Feeling like you're complicit in the addiction problem...

[ScientistSalarian]

I've read so many articles and listened to so many podcasts dealing with the origins and consequences of the opiate addiction problem here in the US. I see the fallout almost every day that I work on my critical care unit and see the repercussions touching nearly every single demographic we work with. Opiate addiction - whether it be patients getting their fix from an ED doc, a hospitalist, a primary care or pain clinic practitioner or a street heroin dealer - is clearly an issue that stretches across the continuum of care.

None of this, I believe, is much up for debate at this point.

My question is this: in the midst of such a widespread systemic issue how much am I, as an individual nurse, helping to perpetuate the problem? How can I do my part to, if not help solve it, at least not make it worse? What's my role in all of this?

As a non-prescriber I know there's only so much I can do, but as someone who administers a whole lot of ordered pain meds I feel a certain amount of responsibility here. I obviously don't want my patients to suffer, and I've very much had the whole "pain is whatever the patient says it is, regardless of your assessment of the situation" thing drilled into me, both by nursing school instructors and by hospital administrators who don't want to hurt our patient satisfaction survey results. I try to make a concerted effort to find the balance between making my patients comfortable and using the least 'heavy-duty' option to get them there.

But when I have patients who order IV dilaudid as if they're choosing from a menu or whose pain is never less than a 10/10 while they're chilling in a recliner reading magazines I can't help but wonder if there's something I should be doing aside from just going with it. I know that for a chunk of the population, every day is filled with constant, unending pain, and these people are why I can't bring myself to challenge patient's pain ratings or under-medicate. But when approximately 5% of the world population is consuming something like 80% of its narcotics it feels equally unhelpful to pretend as if none of my patients' behaviors are coming from a place of addiction. I just feel helpless. What, if anything can/should I do as just one nurse?

[Atl-Murse]

The sooner you realize you you are not the world's moral police, the sooner you give your brain some rest. Live your life how you see fit and do not worry about people's lifestyle.

[Sour Lemon]

I will discuss the issue with certain types of patients ....usually post-ops who are new to narcotics and seem to be requesting more medication more frequently instead of tapering down. This group is receptive to teaching most of the time.

The long-term users are beyond my ability to help. I can't tell them anything that they haven't heard before.

[VioletKaliLPN, LPN]

I agree with Atl-Murse, BSN.

I understand the idea of wanting to help people end their struggle with addiction. I hope this is where you are coming from, a place of love and not judgement. Unfortunately, you cannot police everyone or save them from themselves. Do the best you can to give care and treat pain, and the rest is not on your conscience.

[SmilingBluEyes]

As a nurse, if you have a role, it's to educate and then let this be the issue between patient and prescriber. End of story. No moral judgments or attempts to police others, please, just do your job within your scope.

[FineAgain]

whether it be patients getting their fix from an ED doc, a hospitalist, a primary care or pain clinic practitioner or a street heroin dealer

And I am none of these things...I am a nurse. I can educate but if a med is prescribed, I give it. When I dropped the judgement, I felt better. I cannot change people in an ED visit.

[traumaRUs, MSN, APRN]

I'm a prescriber and I do educate when I prescribe. I don't write narcotic scripts without a lot of thought. However, my patients are sicker then ever, they get discharged sooner then ever and with more pain then ever before because we do incredibly invasive procedures to pts and then send them home.

So...I try to temper my script-writing with caution but I'm also cognizant that my pts have pain and need relief.

[KatieMI, BSN, MSN, RN]

When I was working in ICU, I mostly followed the path of "being the only nurse". Luckily for me, my current area permits much more freedom.

When I establish strong enough conract with the patient AND family, I routinely ask about their goals for pain control. Ridiculously, many of them realize that 100% freedom of pain is not realistic, and many more are concerned about addiction. We are encouraged to discuss such concerns with RRT, PT/OT and even SLP. The plans are routinely made so that patients would not be medicated at the point where they are better be awake and make efforts to participate in therapies. "Premedication" with acetaminophen-containing oral meds for therapy -related pain works much better than "emergency" relief from dilaudid when it is already 10/10. We use and teach many pain-relieving techniques and teach families to use them if they feel comfortable. I made my own fairy tale about gate theory of pain and give talks if it is appropriate. We also have to encourage proper pain relief when families demonstrate denial by refusing proper pain management for their clearly dying loved ones.

It really helps to have a knowlegeable and enthusiastic pharmacy team to support our efforts and made everyone informed and, again, knowlegeable about opioids effects and "opioids weaning". The process is always not straightforward (that I tell patients right away so that they do not feel like they must stop cold turkey or fail) but with time we often enough can stop escalation and see requirements slowly go down. Not all nurses like to do it, and some still go the way of "my job is to follow orders". But at least nobody prevents me and the majority of nurses there to practice what is perfectly within our scope. No more write-ups for me for teaching FBM patient "hot-cold" technique because it "interferes with customer satisfaction".

It is still a rare event in LTACH to see a guy who was brought in on vent and begging for dilaudid every hour walking out of there breathing, speaking and just popping accidental Norco. But it does happen. It really does.

And yes, judgement got to be dropped. It is, ultimately, their choice, not mine.

[NurseGirl525, ASN, RN]

Just a point to consider, even addicts experience pain. Especially say, after a major surgery.

It is not your job to judge and decide who are addicts and who is in pain. Pain is subjective. What we do in the hospital does not turn them into addicts. Administering pain medication within the appropriate parameters does not turn someone into an instant addict. They are not with us long enough. It's the repeated 30 day scripts that get them addicted.

[Sour Lemon]

Administering pain medication within the appropriate parameters does not turn someone into an instant addict. They are not with us long enough. It's the repeated 30 day scripts that get them addicted.

You'd be surprised. Some people are more susceptible than others.

[KatieMI, BSN, MSN, RN]

It is not your job to judge and decide who are addicts and who is in pain. Pain is subjective. What we do in the hospital does not turn them into addicts. Administering pain medication within the appropriate parameters does not turn someone into an instant addict. They are not with us long enough. It's the repeated 30 day scripts that get them addicted.

Some of them stay long enough. Some stay frequent enough. Some of them are more susceptible. And some experience opioid-induced pain, which, in turn, is dutifully treated by more opioids because it is "subjective".

And yes, I consider it to be part of my job to figure out where, how, etc. exactly they hurting and what approximately the cause might be. Otherwise, I would continue to jump about like crazy on every mention of "my chest hurts", even when it sure hurts after a good breathing exercise session and everything it worth is my wholehearthly praise about job well done and getting rid of that trache gets a bit closer. Plus an icee and my talk with RRT to use some TLC with poor old soul. And maybe Lido patch.

[Here.I.Stand, BSN, RN]

Meh, personally I'd rather err on the side of "contributing to the addiction epidemic" than err on the side of letting someone suffer. Besides, the stuff I see in my practice makes this a moot point; addicts and non-addicts all are going to require pretty hefty pain control when they've had injuries that land them in a level trauma ICU.