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 have had 14 surgeries, 3 of which were back surgeries where the pain was so bad beforehand that I wanted to die. I find right after surgery I require a lot of pain meds but after about 3 days I can almost completely stop them with no issues. I was on large doses of hydrocodone before my first back surgery for a few months and a month after that one but had no trouble getting off of them when the pain finally stopped. My husband had his knee replaced and was on pain meds for 3 months and then went through an awful physical and emotional withdrawal that lasted about 5 days including suicide ideation. It was terrible to watch. He will not take any pain meds any more after that, besides the fact that there are random drug tests at his workplace, he never wants to go through that again. That just shows you the difference between people and their reactions.
I have had nurses hold pain meds until the 4 hour time limit even with the Doctor telling her to go get it and give it 30 minutes early. I have encountered many nurses talking about drug seeking patients. I have friends addicted due to chronic pain. We give them these meds knowing their bodies will be addicted in a few days and then send them home without telling them how to stop. Now, we just stop giving them the pills and some people start the withdrawal process without help. Luckily for my husband I was there to make sure he didn't hurt himself. We need to find a way to help them but as nurses on the floor, we need to give the meds and offer as much education as possible.
"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."
Personally, I don't see this as an opioid problem. I see it as a mental health problem. Our society does not have the ability to cope with life anymore - and yes, this is a very generalized statement. While I appreciate that access to the meds does increase its use, saying that having a lot of drugs around is what causes addiction is like saying that the gun violence happening right now is because too many people have guns. It is happening because people do not know how to handle their frustrations.
Thank you for defending yourself! I read in between the lines, understood, respected, and knew what your meaning was. It is ironic that the ones telling you about judging are judging you. But then, that is our world these days: not reading for comprehension and jumping to conclusions in order to admonish instead of listening and attempting to understand.
I didn't infer judgement from the original post. It's a tough question that many of us at bedside (and lots of other places as nurses) must confront on a routine basis. Thank you to all you wonderful nurses who continue to ask and wrestle with these questions. I love nurses. Nurses are awesome people.
For me, one of the hardest parts of bedside nursing at the zoo (can I get an "amen?"), is staying present in the moment, while being pulled in 5 different directions (all seemingly important). For me and my practice, staying present is what it often comes down to. Caring, for me, is a moment to moment choice to make. I qualify that because my patients are individuals. I consider one of the most important things I do is to establish and maintain rapport with them. Sure, I work hard on staying current on best practice so I can offer the best science and info at the time (it doesn't hurt that I'm a nerd when it comes to that stuff), but I know there's a better chance that info will have some sort of impact if there's rapport. The adage "people do not care what you know till they know that you care" resonates with me. It's so easy to get caught in the machine (even if only momentarily) and become one of the cogs, or make our patients one of the cogs, in an algorithm.
Some of my best connects with patients have been when I say "I'm sorry," and confess to them that I do not know what they are feeling. When I explain that I am not an authority on their pain and ask them to be a part of the struggle of how to intervene for them (can you tell I'm a holistic nurse lol?). When I manage to be present, and care, what I say and how I act never seems to be the same from person to person. I look to connect to them by exploring their source of pain ​with them. That's not always something that can be identified, by us or the patient. But for me, caring to help that individual where they are currently at is what I want to do... and often fail at, but I never want to stop trying.
You are a nurse. It is your job to follow the orders of the physician and administer the pain medication as ordered. Unless there is a medication error or giving the medicine at that time is contraindicated, you are to administer it when the patient needs it and as ordered. We are not the morals police and we are not lawmakers. Fixing the addiction problem lies with prescribes, their patients, and unfortunately, lawmakers... Not you.
Specializes in PICC, ONC, Ed, Peds, Public Health.
This issue begins and ends with three things; the prescriber, the pharmacy and the insurance (if insured). I have seen patients in many settings, being a rounding nurse for many facilities, and notice trends like "Doctor shopping". Just recently, I was at a local hospital conducting reviews of patients that have been seen frequently for the same illness. I had one patient that I encountered briefly that was there for "neuromuscular pain management". Looked briefly into it and just nodded it off. That same week, a different facility, a different provider and a different day. This same patient was in the ED for "back ache" resulting from a "fall from bed while getting up". I recognized this patient and became curious as to what's going on.
As my right and contractual agreement with my facilities, I can chose when, who and where I can speak to my patients that are my cases or are cases in my dept. I looked her information up after approval from my medical director and was floored to see what I just uncovered.
This lady, was going to a low income clinic and paying cash (remember folks, cash talks for healthcare!). No remarks made about her seeing FIVE ADDITIONAL PROVIDERS!
Further investigation lead me to the DEA portal, as many probably know where doctors send in scripts that cannot be called in or per policy of facility. This lady was using a fake name at the "cash-clinic" as we call it in administration. She was receiving Benzos, Roxy, Oxy, Hydro--- at an amount so large and high dosed, she could easy put all of the Midwest in a nice sleep! Furthermore, the pain management center prescribed FENTANLY TD patches!
Fastforward, my medical director and I looked into how this is happening and stopping it immediately by contacting the DEA to put a strict look into this. Well, low and behold he patient was insured, in fact she held a great job as a public service member and has a great career (so why would one be putting themselves into this situation?!).
Here's how we found the issue, which is actually how about 70% of all drug related issues are carried out:
Patient X visits ER or Primary c/o pain (documents how incident occurred, injury and all that jazz). Patient X finds that "well one Percocet don't do the job, so I take one more to just give it a 'kick'". Patient X then becomes dependent on this drug to function. (Throw yourself back to Parma class and how these abused drugs build up tolerance and thus body becoming dependent on that drug because of that drug is stopped they will go through with drawls which could have a potential to be fatal)
So, Patient X visits primary or ER because "the pain is just so bad it unbearable". ER- push drugs, send them out. Not a blink of an eye unless your providers know these frequent flyers or the tell-all-signs of an addict. Primary doctor says "well let's see what's causing the pain so let's refer you to ortho" (maybe a higher dose is rx'd) and they're out the door.
Patient X then goes to ortho. Patient X tells ortho doc "oh my pain is so bad I had these pills I cannot remember what they were but they helped a lot". Ortho rx's ANOTHER narcotic. (We are at three scripts now and not one flagged raised)
Patient then goes to urgent care or "cash clinic" because they don't run insurance. Patient is seen for "chronic pain" and "was on Percocet for this pain back in the day and it worked well". Doc okays ANOTHER rx.
(by now the patient is well versed how her insurance goes through to the pharmacy, so tells every doc a different pharmacy so no insurance has record or physician or pharmacists).
Patient X has 4 scripts right now for extremely addicting and dangerous medications.
Patient X has script #1: From ED for med X for pain, maybe a refill or two depending on how nice the attending is. Uses pharmacy A; insurance not on file since was in ER.
Patient X has script #2: From PCP for med X for "pain", probably 3-12 refills; depending again on provider. Uses pharmacy B; insurance probably on file when office has proof of it so pharmacy can get it approved before patient arrives.
Patient X has script #3: From Ortho for med X for the referral for "pain", again, probably 3-12 refills. Uses Pharmacy C; POSSIBLY insurance sent with script, but regardless, insurance sees it as different provider, different diagnosis and different time submitted.
Patient X has script #4: From "Cash clinic" or Urgent care. No insurance used; paid the 40 buck for the visit, mid-level provider gives script and sends patient X out the door. Uses Pharmacy D: the script is ran through, asked if have insurance, patient X declines and pays cash.
This all happens over a span of less than a month. Add those scripts up. 4 scripts, maybe a mix of Percocet or Hydrocodone or maybe more intense drugs. Also, maybe they complained of other ailments at appointments and they're carrying 2,3,4 scripts of a different class of controlled substance rx.
Meanwhile, providers are not communicating because there's abivous signs of missing events that providers simply cannot and do not have time to link. Insurance catches some, but like I said, different place, time, diagnosis and provider.
Pharmacies are not communicating because they don't know, they're not affiliated to one another and/or they are using outdated ways to conduct business; which is the sole source of the medications that are causing this
epidemic.
Solution? Simple: We have the technology to transmit information via the Internet and have had that technology. Why are we not using a system that tracks this behavior? While that is one solution; having ONE portal to send scripts to the pharmacy attached to the patients info and can flag multiple scripts of the same medicine and allow Doctor to Doctor conversation about such flags.
The above is just one simple way we can dramatically reduce the number of addiction to dangerous mediciations.
While we have this epidemic, we now have the issue with providers that are scared to even give a script for a simple 10 tabs of 5/325 Hydrocodone-Acetaminophen for that patient that REALLY hurt themselves. Providers are scared they are going to be "that Doctor" that put "that patient" in a downward spiral of addiction to those medications.
The main key to this, as well as any problem in healthcare, if you SEE something that DOES NOT seem right, SPEAK UP! In the same breath though, don't ASSUME or jump to conclusions about a certain patient or their behavior! (mom always said, "assuming makes and ASS out of U & ME * smile and read those capital letters (; *
Again, this epidemic is something that can be stopped. We need to stop it. I've seen 10 year olds in the ED that have OD'd "trying" these pills for "fun" and when asked where they got it, answers from parents cabinets to friends to they're getting it from a dealer..... This needs to end. As a medical professional; make sure to ALWAYS use your best judgment and usually that 'gut feeling', is right more than not. Remember your ethical teaching and ways to practice. Working together will help tremendously, starting with the first step: COMMUNICATION!
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.
My husband is 31, and has had a life full of injuries, culminating in a car wreck that has pretty much left him disabled from working. Unfortunately, he got to experience part of the problem with narcotics that this country has.
When he had the accident, he was given 3 days of hydrocodone and methocarbamol from the ED, and told to follow up with a primary. He didn't have one, so we made him an appointment and established a primary physician. She would do nothing for him for pain other than refer to pain management. He also had chronic migraines, and she apparently thinks pain management manages those too. It was a colossal waste of money. He didn't want to be on opioids, really just wanted to know what was wrong, and fix it. He also really wanted to find non-opioid options for his pain control. The MD didn't seem to know what to do, other than refer him. The pain management MD didn't care to do anything besides handing out hydrocodone, 180/month, and ignore all input we gave on side effects, constipation issues, etc. We asked if gabapentin could help. He tried it for a month, at a very low dose. It helped but not a lot... so he didn't prescribe any more. Nobody tried to offer anything like Voltaren gel, or lidocaine patches for his back pain; just hydrocodone. Questions regarding preventative meds for reducing migraines, got nothing. After three months of the pain management MD ignoring our feedback, by husband blew up at him for not listening, and the doc offered to do some steroid injections in his back. Of course, by this time, there was no way he trusted the doc. So he never fill his last script, never went back, and lost hope in pain management in general. He pretty much just takes nothing now, and just hurts all the time instead. Some days he can't even wash dishes or do any chores around the house.
He is doing much better now, almost two years since the accident, but it is really sad that everyone he tried to get help from, either seemed to not take him seriously because he is "young" and therefore can't possibly be in pain, or must be an addict, and it is really sad that primary md's aren't knowledgeable about non-opioid options.
"The discussion I was trying to start, and the advice I'm looking for, is what can we as bedside nurses do here?"
Believe it or not, the answer for most nursing positions (especially for the acute care/hospital based nurses) the answer is just that...nothing. Relapses happen, and they are most likely instigated by acute illness or injury. This is something that is beyond your control.
Addiction is a long term, mental illness that makes permanent changes in the brain and there is nothing that you can do to change that, especially when the patient is recovering from surgery or injury. We, as nurses, want to do everything we can for our patients and I get that. However, addiction treatment takes a whole lot longer than we floor nurses have and needs to be approached when the client has the social supports to take on that life long commitment.
Well, one thing I do that has helped is to use FLACC pain scale, not "give me a number". I hate the numeric pain scale. Another thing I do is when I hand over opiate prescriptions I blatantly tell the patients: 'this is an opiate pain medication, which is addictive.'
If you want to know about the degree of your complicity in the drug epidemic, the best people to ask are the people to whom you supply drugs. The problem is that they can't be honest with you, and still meet their needs. They are however, honest with each other- even on public forums.
This is an old collection of quotes/links. Some of the links are bad, but were good when I got them.
I heard some stories people go into the Emergency room and say something like. i have been moving big things. shoving heavy gravel and tossing it being my back and now my back in going into spasms.
and they got a small shot dose shot of demeral and a small script of vicodin.
Ive never had insurance in years... anyone got any ideas on things to ***** to doctors and possibly get a one script of vicodin? because they cant bet too hard to get right. one year...i got an infected swollen tonsil after antibiotics they gave me 25 vikes and i woulda been find with out them. i have been through all more pain than that tonsil and got by fine..
we all know it's very difficult to walk in to a doc you've never seen before and talk your way into a script for pk's... almost impossible for some people... myself included... but i have discovered an EASY, GUARANTEED way to get them...
OK, i've been reading different threads, and hearing "oh, i just left the ER with 60 dilaudid" etc etc. So, I've hit a couple spots to try and score some good drugs, and all i end up with is hydro, or codeine. I'm at a point where I'm about to not have any insurance for a little while, and I want to try one more time. (Sorry if this post ****** anyone off, but hey, I'm a junkie and I'm just trying to maintain.)
So, my question to anyone who might have some advice is: What should i tell the doc? Will fake kidney pain/stones work well if i drip some blood in my urine sample? Should i just go for bad neck/shoulder pain? My original horrible toothache story obviously isn't working. What are some good "unprovable" ailments that will get me some legit opies? Thanks in advance to any advice.
I urinated in a cup and afterwards pricked my finger and let a few droplets of blood mix with the ****... I was still expecting nothing and was expecting disappointment
That IV dilaudid every two hours is what popped my curiosity cherry about IV opiates. It was after that I tried shooting for the first time. Just a friendly warning.
Everytime dude needs $50 for this or $100 for that I keep telling him, "go get some happy pills from the hospital and flip 'em and use the money to pay your bills.
I am a DOCTOR shopper and i get narcotics from a million doctors by faking back pain and kidney stones...i just filled 20 lortab today....two days ago i got two shots of INTRAVENOUS dilaudid...what a rush!!! AND he gave me 30 extra strength 10mg percocets!!
You have to use different pharmacies that are not linked by a database. CVS and Walgreens are linked. Most grocery stores are linked. I cant find one dr to prescribe me pain meds so its not an issue anymore but in the past, my Every day DR was prescribing me and my pain management dr was prescribing me as well. I just used Walgreens with my insurance for one and Target claiming to have no insurance and paid cash. Their databases were not linked. Never use insurance if you are going to go to more than 1 place. A month of Hyd is like $22 at Target so its not like its expensive to not use insurance.
Accolay
345 Posts
I think this article does a nice job.
Who Is Responsible for the Pain-Pill Epidemic? - The New Yorker
Money, Over prescribing, Subjective pain scales, Quick Fix/society/first world problems and the expectation that pain should be 0/10 all the time.