction (not just to drugs, but any addiction)? Judge not until you have walked in another's shoes. Whether this patient had true pain or not, whether he was drug-seeking or not, an addict or not, who are you to judge him? Did you have to administer the dilaudid from your personal medicine cabinet? I'm not being nasty, hear me out. People with chronic health problems, whether that's heart disease, diabetes, renal disease, pain or addiction, wake up every morning wanting to feel normal or even just wake up feeling decent. Those people hope and pray that tomorrow will be a good day. That hopefully tomorrow he/she will be able to get out of bed. Those people put their pants on just like you and I, one leg at a time. A patient with diabetes can take their medication (insulin or oral meds) to help better control sugars. A patient with hypertension can take medication to bring bp down. A person with poor vision can wear glasses or contacts to help see more clearly. What can a person with chronic pain or a person who is addicted to opiates, or any other drug for that matter, do to help what ails him or her? Chronic pain and addiction are medical conditions in and of themselves. If it's a physical condition that can be helped by physical therapy...then great! If the condition can be controlled by surgery or procedures...then great! If the condition can be managed with medication...then great! Counseling, drug rehab.....great, great! But what about the person who has tried all those things and still has no relief? What can that person do? We all know tolerance to opiates builds up fairly quickly. I will tell you what a person with no relief does: either seeks out pain relief, or drug of choice illegally, or turns to the ER, or a pain management specialist (assuming he/she has one). We, as nurses, are there to help patients in need. We aren't only nurses during codes, or only when someone has an infection, or a laceration. We should still be there to help when we can't see a patient's illness or condition with our own two eyes. We don't check out as nurses because someone has chronic pain or is an addict and needs help just to function normally. Do you have a problem giving insulin to the patient with a blood sugar of 300 that comes into the ER? Do you have a problem administering nitroglycerin and aspirin to the patient who comes in with an MI, now what about if it's that patient's 4th MI, and he is obese and is non-compliant with medications and diet? Do those patients make you "feel dirty" too? Those are societal problems as well because many of those patients don't even have insurance and many require chronic care and become a financial strain on our already broken healthcare system. If the answer to those questions is a resounding NO, then why do you have a problem administering a prescribed pain medication to a patient who says he has pain? Because you can't see his pain? Because society says that opiates are bad? Because you feel if you give an ordered opiate to a breathing, stable vital sign patient, that you are contributing to the over-prescribing of opiates in our country? How so? You didn't prescribe the medication to this patient when he started down the opiate road initially, and you also didn't prescribe his dilaudid that day. What you ARE doing by giving that prescribed medication, is helping a broken person feel some comfort, time-limited comfort, and that is why your patient is "watching the clock." It's times like those that I as a nurse, personally feel blessed that I am able to be the one to do that. That I can bring relief to someone, no matter how brief that relief may be. There are only two problems I see with this patient scenario, as you have described it. First and foremost, no patient should be able to rant and rave and treat medical professionals poorly, no matter what their health concern is. That should've been the primary concern here! Secondly, you have some preformed opinions or biases against patients who need/want pain medication and/or addicts. Why? I witness this sort of judgmental behavior quite often from both nurses and providers, and quite frankly, I don't understand the coldness, especially from a new nurse. I pray you find compassion for these types of patients before you quickly burn out on the nursing profession. I ask you this, why did you became a nurse? A doctor I once knew told me that people who judge those who use opiates or who have chronic pain, have not had their pain.....yet.

[Horseshoe, BSN, RN]

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.

That is despicable, not to mention UNSAFE. I would have reported that all the way to the top. There is no excuse for that, and she should have been severely reprimanded.

[Jillnage]

I agree that the ER is not the place for chronic pain management. And it is a waste of resources. Adequate pain management is essential for patients with chronic pain issues. No chronic pain patient should ever have to utilize an emergency room. Not effectively managing patients with chronic and persistent pain is unacceptable, in the outpatient setting. But these days, Prescribing Physicians are terrified of loosing their prescribing privileges...and you can thank the government, and the DEA for that. People with chronic pain, dependent on prescription medications are viewed as suspect, drug seekers. My roomate had stage 4 bladder cancer. Was under hospice care. She was in horrific pain, and was forced on her death bed to go to the hospital to get pain medication. People don't have to be dying to be in pain. Patients in pain shouldn't have to suffer, or go thru these measures, drastic measures, to get relief. It is just cruel.

[heron, ASN, RN]

OK, let's get real here ... we all have dealt with substance abusing patients. We have all been steamrolled by their drive to get their substance(s) of choice. I remember when mouthwash disappeared at an alarming rate ... until they started making it alcohol-free. Even now, in ltc, I have a resident who has to be watched constantly because he snipes cologne and after-shave from other residents to drink. A real sleaze-bag who'll steal anything not nailed down.

Health care providers have access to drugs ... the "good stuff" ... addicts need drugs ... and nurses get targeted because we have the keys. The behaviors addicts use to stay high, or at least out of withdrawal, are brutal, dishonest, abusive and enraging. It would be unhealthy for any nurse to pretend otherwise.

Substance abusers also present a particularly thorny problem when they are actually having organic pain separate from their addiction but requiring treatment with their drug(s) of choice. The challenge is how to deal with those behaviors professionally, including being able to discern when the problem is not substance abuse.

The problem is, "drug-seeker" has become the trash diagnosis of our time. This is complicated by our very poor understanding of the physiological and emotional dynamics of both pain and addiction. It's also aggravated by our tendency to blame the patient for not responding to our care the way we think they should.

We need to get clear on what it is we think we're actually treating. I truly believe that our health care system effectively conditions people who have chronic severe pain to behave like out-of-control junkies because we refuse to deal with their pain any other way. We get more invested in winning the power struggle than in what's actually going on with that person and how we could help.

In my own practice, I found that I had to make a decision about my priorities. Is it more important to me to foil a junkie or to relieve pain as best I could. Since detox and substance abuse are not my area of practice, I choose to prioritize pain relief. I also have to accept that some addicts are going to "get over". I feel that to do otherwise is to let the addicts suck all the oxygen out of the room and run the show. Meanwhile, people who need pain relief have to face their pain, and the complications thereof, alone. Nope, not gonna do it.

[JersE.Joe]

Great suggestion! I personally think it would really help.

[banterings]

The question here is which poses a greater risk to the patient: Potentially not giving appropriate pain medication to a patient who really needs it OR potentially giving pain medication to a drug-seeker who does not needs it?

This is similar to the dilemma with our justice system: What if we could get every criminal off the street but also got 1 innocent person for every 10,000 criminals OR we could get 80% of the criminals and not wrongly convict any innocent people?

The answer depends if you are the one in pain or not. For the nurse who is administering the meds it is very easy to second guess the patient's motives, especially when you are NOT in pain.

And what of situations like MelissaBarthold's post where the ICU nurse convinced the ICU intensivist that she was a major drug seeker? How is that any different than that nurse going to a patient not in pain and stabbing them in the back with a scalpel? There is NO difference!

When one makes the determination that one is a drug seeker, there is NO definitive answer, they can only assume. (Remember what

?)

[heron, ASN, RN]

Although it could be argued that the addict also "needs" medication. Withdrawal is neither fun nor risk-free.

[Dragonnurse1, ASN, RN]

I agree with poppy cat and hppygr8ful. I live with 4 disks in my neck fused(2 separate fusions without total pain relief) and another herniated disk (going on 5 years) in my lower back, arthritis in the right shoulder (shoulder replacement recommended) and in both hands and one torn up knee. I also have permanent radiculopathy in my right arm. My pain on a daily basis is no longer controlled with 4 lortab 10's and 4 zanaflex. I continue my daily activities that include: mowing a lawn, taking care of 9 dogs, 3 cats and cooking for 4/5 people daily. No one would think that I am in constant pain but when I stop doing the pain is the only thing I can concentrate on therefore I try to keep going.

Diabetic patients do not experience pain the same way as non-diabetic patients. Until you have a family member that has lived with diabetes and end-stage renal failure you may not understand how different their pain can be. Neuropathic pain is something that cannot be described. Words commonly used include: burning, searing, pins and needles, none of which the average healthy person can comprehend.

I worked in the ED for 9+ years and dealt with the people that you are referring to and you cannot let your perception of their pain color your actions. You can only rely on the MD to decide whether to give narcotics or something else. It is not your job to decide whether or not the treatment ordered is appropriate or not, it is your job to carry out the MD's plan of care. It is never your job to decide whether their complaint of pain is valid or has merit.