Drug seeking patients

[Art_Vandelay]

The patient had a history of drug seeking behavior, but he also had a cardiac history and was taking cardiac meds.

So, one day he presents to me with c/o chest pain on the left side of his chest that is not radiating anywhere. Vitals are taken and all are WNL. He says he has had heart attacks before, but none felt like this and he "wasn't sure" so he "wanted to tell" me. He has no other symptoms. Assessment is normal. My gut tells me over and over he is lying. I give him ordered PO narcs and call the doctor and ask for a callback. He has no nitro ordered. The doctor doesn't call me back right away and the patient presents to me again, stating "it's radiating to my neck now." I call 911. The paramedics arrive and assess him and --what a shock!-- their assessment findings are all WNL. And voila!, his pain is not radiating to his neck anymore. Oh, and he is not sure about his pain location now, it might be in his ribs. "I told you I wasn't sure." Meanwhile, the paramedics are looking at me like, "Why did you call us? This patient is perfectly fine." Nevertheless, by this point I had talked to the doc and received the order to send the patient to the ER. I am still so irritated about it. I knew the patient was lying from the start, but I didn't trust myself. And here I am looking like the fool. It makes me so resentful toward these types of patients!!!!!! Just wondering how other nurses would have handled the situation...

Oh, and by the way, the patient came back that day with EKG and labs normal. Gasp!

[usalsfyre]

Why? In what other regards do we ignore objective information, and only go with the pt's report? Wouldn't you give narcan to an obvious overdose, despite the pt having denied using narcs? Or would you say, "the pt's drug use is what he says it is. It's not up to me to decide."

Probably wouldn't give Narcan to anyone conscious enough to tell me they hadn't taken narcotics.....

Or- regarding pain- an elderly pt has an obvious mechanism for pain. He is wincing, grimacing, tachy. He denies pain. You know he has had a bad experience with narcs- maybe somebody pushed some Dilaudid too fast. Woupdn't you push the issue a bit to encourage effecive pain relief? Or would you base your actions on the "pain is what the patient says"? IE disbelieve the p's pain claim.

You can encourage all you want. The patient has a right to refuse pain control if they want to, just make sure you give them TRULY informed consent.

Stoic LOL in obvious severe pain rates it 3/10. A guy takes a break from eating his pizza and texting his GF o tell you his pain is still 10/10 even after the Dilaudid. Who gets treated first?

The guy rating it 10/10. Is it right, probably not.

From your signature, I see you are a hospice nurse. I support your aggressive treatment of pain in hospice patients, and understand that pain is an individualized experience, impossible for another to fully assess.

(bolding mine)

Why just hospice patients? Patient's who aren't dying don't deserve relief? What you said about pain is true across the board, not just in terminal patients.

But..... I disagree with "the pain is what the pt says it is". Where does this come from? People lie all the time about all kinds of things. Drug addicts- or people who just like getting high- lie about drug use and pain.

Why do you care? Are you planning on treating their addiction right there?

My assessment includes subjective (what they say) and objective (what I see/feel/hear etc.) data. This goes for ortho, respiratory, pain, whatever.

So pain isn't "an individualized experience, impossible for another to fully assess"? Or do you just like to think you know better than the patient?

I do my assessmnet, communicate it to the provider, and follow my orders. If a pt is ordered PRN, and complains of pain, i give the med. If I have a dose range, and I think they are in pain, I will start low, and titrate to maximize pain relief, and minimize side effects. This is the LOL with the broken hip. The guy who is on his call bell at the exact time of his prn, who always rates his pain 10/10? The guy who is eating and holding a normal conversation when you are outside the room, but all of a sudden is wincing and can barely speak when I come in? He gets the full ordered dose. Save both of us a bunch of time and effort, allows me to move on with my moe important tasks.

And to the OP: You did the right thing.

Do the LOL a favor. Learn what appropriate narc dosing is and start there. Too many times "starting low" is way to low a dose of opiates. As far as just giving the patient what they want, bravo. There's no reason to leave someone complaining of pain in it, whether you think it's real or not.

[ajhill00]

I really wish there were no drug seekers. Their abuse of the system makes it hard on everyone, the nurse, the doctor and especially patients that legitimately need pain relief. Plus, with their history of drug seeking behavior, it makes it hard to assess a real problem vs. a fake one.

I think you did the right thing, better to be safe than sorry. If he was having a heart attack and you didn't call 911, it could have been a much worse outcome.

[Guest219794]

Look up "pseudo-addiction".

I won't go into the ins and outs of "drug seeking" vs labeling pts as such. Run a search on the term ... there are a jillion threads on the subject.

It's not a simple situation.

I agree 100%. It isn't simple. Hence my objection to the phrase "pain is what the patient says". I believe it is a gross oversimplification of a complex issue.

FWIW- I understand the behaviors that undertreatment of pain can cause. pseudo-addiction refers to a set of behaviors that is frequenly nisinterpreted. I also understand how ignorance of this phenomenon can result in inadequate treatment of legitmate pain concerns. Inadequate treatment of pain has multiple adverse effects. That is why I think that a nurse should use all of his/her assesment skills.

Also- regardng the term "drugseeker". I work in an ER where the term is frequently used. I don't use it, and don't find it helpful.

[AJPV]

Why would you be upset for being "tricked" into sending the pt to the ER? It's the pt's bill in the end. More job security for the ER staff & revenue for the hospital.

[Up2nogood RN, RN]

Why would you be upset for being "tricked" into sending the pt to the ER? It's the pt's bill in the end. More job security for the ER staff & revenue for the hospital.

These types of pts rarely have health insurance. It's a misuse of the health system, a drain on staff, it raises insurance premiums for you and me just to name a few.

I'm not trying to generalize as a lot of pts do have legitimate CP and some pts who don't have CP do have insurance.

We were informed at my hospital that for the identified pts who routinely visit our ED with fake symptoms will now only be offered narcotics and phenergan in suppository form with no exceptions unless testing indicates a valid health issue.

Apparently management has just found out that word is on the street that our hospital is easy to get IV drugs from in a pinch.

[AJPV]

I honestly wonder, the pts might not mind too much if it's in suppository form. As long as they get their hit, they might not care.

[Up2nogood RN, RN]

I honestly wonder, the pts might not mind too much if it's in suppository form. As long as they get their hit, they might not care.

If they're regular IV users and/or have chronic pain the amount of drug in a suppository won't even touch them. They hopefully will most likely move on to another hospital so the ED can devote their time to those who really need it.

In reply to the OP, I know it's frustrating but like someone else said, I know I would be horrified if I didn't treat CP and found out later the pt had a cardiac event.

[Mrs. SnowStormRN, RN]

I really dislike the "drug seeking" label, only because people are often mislabeled and because we are human it affects the way we think about the patient. If someone says theyre in pain, theyre in pain. Some people suffer from chronic pain, and tolerate it - while others get a scratch and its the end of the world (pain is subjective, because we cant feel what they feel. Just because they arent grimacing doesnt mean they arent in pain). If the EKG shows nothing, doesnt mean he wasnt having chest pain. I just dont like labels, it just seems so judgemental. That just my opinion.

[Samantha79]

"But..... I disagree with "the pain is what the pt says it is". Where does this come from? People lie all the time about all kinds of things. Drug addicts- or people who just like getting high- lie about drug use and pain."

I am a current nursing student and "Pain is what the patient says it is" is what is currently being taught regarding pain. People handle pain differently and you may not always see outward signs of how much that patient is hurting. I really don't think it's our job to decide for the patient how much pain they are in. I wouldn't want a nurse deciding for me that I'm not in pain because I'm not breathing fast enough or have a fast enough HR. I know when I am in pain.

I haven't had to deal with drug seekers, yet, but until there are better guides in place for handling them I will follow prescribed orders. Just because someone is drug seeking and a frequent flyer doesn't mean that they aren't actually in pain THIS time. I'm not a mind reader or psychic, and even though I may "assume" they just want to get high, I have no actual evidence of that unless the pt states "I just want to get high."

Just my $.02

[wannaB RN]

This is how I look at it:

5. Drug seeking is a choice...it all starts out by partying or taking pills that are not prescribed to you (in 99% of the cases), that is another reason, why I could care less if these people get their "fix" or not.

quote]

What about the people who had surgery and was given a narc for pain. Then one day, after taking the narc's for over a month, they missed a dosage and realized their body is indeed addicted to it. I've heard many cases of this happening, addicted through prescription. So, NO it doesn't ALL start out by partying or taking pills that are not prescribed.. in some cases the pills are prescribed to that person. Keep your mind open and realize that some addicts did not chose to be addicted.

[Up2nogood RN, RN]

This is how I look at it:

*snip*

5. Drug seeking is a choice...it all starts out by partying or taking pills that are not prescribed to you (in 99% of the cases), that is another reason, why I could care less if these people get their "fix" or not

*snip*

This is not the case 99% of the time. I'd love to see the research on this. Many people with addictions start out with valid health issues.

"Drug-seeking" pts most likely don't feel as they have a *choice*, they need drugs to function. I wish there was more of our tax $ devoted to tx instead of MD's just handing out Rx's.

[heron, ASN, RN]

Dealing with addictive behaviors in a textbook is very different from facing it over and over again on the job.

The exasperated, angry and cynical posts I read about "drug seekers" are a normal response to being manipulated. It's easy to get pulled into the contest over whether the junky gets his fix.

The misuse of EMS is a big part of the problem, as is management's delusion that pt. satisfaction scores has anything to do with quality of care.

There are some places taking measures to curb the use of EDs to feed drug habits: pharmacy data bases to spot prescription abuse, strict narc policies, billing or even filing criminal charges for misuse of ambulance services.

I fully believe that there needs to be a forum similar to al-anon for nurses dealing with drug abusers - we're the ones taking it on the chin day after day. Ignoring the damage done by this is setting us up for precisely the kind of polarization we see over and over in these threads.

It is not our pts' job to take care of our feelings ... and that's what power struggles over whether a pt is "really" in pain is really about, IMHO.