Drug seeking residents?

[Rach823RN]

Hello, Long-time reader/first-time poster here... I am a new grad (May '11) RN, but have been a CNA at my job for 3+years prior. I work in a Veteran's LTC SNF. I am the 3-11 FT charge nurse for my unit, so luckily I don't float and have a great relationship with my 30 residents & families. Many know me from my CNA days before graduating, which really helps. And yes, I chose to stay with the population I love over transferring to our big university medical center! But, I have one resident I seriously don't know what to do with! He is perceived as the "celebrity" on our unit, very needy, and the ETOH dementia has gotten the best of him. Constantly screaming for help (forgets the call bell), and is disruptive to his peers (I have to break up fights when another resident is offended by the verbal abuse he spews out!). Then, when we walk in the room he usually doesnt know what he wants, and then continues to call out again a minute after we leave. Trust me, I have plenty of experience with dementia/Alzheimer's, but he's different. He does have some expressive aphasia, but I can usually determine what he's asking. Most of the time I know he's just bored/lonely, and that I really do empathize with. Hx of very recent substance abuse is known, which leads me to the drug seeking... He is constantly begging for "pills," namely "percocets and sleeping pills". He knows the magic words... I always try non-pharmaceutical interventions first, but he is very noncompliant. And when he doesn't get what he wants, he literally throws himself on the floor! He currently gets oxy5mg BID, but has Tylenol and more oxy5s available as PRNs (in addition to his many antipsychotics/mood stabilizers). Problem is, after he does get his pain meds, he forgets, and continues to scream for help. I go home hearing him for hours after my shift ends! Clearly, what's going on right now isn't working. And while I don't want to see anyone agitated, it urks me to think he's hanging out waiting for his next fix. I know pain is what the patient says it is, but what would you do in this situation? If it were as easy as just giving him what he wants, I would. But I question this when he doesn't even remember when he has just taken the pills. Sometimes I leave him notes to read that explain when he got his last, and when the next is - but no, he continues to call out. Clearly he has a high tolerance, but does that really mean we should just give him more?! Any advice would be appreciated! Even if I don't agree with the treatment, I can't have the constant disruption to the unit anymore!

[*LadyJane*]

Perhaps the doc needs to up his scheduled pain med? Other than that, I see him getting ignored by all, and then when he really gets hurt, no one will respond right away.

Tough situation all around!

[nerdtonurse?, BSN, RN]

Why is he in pain? If there's a reason -- back issues, arthritis, etc. -- make sure the med he is getting is actually the best pain control for the problem. When I have patients with mets'd bone cancer, they actually do better with a duragesic patch and something like flexeril to calm the spasming muscles around the mets sites as opposed to a PO narc -- you just give the percocet, and not only does it not help with their pain as much, they tend to need more and more. I'd hit him with my "cocktail" of Haldol, 150mcg Fentanyl patch, Gabapentin, Flexeril, Zofran (8mg) and Adivan. If there's a physical pain, that should really knock it down. It addresses bone pain, muscle pain, nerve pain, nausea and psych/anxiety.

I would get an order for the fentanyl, and put it between the shoulder blades where he can't reach to pull it off and chew it. Then for PRNS I would get an order for 81mg ASA, and when he yells for pills, alternate the 81mg ASA and a tylenol.

If his problem is that he is a junkie -- no pain source, just wants to get high -- he's psychologically addicted, if you gave him a bucket of vicodin it wouldn't be enough. Then unfortunately, there's not much you can do at this point. He's pickled his brain, he knows that throwing a fit "works" to get him something for a high, and he'll continue to do it. If you think that's the case, I'd advocate for a very high dose Fentanyl patch, and have no PRN meds except Ativan and Haldol. It will be a horrible couple of weeks, but when he learns that throwing a fit won't work, that the behavior does not cause him to get the reward (narcs) he'll stop (or sign himself out to move on to greener pastures). Plus, with a 150mcg Fentanyl patch, he's surely got enough pain control on board for someone who's able to throw themselves in the floor and get into fights, so it's not like you're not addressing his complaint.

[Rach823RN]

Thanks for the responses... I'm not quite sure of the cause of his pain, he reports it's in his back, but I haven't discovered anything more than osteoarthritis in his history/md assessment (if he did have something like ca, i wouldnt feel this way). He also gets Bengay/Voltaren gel. I think some of it has to do with his positioning in bed, which he refuses to change (always holds the right side rail facing the hallway, won't let go. If I turn him or block the rail he screams till I put it back). He is in his late 70s, not possible to DC, has been to a few other facilities. Was separated from his wife because of their vodka binges (40 bottles were removed from his house, where he thought "little men that weren't quite human were taking care of them!!!). He def has an addiction, but some of my colleagues don't see the need to change that at his age, we're not that kind of rehab facility! He even admits that his behaviors "work" to get him what he wants (screaming and throwing himself on the floor). And that's where I tend to lose my patience! And I see visions of The Boy Who Cried Wolf story being played in my head...I will try to suggest a fentanyl patch, I do think he needs something long term. But I know I will meet resistance because the MDs don't like "sloshing" the residents. More then anything though, he needs some vitamin H or Ativan!!! Because along with throwing himself on the floor like a toddler, he threatens to kill himself when he doesn't get what he wants (another thing documented in his history upon admission). All of our nursing staff knows how he is and what he's capable of, but the MDs aren't on the unit long enough to see him in action... it seems to be all about the documentation

[CompleteUnknown]

Sounds like a horrible situation all round but I think that when it's like this, it IS all about the documentation. If he's relatively 'okay' when the doctors are there it can be quite difficult for them to understand the extent of the problem and the issues you're facing.

Anyway, from reading your post it doesn't sound as though he's on a great deal of pain medication anyway? What about giving the PRN Tylenol three times a day for a week or so at set times to see if it does anything for the back pain? Osteoarthritis can be very miserable. I think the fentanyl patch is a good idea too but I wouldn't necessarily say he doesn't need the tylenolol if he's wearing a patch - they work differently and the tylenolol can take the edge off that arthritic pain.

The other thing I'm thinking is that I agree with your colleagues to a certain extent in that trying to cure any addiction seems like a losing battle at this point. It all sounds very difficult but maybe if you can get any physical pain under control, perhaps the behavioural issues will lessen a bit. Well, you can always hope anyway and any reduction in the amount of throwing himself on the floor type stuff would have to be an improvement. Is there any reason he couldn't have a glass of wine or a beer once or twice a day?