Drug Seeking Patients

[Quinnbee]

Hi all! So this is going to be a rant slash plea for advice. I've been working as an RN for about 6 months now, and my patient population has really been terrible as of late. I work on a fairly busy med surge floor, and recently, it feels like every single patient I take care of, is just there for the pain medications. I'll have patients that come in for intractable pain, n/v, from surgeries that they had 6-12 months ago. And when they're assessed objectively, scans show no abnormalities, and vitals are also within normal ranges. Yet, they'll complain of 10/10 pain, that doesn't get relieved with heavy doses of morphine, oxycodone, dilaudid, etc. These are patients that have histories of multiple admits at multiple hospitals for the same issues. At what point do the doctor's decide to stop admitting patients like these? When do they stop giving in to their tantrums?

Just last week, when I let one of my patients know that she would be getting discharged and I had to stop her IV dilaudid, I walked into her room 10 minutes later to see her on the floor, claiming that she had fallen and hit her head. No bruising, no lump, no cuts, not even a hint of redness to her head. In the same week, I took care of another patient complaining of abd pain, n/v, and after being told she would no longer have IV pain meds ordered, she mysteriously started vomiting up all her oral medications. Always when her door was closed (requested by her), and almost on the hour episodes of emesis. No vomiting when she ate food, but any oral pain meds would be upchucked within minutes. And of course IV zofran did nothing for her nausea, only the promthezine ever worked, and only for a very short time.

It's gotten to the point where I feel that if I continue like this, I'll slowly come to hate and resent my patients, and nursing as a whole. I'm just barely starting out as a nurse, and this is not the outlook or mindset that I want to have. Please, please share any tips or advice on how you deal with patients like these.

[Nurse SMS, MSN, RN]

The only way to deal with this without losing your soul is to disengage. Follow physician orders. Assure your patients they will get their PRNs on time and only on time and only if their vital signs and overall assessment indicate its safe. Then move on to the next patient. You will not solve this problem. You won't cure them of their situation, whether pain, psych, tolerance, addiction or combo of all the above. So minimize their impact on you. Do your job. Remain curious about their pathologies. Advocate for them as needed. Medicate them as prescribed and appropriate. Avoid the rabbit hole that is their motivation for being there. It really doesn't matter. You have a job to do, so you do it. If you can keep from thinking in terms of deserving or undeserving, you will be happier for it.

["nursy", RN]

I totally agree with the previous posting, and many nurses do exactly that and pretty successfully. I would add though, that ultimately you may want to decide is this med surg floor where you want to stay. Not all of nursing deals with this particular patient population, and if it makes you start hating nursing, look for the type of nursing that will bring you fulfillment.

[Lunah, MSN, RN]

*cue music from Frozen* Let it goooooooooooooooooooooooo... ❄️

Seriously, once you decide these incidents are not worth your energy or judgment, you'll feel better. Yes, if you are concerned for polypharmacy or unsafe administration to the point of respiratory compromise, address it with the physician and document, document, document. Otherwise, let it go. I worked bedside in the ER for many years, including the years when there was an opiate crisis already but we were still chasing pain to a zero. Once I took myself out of the equation beyond patient safety, it wasn't nearly as soul-taxing. And once I realized that addiction really is a sickness, it made it easier to bring compassion back to my interactions.

[beekee]

Your job is not to fix their addiction. That’s way out of the purview of a short hospital stay. Disengage. Sometimes this population gets more tolerable if they sense compassion with respect to their addiction. Often, the pain IS real; it’s just not (entirely) physical pain, but mental/emotional pain.

[ruby_jane, BSN, RN]

1 hour ago, not.done.yet said:

The only way to deal with this without losing your soul is to disengage. Follow physician orders. Assure your patients they will get their PRNs on time and only on time and only if their vital signs and overall assessment indicate its safe. Then move on to the next patient. You will not solve this problem. You won't cure them of their situation, whether pain, psych, tolerance, addiction or combo of all the above. So minimize their impact on you. Do your job. Remain curious about their pathologies. Advocate for them as needed. Medicate them as prescribed and appropriate. Avoid the rabbit hole that is their motivation for being there. It really doesn't matter. You have a job to do, so you do it. If you can keep from thinking in terms of deserving or undeserving, you will be happier for it.

Beautifully said.

OP, you said you've been a nurse for six months. What's the average number of patients you care for in a shift? Just curious. I would tell you to stick out your tenure for the remainder of the magical year of acute care experience and try something else. But....you'll never know the whys. And outside of the ER, where EMTALA regulates what a patient is entitled to receive, doctors don't "decide" about anything.

[Quinnbee]

Thanks for the advice, you guys, I sometimes find it hard to disengage, but I think it's definitely something I need to start working on. It's especially difficult when I get one or two demanding patients that take up most of my day, and by the time I'm done with them, I have very little left to spare. @ruby_jane Our standard ratio is 5:1, but most of the time we're at 6:1 or 7:1, with several admits and discharges throughout the day.

[Davey Do]

We all need to feel good. We all need to avoid pain, be it of the mind or body.

I feel pity on those who have to go through great lengths to get that need met.

There for the grace of God go I.

[LovingLife123]

Can I ask how you approach pain control with your patients? Is it the standard to give IV pain meds right up until a few hours before discharge, or do you start POs once swallowing is established?

Do you explain to your patients that they will get better pain management with PO meds and that IV meds don’t do much for overall pain control. Explain that they are do short acting it should only be used for breakthrough pain.

I find many nurses basically take the easy way out and get the patient the immediate relief from an IV med. usually in 30-60 minutes, their pain is out of control again.

I discuss pain management with my patients from the get go. I’m sure that 90% of my patients are in pain. It’s not my job to decide whether they are “drug seeking” or not. I tell them it’s my goal to help their pain get better. I can’t completely get rid of it, but I will do the best I can. I discuss the difference in IV vs PO meds and how POs will give them much better relief. And if the dose they are prescribed is not working, we will work on something better. Maybe 2 norcos will work if I’m giving 25mcg of fentanyl every four hours. Maybe we need to go up on orals and no IV for breakthrough.

My point is, it’s all how we approach it. You are the nurse, you are the knowledgeable one. Patients will listen to you. But, if you act like you are completely taking away the only bit if relief they are getting, you will meet with resistance.

[Quinnbee]

16 minutes ago, LovingLife123 said:

Can I ask how you approach pain control with your patients? Is it the standard to give IV pain meds right up until a few hours before discharge, or do you start POs once swallowing is established?

Do you explain to your patients that they will get better pain management with PO meds and that IV meds don’t do much for overall pain control. Explain that they are do short acting it should only be used for breakthrough pain.

I find many nurses basically take the easy way out and get the patient the immediate relief from an IV med. usually in 30-60 minutes, their pain is out of control again.

I discuss pain management with my patients from the get go. I’m sure that 90% of my patients are in pain. It’s not my job to decide whether they are “drug seeking” or not. I tell them it’s my goal to help their pain get better. I can’t completely get rid of it, but I will do the best I can. I discuss the difference in IV vs PO meds and how POs will give them much better relief. And if the dose they are prescribed is not working, we will work on something better. Maybe 2 norcos will work if I’m giving 25mcg of fentanyl every four hours. Maybe we need to go up on orals and no IV for breakthrough.

My point is, it’s all how we approach it. You are the nurse, you are the knowledgeable one. Patients will listen to you. But, if you act like you are completely taking away the only bit if relief they are getting, you will meet with resistance.

Generally, I don't give IV pain meds once my patients are out of their acute pain stage. If they've just come out of surgery, I'll give IV for the first few hours, until their pain is under control, then transition to PO for the duration of their stay. I explain this to them beforehand, and let them know that their POs will be given in a way where we can catch the pain, before it gets to be unbearable. One thing that I really enjoy is educating my patients. And with the patient population that I'm currently having, it's practically nonexistent. I'm aware that PO pain meds work longer, and sometimes better to relieve pain, but my frequent flyer patients rarely want to hear anything about getting PO meds. These are patients with histories of IV drug use, so all they want is what they know. I've had patient's outright tell me that they only want IV pain meds and nothing else. Given like they're scheduled, even though the meds are prn. I've had patients ask me to write down when they last received IV pain medications, and when they can get them next. Patients who have woken up out of a dead sleep to tell me that they're having 10/10 pain that 1.5mg of dilaudid did nothing to relieve. At points like this, the frustration sets in, but I'm taking the advice from several replies, and disengaging. Handling these patients in a literal and objective way is what I pray I can do from here on out.

[LovingLife123]

5 minutes ago, Quinnbee said:

Generally, I don't give IV pain meds once my patients are out of their acute pain stage. If they've just come out of surgery, I'll give IV for the first few hours, until their pain is under control, then transition to PO for the duration of their stay. I explain this to them beforehand, and let them know that their POs will be given in a way where we can catch the pain, before it gets to be unbearable. One thing that I really enjoy is educating my patients. And with the patient population that I'm currently having, it's practically nonexistent. I'm aware that PO pain meds work longer, and sometimes better to relieve pain, but my frequent flyer patients rarely want to hear anything about getting PO meds. These are patients with histories of IV drug use, so all they want is what they know. I've had patient's outright tell me that they only want IV pain meds and nothing else. Given like they're scheduled, even though the meds are prn. I've had patients ask me to write down when they last received IV pain medications, and when they can get them next. Patients who have woken up out of a dead sleep to tell me that they're having 10/10 pain that 1.5mg of dilaudid did nothing to relieve. At points like this, the frustration sets in, but I'm taking the advice from several replies, and disengaging. Handling these patients in a literal and objective way is what I pray I can do from here on out.

Is this then being discussed with the physicians? If they are ordering it and are ok with it being given, give it. You are not in the type of setting to deal with addiction, you just aren’t. If it’s a prn medication, I make the patient request it. I don’t give it around the clock.

I also think that it has to be the whole unit working together as well. So trying to do anything about the constant iv pain meds can be a losing battle.

[Quinnbee]

Just now, LovingLife123 said:

Is this then being discussed with the physicians? If they are ordering it and are ok with it being given, give it. You are not in the type of setting to deal with addiction, you just aren’t. If it’s a prn medication, I make the patient request it. I don’t give it around the clock.

I also think that it has to be the whole unit working together as well. So trying to do anything about the constant iv pain meds can be a losing battle.

Yes, and sadly, I'm learning that very quickly. Luckily I have a great team that I work with, and my unit has been a very supportive environment. Which is probably the only reason why I'm still at this facility.