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?

[NightNerd, MSN, RN]

I'm in the camp of, "They have to want it." We can certainly educate and encourage our patients, but anything further than that is going to be met with a buttload of resistance (that's a precise measurement, buttload). Two of my immediate family members are recovering addicts, and during inpatient stays, whether related to their drug use or not, I could see the intentions of well meaning healthcare professionals going to waste because they simply weren't in a place to hear it.

I think do think we have the opportunity to assess when patients are in that more receptive state of mind and act on it, encouraging them to do the best they can by themselves and connecting them with resources to get clean. I won't go into detail, but this week I've seen two patients with stuff going on in their lives that put them in a place to listen and receive help. It's on them to take it, but right now it's looking hopeful for them. A month, a year, a decade ago, this may not have been the case. Sometimes there is a lot of waiting involved in helping our patients with these issues, and I think that's okay.

Again, from a family member's perspective, I was just always weirdly grateful when my loved ones were in the hospital. I knew they were safe and that someone was looking out for them for at least a short period of time. Don't underestimate how much that can mean to someone. Sometimes the kindness you show, competely unrelated to someone's mental or emotional condition, can truly make all the difference down the line.

[elkpark]

I'm a long-time psych nurse. I remember, early in my career, being v. much a "true believer." When people came to the med window wanting their prn Ativan or Xanax, I'd put a lot of effort into trying to convince them to try alternative, nonpharmacologic interventions, offer to work with them on breathing exercises, meditation, the whole ball of wax, before they took the pill. People were rarely interested. They just wanted the pill and the "quick fix." Over time, I came to realize that, for most of the people with whom I work, a few Valium or Xanax, or Norco or Lortab, more or less is just spitting in the ocean. It doesn't make any difference in the long run. They're going to do what they want to do. I will still spare no effort in trying to help people who want help. But I've quit wasting time and effort, more than required for my job, on the others.

[Kooky Korky, BSN, RN]

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.

Just want to say I didn't perceive you as behind judgmental.

Wish I had some answers or suggestions.

When my friend was quitting smoking and craved tobacco, I used to tell him to "smoke the next one". In other words, wait 15 or 20 minutes and not smoke one right now, but smoke the one that would have been after the wait. During the wait, the craving would usually stop, so he didn't smoke then either. Pretty soon, he was able to go longer and longer between smokes and actually went indefinitely. So, decision on the part of the one doing the quitting was necessary, plus my encouragement helped. In the waiting interim, the craving was usually lost.

Thank you for caring. Don't let the critical cynics get you down. Keep brainstorming. Maybe ask the pt what would help?

[Serhilda, ADN, RN]

This is something I think about a lot since both of my parents were like that. Heroin addicts resorting to opioid abuse whenever possible. I remember being resentful of nurses as a child because unlike the previous posters, even at that age I could see how the nurses were directly involved in their addiction. It's pretty obvious. Objecting to being part of that process isn't "judgement" or policing anyone's behavior, that's absolute nonsense that undermines the seriousness of the issue at hand. Their addictions have huge repercussions on everyone around them and society as a whole. People have every right to want to avoid contributing to that. Once someone's choice begins to harm others, it becomes everyone's business.

However, as an adult now, I see how nurses truly have their hands tied. Also, it's a bigger problem than you alone can control. My pharmacology professor addressed this and it sort of helped me feel relieved of any responsibility in enabling them. She mentioned that their addiction will eventually be addressed, but just not here and not now. They'll be referred elsewhere for help with their addiction and for right now it's merely our job to deliver drugs even if it's obvious the patient isn't in the degree of pain they say they are.

I'm just a nursing student right now so I don't know if this will eventually bother me too but for now, it's put my concerns to rest. Hope that helps some.

[whichone'spink, BSN, RN]

I used to feel somewhat dirty when I worked ER and the floor, giving narcotics to known and suspected addicts. But it was the path of least resistance. Last thing I need to deal with are patient complaints and aggressive behavior after I tell them we are weaning them from IV narcotics. Now as a PACU nurse, I have a different set of frustrations. Those that take narcotics on a chronic basis take a lot of IV narcotics post op to get their pain under control. It's a major pain in the ass. Makes me want to shoot the providers that got them hooked on narcotics in the first place.

[Shortcake_BSn]

I don't think that you were being judgmental at all. I actually left the hospital for this very reason. I worked on a unit of a hospital where the majority of the population of patients were drug seeking. I wasn't being judgmental or acting as a member of the moral police, but it was draining on me from the nursing aspect of it. The hospital where I worked at had pain reassessments that had to be done (1 hr after PO admin and 30 mins after IV admin). When you have four patients that are getting 4mg of dilaudid IV q3H and you have to pain reassessment, that's already two hours taken out of a 12 hr shift. Keep in mind these patients want the med as soon as it's due (some even set their phone alarms for the next time that it's due). It's extra documentation on top of what you're already documenting and, on top of everything else that you have to do. That alone makes me wary of narcotic administration.

[BostonFNP, APRN]

As a prescriber, I do feel like I am part of the problem (all people who prescribe narcotics should). I also hope I am part of the solution, or at least I try to be.

First and foremost, I follow all of the federal and state recommendations for opioid prescribing which includes discussing/documenting potential side effects including physiologic and psychologic dependence, single-prescriber-single pharmacy, reviewing the prescription monitoring database at each visit, concurrent therapy, periodic testing and random testing, attempts to taper the dose to the lowest possible effective dose, etc.

Second, I have candid discussions with patients prior to writing a script that includes mention that it is my job to do what I think is best for them even if it is not what they think is best and often that means tapering off and discontinuing medication. I ensure they know it is for short-term use only.

Third, I don't prescribe opioids for more than 7 days without objective evidence of the etiology. I don't continue other providers scripts without repeat tesing.

Fourth, I don't prescribe opioids chronically for younger patients (under 40) for non-oncologic pain.

Fifth, I refer all patients for evaluation with a pain specialist prior to chronic opioid management (longer than 6 weeks).

I still feel part of the problem after all these efforts to avoid inappropriate prescribing. To be honest, all it does it ruin my day most of the time to get into debates with patients about these meds and I often wish I didn't prescribe them at all. I wouldn't if it weren't for the patients I know need the medication to survive because there is no other option.

That being said, if I am attending a patient in the hospital and I write orders for an opioid, I don't expect the RN taking care of the patient to insert themselves into the issue by not giving the medication as ordered, without an objective concern.

[Krzysztof]

As a prescriber, I do feel like I am part of the problem (all people who prescribe narcotics should). I also hope I am part of the solution, or at least I try to be.

It was very interesting to read about your parameters and requirements. I hope a good percentage of prescribers handle opioid management with such care and attention to detail. Thanks for sharing.

[vampiregirl, BSN, RN]

As a hospice nurse, pain management is huge for me. Concerns about addiction are not a primary concern.

However, as a hospice nurse I do believe I have certain responsibilities related to the question posed by the OP. Yes, pain is what the patient reports it as but there are also other considerations.

First, a good patient assessment is important. I also observe for non-verbal s/sx (although sometimes these can not be 100% accurate). I also consider the etiology of the pain. Sometimes if someone is having pain, the initial response is to throw more medication (typically narcotics) at it. But different types of pain respond better to specific types of medication, which can include NSAIDS, benzodiazepines, antidepressants, and steroids. If I suspect that one of these would benefit my patient, I have that discussion with the provider.

Also, exploring the patient's goals related to pain. Some patients want the pain under control no matter what the side effects. Otheres want to be more alert so they can interact w/ family/ friends. Others just want better pain control at night so they can get good quality sleep. There are some patients who are addicted and/or trying to medicate for other reasons; listening to what the patient is saying can give clues to this. And understanding that if someone is addicted, if they are experiencing pain they may require higher doses to truly address the pain.

Non-pharmalogical interventions can also help tremendously - positioning, application of warm compresses, massage. I've gotten PT evals for my patients occasionally as they have some really great recommendations.

And the importance of education cannot be undervalued. Sometimes patients aren't aware that if they take the medication earlier versus waiting until the pain is intolerable allows pain to be managed w/ smaller amounts of medication. Also making sure the patient understands their pain control regimen. Morphine IR versus morphine ER for example. Identifying a clear regimen for the medication and reporting when interventions are not effective so it can be addressed.

Lastly, educating patients to their responsibilities. Logs of use and pill counts are sometimes implemented with clear explanations of the consequences if discrepancies arise. Sometimes just knowing that there is accountability and consequences can prevent issues. And keeping the lines of communication open with the patient. I've been surprised a few times about what patient's have told me, but if they know a caregiver will listen respectfully you can get the info you need.

[toomuchbaloney]

Americans consume more opiates than all other countries combined.

We spend more money on pharmaceuticals than any other country.

Our health outcomes are not anywhere near the top.

Why?

[Guest219794]

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?

Lots. You are an integral part of both the supply and demand.

How can I do my part to, if not help solve it, at least not make it worse?

Honestly, not much. At least not as a nurse. You could continue your education and prescribe responsibly, or get into the addiction field. You can vote for politicians who might effect policy change, like moving away from this "customer satisfaction" nonsense.

What's my role in all of this?

Huge. You often introduce susceptible people to their first dose. You then help keep them supplied, even when it's obvious they are lying to get narcotics.

Sorry to put a negative spin on this. I am an ER nurse in a hospital that has both psych and rehab services. I regularly supply addicts and abusers with narcotics. I advocate for what I believe is in my patients best interests, then do whatever is ordered. I do it professionally, and go on with my day.

The narcotic situation in this country is absurd and getting worse. The current "reform" efforts are a joke, and doomed to fail. Asking what an individual nurse can do about drug addiction is like the guy who drives the Budweiser truck asking what he can do about the alcohol problem.

[Axgrinder]

Here is something to consider: There is no Pain-O-Meter 5000 out there to unequivocally and irrevocably prove any pain rating given by a pt. Your eyes tell you "resting comfortably" when in fact the pt has been raised to be stoic and is also experiencing significant pain. How can you tell the difference? Not everyone will cry, gnash their teeth, or wail loudly while enduring pain.

My mother (God rest her soul) suffered horrible, wicked chronic pain for years. She'd smile, and never complain - but behind closed doors in the privacy of her bedroom she often wept softly from pain during flares. For the most part her pain was fairly well managed, but not always. And she never went to the ER during those flares - she always toughed it out at home. Until the day she died, my mother never, ever let on how much she suffered, especially to strangers.

Something else to ponder: Someone has chronic pain, and takes routine pain meds Q D (say 1 vicodin TID) for years. Then this pt has to have surgery - naturally the usual post-op pain regime won't be effective to control that person's pain. It's just the laws of nature.

We've all experienced pt's whom very likely were drug seeking once to many, many times during our careers depending on how long we've worked. But there are also those whom you just don't know about for sure. Is it really fair to treat all pt's claiming pain the same because of the pt's whom abuse it?

Based on my personal experience with my mother (stoic to a fault, and private to boot) I'd rather err on the side of caution than let someone suffer. If they are inpatient, they wouldn't be my concern forever anyway. I also view it in such a way as if their blood glucose was 500, I wouldn't quibble about administering regular insulin according to a sliding scale.

Pain is unfortunately a way of life for many people. I'm not the jury or the judge in those cases, and thankfully it's not my place to be. And obviously, no two pt's are alike.

I pray to God with the draconian mind set of pain management - particularly chronic pain - in the present culture that I, or someone else I love never, ever have to experience it either. I'm keeping my fingers crossed in any case.