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.

[moriahcat]

I guess my father was lucky. Since his drug of choice was amphetamine, it wasn't something he could "score" easily from physicians. But any addict has a similar rep when it comes to seeking, and for good reason -- even if it's not the high they prefer, narcs are still quite capable of giving them *a* high.

Dad had been able to work with a physician outside of the hospital for his pain management, and that's what this patient really needs, from everything that has been said. But just based on my Dad's experience, a request for an opioid and becoming hostile, but then accepting a dosing schedule that isn't going to address pain (Dilaudid is an ugly opioid because the short action makes it far more addictive, and every six hours is still not often enough), makes me wonder about extremely loose stool being an issue he's dealing with but unwilling to discuss. That regimen might not address chronic pain effectively, but might be helpful with fecal incontinence from unhappy gut flora. Dad said that was the most embarrassing part of his illness.

[Farawyn]

I guess my father was lucky. Since his drug of choice was amphetamine, it wasn't something he could "score" easily from physicians. But any addict has a similar rep when it comes to seeking, and for good reason -- even if it's not the high they prefer, narcs are still quite capable of giving them *a* high.

Dad had been able to work with a physician outside of the hospital for his pain management, and that's what this patient really needs, from everything that has been said. But just based on my Dad's experience, a request for an opioid and becoming hostile, but then accepting a dosing schedule that isn't going to address pain (Dilaudid is an ugly opioid because the short action makes it far more addictive, and every six hours is still not often enough), makes me wonder about extremely loose stool being an issue he's dealing with but unwilling to discuss. That regimen might not address chronic pain effectively, but might be helpful with fecal incontinence from unhappy gut flora. Dad said that was the most embarrassing part of his illness.

I'm really sorry for your Dad.

[beckster_01, BSN, RN]

1mg q6?? Meanwhile in the ICU:

*pushes 1mg q1h

*turns up dilaudid to 12mg/h, patient is still coherent and in pain

*manages a dilaudid PCA that runs at a concentration of 20mg/ml

I have worked in post-surgical and MICU for 5 years, and can count on one hand the number of TRUE drug seeking behavior, unexplained by a pathological reason for the pain. And what do you do? Consult with the doctor, set limits, and establish a plan for pain control. I consider pain relief one of the most important parts of my job. The damage that being in constant pain caused to your body and affects (effects? I never get that right) rates of healing is worse than the off-chance that you are contributing to drug-seeking behavior.

[alfa-sierra, BSN, RN]

Passing judgment is counterproductive: doesn't promote healing and some patients will pick up on those vibes. You ask for helpful links. Google "Motivational Interviewing" for a different approach. It requires some finesse, and practice. MI takes time and is most applicable in Mental Health/Chemical Dependence settings. Like a seed that must germinate, MI has a high therapeutic value for the patient...in the future. In the meantime, as a bonus, it sets us free from judgment and associated troubling feelings. Quite empowering also for the nurse-healer in you.

[ixchel]

Passing judgment is counterproductive: doesn't promote healing and some patients will pick up on those vibes. You ask for helpful links. Google "Motivational Interviewing" for a different approach. It requires some finesse, and practice. MI takes time and is most applicable in Mental Health/Chemical Dependence settings. Like a seed that must germinate, MI has a high therapeutic value for the patient...in the future. In the meantime, as a bonus, it sets us free from judgment and associated troubling feelings. Quite empowering also for the nurse-healer in you.

A small warning - "MI" in the context of this thread will be read as Mental Illness, even if you did mention earlier in your post that you're talking about motivational interviewing.

[danceyrun]

I'm not sure if this has already been addressed, but besides the labeling etc.- you are there for 12 hours (technically more but you know what I mean) and you can give it q6. You are giving it twice. Three times maybe. Get the wad out of your panties and give the drug.

[dlcjrnlac]

Ok, the "I feel dirty" comment made me LOL! Thanks for that! I'm stealing it next time I have to "medicate" somebody. So, I used to feel the same way about feeding someone's habit. But I realized I would just make myself miserable trying to change things I had no control over. Here's your permission slip to stop torturing yourself over this. For one thing, your patient is addicted. You are not going to detox them on your floor. They're being admitted with orders. Definitely check VS before giving it and don't give it if they appear sedated, even with good VS. Document, document, document. Don't give it a second thought when they manipulate you. Yes, you know they're doing it, but it's not you, it's not them, it's the addiction. Just give it if ordered. One thing about Dilaudid, though, the respiratory depression effects are cumulative. So, I would definitely make the recommendation to the hospitalist after day one or two to switch over to IV morphine, Percocet, etc. Yes, the patient will throw a fit, but they won't go into withdrawal, and they'll be safer. As will you. Good luck and try to let go of this.

[dlcjrnlac]

why can't I delete?

[dlcjrnlac]

Wow--I just read over some of the comments, especially the ones labelling the OP as "judgmental". Hmmmm, projection, anyone? This is an important topic and one every nurse learns about quickly when starting out. Shame-throwing has no place in what we do. Our jobs are hard enough as it is.

[heron, ASN, RN]

Are you referring to the posts expressing anger at the treatment some posters received at the hands of medical professionals?

Our jobs are hard, yes - but that doesn't make shaming our patients ok, even the addicts.

[Horseshoe, BSN, RN]

Wow--I just read over some of the comments, especially the ones labelling the OP as "judgmental". Hmmmm, projection, anyone? This is an important topic and one every nurse learns about quickly when starting out. Shame-throwing has no place in what we do. Our jobs are hard enough as it is.

Oh good grief. Anyone who says giving ordered 1mg Dilaudid q 6 (with a freaking percocet for good measure) to a patient with a horrible chronic and painful disease makes him feel "dirty" is being JUDGMENTAL. Talk about "shame throwing!"

[righteousjenn]

I didn't read all the posts on here so I don't know if anyone else went over this but most of the "drug seekers" had legitimate pain at some point and some of these people are in chronic pain all the time and unfortunately were prescribed these black box drugs that has the potential of addiction.

Some of the time watchers are probably in so much pain when the meds wear off that they're scared of it starting to hurt because it's a lot easier to prevent the pain than to treat it when it's happening.

I feel the upmost sympathy for these people and will continue to always medicate accordingly. I don't know their backstory and maybe them sitting there on their phones chatting and laughing and watching tv are their way of distracting themselves from what is hurting.

I know personally that I can break an arm and tolerate the pain but am a big fat baby when it comes to migraines and ear aches.. Even when it's mild I wish I could have some dilaudid to knock it out because to me it's the worse thing ever and have a very low tolerance to that type of pain than I would a broken arm.

Don't judge just medicate that's all we can do and it's not like the money for these meds come out of our pocket anyways.

ps I live in a large city with I think now we are home to the largest homeless patient population and do clinicals at a county facility so I see these types of patients on the daily