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?
I wasn't trying to start another one of those pain rating debates that's been rehashed ad nauseam on this site. I'm sorry if people read what I wrote as judgmental or as if I was looking to "police" my patients, that's certainly not where I'm coming from. It's not that I'm scrutinizing my patients and judging them when they have a high pain rating or impressive tolerance level. I fully realize that many of you are going to think I'm simply incredibly naive, but I truly want to help.
That said, I don't think advice to "drop the judgment" and just go with it is helpful. It's not a judgment call to recognize that we have an addiction problem; it's fact. We have a huge, nationwide public health issue here and I don't see how we as healthcare professionals and as a nation can get it under control if everyone simply decides to stick to the status quo.
This is an issue very close to my heart; I've watched people very close to me struggle with addiction firsthand. Please believe me when I say that I know that none of us are going to "fix" someone in the course of one visit. I may be idealistic, but I'm not an idiot. The discussion I was trying to start, and the advice I'm looking for, is what can we as bedside nurses do here? I realize that the options are extremely limited, but I refuse to believe that "nothing, mind your own business" is the answer.
The already-addicted patient has to want help. Denying them pain medication isn't going to snap them out of addiction (and as a recovering alcoholic, I feel like I can speak personally to this), but it is going to make the rest of your shift miserable. I am not certain what else you can do for this patient population other than perhaps making sure they are appropriately taking their pain pills and not fiddling with their IV access, bringing in street drugs, etc etc.
I love all the thoughtful posts on how to approach pain management in opiate naive or early users. You can make a difference with this patient population!
Specializes in Family Medicine, Tele/Cardiac, Camp.
This is an issue very close to my heart; I've watched people very close to me struggle with addiction firsthand. Please believe me when I say that I know that none of us are going to "fix" someone in the course of one visit... The discussion I was trying to start, and the advice I'm looking for, is what can we as bedside nurses do here?
I don't know you personally, but I wonder if you might benefit from attending an Al-Anon meeting for family and friends of alcoholics (and drug addicts too, really). Sometimes those of us who have experienced addiction first hand through a loved one tend to believe we have a greater influence on people than we actually do. I know that when I first entered nursing I had a difficult time separating myself from some of my patients and believing that there comes a point at which we no longer have an effect on their choices. Just a thought.
Educating yourself more on addiction may also help you to understand more where this patient population is coming from and be able to help them at the bedside while still maintaining a healthy level of detachment.
And educating both yourself and your patients on different methods of pain relief (PT, yoga, TENS units, imagery, acupuncture, massage, etc) may also make a difference - at least to those who haven't tried them yet and are open to the idea.
I certainly see the opiate epidemic in my practice and am continuously in search of alternate methods of pain relief for my patients.
OP, I don't think you sounded judgemental in your post. To me your concerns sounded reasonable, your questions sound and information seeking. I think you received some of responses due to fatigue with a common question seen on this site often stated from a judgmental perspective.
With all due respect, unless you have education/training/experience in addiction counselling, withdrawal, treatment, etc, have authorization from your facility, & the patient specifically requests your help with their issues, you're not really qualified to deal with patients addicted to opioids (or other substances for that matter). Addiction and treatment is a VERY VERY complex issue and not one to be addressed in an acute care setting. As nurses, our job is to treat the pain as reported by the patient according to the orders written (and to obtain orders if they are not sufficient to control the patient's pain level). It's not our job to save the world, solve the addiction crisis, or to fix every issue in our patient's lives. And ultimately, a vast majority of those patients do not want you to save them! They are in your facility for surgery or illness and that is what they want taken care of. The rest of their problems are none of your business.
I DO understand though, being a nurse there is a natural instinct to want to educate and help people -- but our role in their lives is very limited for the most part.
Another side of the "you can help with the naive user" aspect:
I was surprised recently to my reaction to taking a narcotic for pain after a dental procedure. I have a fairly high pain tolerance I guess and tend not to take a lot pain meds -- often turning them down when they are offered. But a few months ago, I had some dental work after which the pain was exceptional and I had to go back to the dentist and ask for some help dealing with the pain as the first thing he gave me (can't remember what) wasn't working at all. The dentist did a little more work to improve things in my mouth and gave me hydrocodone: 10 pills.
Fortunately, the extra work in my mouth fixed the situation. But I still needed the hydrocone for the rest of that day and the next. I took a total of 4 pills over those 2 days. Boy did they make me feel good! Not only did they relieve the pain, but they made me feel great and happy. That didn't surprise me. What surprised me was that after only those 4 pills of hydrocodone (plus the 10 pills of the lesser stuff I had taken first), I felt myself craving them for a couple of weeks.
It really was a craving and I can easily imagine how someone who still felt physically uncomfortable and who was not fully aware of the dangers of even a few narcotics could have finished that bottle of 10 pills unnecessarily and asked for more ... and then more ... etc. I was surprised to feel that urge form them even though the pain problem was resolved.
I am happy to report that I still have the remaining 6 pills and didn't give into that craving -- but that's because I knew how dangerous that would be. I stopped craving them after only a couple of weeks ... but that was after very few pills for a very legitimate reason. The experience made me wonder how many people become addicted from such seemingly minor, legitimate uses. We can all help by educating our patients, friends, and families about the need to be careful with even such seemingly low-risk situational use.
I think there is still a place for the bedside nurse to evaluate whether orders are appropriate. The doctors do rely on us regarding these medication and daily management issues; we are still the ones who are with the patient all day. In particular, nurses are the ones more likely to notice if there is an anxiety component to the patient's pain and something to reduce anxiety might result in reduced use of narcotics. Sometimes also different doctors, even on the same team, will add something to the patient's PRNs and before you know it the patient has five different orders for pain medication, piling narcotics on top of each other. The nurse might be the one who has to point that out.
When we're with patients we can consider, is there something else that might help this patient's pain? Could adding an NSAID, a sleeping pill, a muscle relaxant control the pain better than narcotics alone? I've had quite a few patients that have unused non-narcotics in their PRN list because nurses have gotten in the habit of just giving the oxycodone or vicodin the patient asks for, with perhaps a little IV for breakthrough. I see two opposite staffing patterns that can influence this--one when the same two nurses pass the patient back and forth for six shifts and there's never a new set of eyes; the other when the patient gets a new nurse every four hours all day long, mostly float nurses and travelers, and a nurse with the expertise for that floor and patient group never evaluates the patient's plan to see if any changes are needed.
(I don't mean any disrespect--I am a float nurse and I have been a traveler, and patients' care plans fall apart when they constantly have the treading-water nurses. I always advocate for patients to have a nurse from their floor at least one shift of every day.)
It IS a big problem, obviously, and although efforts are being made to address it, I don't think there's a lot we as nurses can do about it, because as you say, we're not the ones writing the Rx's.
Not directly related to this problem, but also with Xanax or any other significant PRN meds, I've always had a 'don't drug 'em up unless we really need to' thought process about it. Yes, we all have those patients who want stuff all the time, but besides them, I try to be a little reserved about how quickly & how often I give strong pain & behavior-related meds.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I also know and love addicts but my boundaries are clear. I think yours are blurred. I agree with the advice to seek guidance and information from groups like al-anon and narc-anon. You have to be careful not to superimpose your experiences on your patients' experiences. I think you have a problem with that.
Just wanted to say thanks for all of the thoughtful responses ... even if I don't necessarily agree with everything, I appreciate reading everyone's different perspectives. You've all given me some great advice and lots to think about :)
Specializes in ER, ICU/CCU, Open Heart OR Recovery, Etc.
Another side of the "you can help with the naive user" aspect:
I was surprised recently to my reaction to taking a narcotic for pain after a dental procedure. I have a fairly high pain tolerance I guess and tend not to take a lot pain meds -- often turning them down when they are offered. But a few months ago, I had some dental work after which the pain was exceptional and I had to go back to the dentist and ask for some help dealing with the pain as the first thing he gave me (can't remember what) wasn't working at all. The dentist did a little more work to improve things in my mouth and gave me hydrocodone: 10 pills.
Fortunately, the extra work in my mouth fixed the situation. But I still needed the hydrocone for the rest of that day and the next. I took a total of 4 pills over those 2 days. Boy did they make me feel good! Not only did they relieve the pain, but they made me feel great and happy. That didn't surprise me. What surprised me was that after only those 4 pills of hydrocodone (plus the 10 pills of the lesser stuff I had taken first), I felt myself craving them for a couple of weeks.
It really was a craving and I can easily imagine how someone who still felt physically uncomfortable and who was not fully aware of the dangers of even a few narcotics could have finished that bottle of 10 pills unnecessarily and asked for more ... and then more ... etc. I was surprised to feel that urge form them even though the pain problem was resolved.
I am happy to report that I still have the remaining 6 pills and didn't give into that craving -- but that's because I knew how dangerous that would be. I stopped craving them after only a couple of weeks ... but that was after very few pills for a very legitimate reason. The experience made me wonder how many people become addicted from such seemingly minor, legitimate uses. We can all help by educating our patients, friends, and families about the need to be careful with even such seemingly low-risk situational use.
Low risk situational use can indeed escalate, very quickly. I learned this through personal experience.
This issue is truly a sticky wicket, one that is larger than any and all of us and is deeply rooted in so many areas of public and healthcare policy. As a nation, we have tended to swing from one extreme to another in this area. What I have not seen is common sense evidence based policy that doesn't involve some kind of moralistic viewpoints in the background, or isn't tied to the judicial/criminal justice system. We don't have a proactive policy when it comes to proper pain management, it is typically reactive and geared towards symptom control, rather than holistically dealing with the point of origin of pain itself and treating the whole patient.
My plan of care would be geared towards individualization of that care. Individualizing my interventions based on history, present illness or injury, and where the patient is going after the present situation is resolved. If a patient might be receptive to education about addiction, I might start a conversation; I'm also going to involve the prescribing provider and others involved with their care. If they aren't, or it doesn't seem appropriate, I treat the pain.
In short, I look for opportunities to find other interventions, but also realize that the people who say they have pain, do deserve pain relief, and if my job is to administer that pain relief then that's that.
The discussion I was trying to start, and the advice I'm looking for, is what can we as bedside nurses do here? I realize that the options are extremely limited, but I refuse to believe that "nothing, mind your own business" is the answer.
Ever the optimist, I believe that many of the "mind your own business"-styled responses are coming from folks who could have written your exact post years ago, but have since come to terms with their limited scope of impact. It doesn't mean they're happy with it. In fact, I'd say that's where a touch of the snarkiness comes in. They're telling you the way they wish they'd been told early on. They might hate the situation but recognize the need to steal away from a place of emotional vulnerability, much as we do in so many other areas. Of course this theory is not reflective of everyone posting above - perhaps I'm off altogether - but that's where I'm operating from.
Being health care professionals, I like to think we have a somewhat deeper level of understanding of this scourge than the non-clinical layperson. The curse is that even with this knowledge, we're markedly limited in our ability to help solve it. At this point, I think a small dose of education might be our key weapon. Nothing heavy duty, mind you (unless, of course, it is sought). Just as with the most hopeless efforts in cessation of tobacco, etoh, or [insert substance] abuse, one small comment about risk or rescue might actually be absorbed at a critical moment and potentially change the course of someone's struggle. Usually not, but remember... we miss 100% of the shots we don't take.
ScientistSalarian
207 Posts
Hmm sorry if I didn't explain myself clearly...
I wasn't trying to start another one of those pain rating debates that's been rehashed ad nauseam on this site. I'm sorry if people read what I wrote as judgmental or as if I was looking to "police" my patients, that's certainly not where I'm coming from. It's not that I'm scrutinizing my patients and judging them when they have a high pain rating or impressive tolerance level. I fully realize that many of you are going to think I'm simply incredibly naive, but I truly want to help.
That said, I don't think advice to "drop the judgment" and just go with it is helpful. It's not a judgment call to recognize that we have an addiction problem; it's fact. We have a huge, nationwide public health issue here and I don't see how we as healthcare professionals and as a nation can get it under control if everyone simply decides to stick to the status quo.
This is an issue very close to my heart; I've watched people very close to me struggle with addiction firsthand. Please believe me when I say that I know that none of us are going to "fix" someone in the course of one visit. I may be idealistic, but I'm not an idiot. The discussion I was trying to start, and the advice I'm looking for, is what can we as bedside nurses do here? I realize that the options are extremely limited, but I refuse to believe that "nothing, mind your own business" is the answer.