Drug seeking patients

  1. 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!
    Last edit by Art_Vandelay on May 12, '11
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    About Art_Vandelay

    Joined: Dec '10; Posts: 468; Likes: 824

    39 Comments

  3. by   BabyLady
    This is how I look at it:

    1. I don't prescribe, I just dispense.

    2. It's my job to communicate my concerns to the physician.

    3. It is the physician's job to make that judgment call.

    4. If I were the physician, no way would I screw around with anyone, drug-seeker or not, that has a cardiac history. There are many, many people that have atypical symptoms and the pain doesn't always radiate...it is well documented.

    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.

    At the end of the day, you have to ask yourself if you are willing to put your job at risk by "refusing" to dispense ordered meds..unless you are, seriously, I would cease to worry about these people. They will ALWAYS be around hospitals and clinics...unless they change the laws, protect yourself, not them.
  4. by   Hospice Nurse LPN
    Quote from BabyLady
    This is how I look at it:

    1. I don't prescribe, I just dispense.

    2. It's my job to communicate my concerns to the physician.

    3. It is the physician's job to make that judgment call.

    4. If I were the physician, no way would I screw around with anyone, drug-seeker or not, that has a cardiac history. There are many, many people that have atypical symptoms and the pain doesn't always radiate...it is well documented.

    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.

    At the end of the day, you have to ask yourself if you are willing to put your job at risk by "refusing" to dispense ordered meds..unless you are, seriously, I would cease to worry about these people. They will ALWAYS be around hospitals and clinics...unless they change the laws, protect yourself, not them.

    I just want to add that a pts pain is what they say it is. It's not up to me to decide if they have pain or not and what the intensity of the pain is.
  5. by   GreyGull
    Quote from aNaders_RN
    Oh, and by the way, the patient came back that day with EKG and labs normal. Gasp!
    You did not know this when the patient presented to you.

    Remember a Paramedic can not tell for sure either since they do not do labs and one EKG may not show everything especially if you do not have a previous one for comparison or correlation with labs if it is a NSTEMI.
  6. by   Art_Vandelay
    I think my original post came across wrong. I have no problem administering narcs regardless of drug seeking history. It is not my position to judge if I came across that way. My irritation was with the patient's faking of cardiac symptoms in order to be transferred to the hospital for IV narcs. It just made me feel like a fool because he was manipulating and I knew it.
  7. by   Freedom42
    No one looks like a fool for erring on the side of caution. If you'd ignored his symptoms and he actually did have an MI, then you'd look like a fool.
  8. by   Double-Helix
    It is definately frustrating to feel like you are ignoring other patients to help someone that doesn't actually seem to need help. It's the same feeling when you have one stable patient who constantly rings for ice cream, another drink, another blanket, etc...

    You did the right thing by addressing his complaints as though they were legitimate. You have to follow protocol and cover all the bases no matter what. There is always the "what-if" factor. However, you are certainly entitled to vent afterward.
  9. by   Whispera
    How would you have felt if you had gone with your gut feeling and he, indeed, was having an MI? Sometimes our experiences with other patients flow over onto current ones and sometimes our feelings are incorrect.

    I have to add that if a patient is seeking drugs, there's a reason he wants them besides putting one over on caregivers or just for the fun of it. Ideally someone would get to the bottom of it and work to make the problem better, whatever it is...
  10. by   CareteamRN70
    I feel for you and understand some of your frustrations. I have a pt with respiratory problems that puts on a grand show at the start of my shift.

    He likes to pile up his PRN narcs. First ten minutes he complains of cough and asks for his prn cough syrup with codeine. Ten minutes after that he complains of dyspnea and wants his prn sublingual morphine. Ten minutes after that he complains of back pain rated 10 and wants his oxycontin.

    I always have to check the MARS and previous nurse report closely because he tries to do the same thing about half an hour before my shift starts hoping, I guess, he can get dosed again before his 4-6 hour alloted dosage schedule (depending on narc).

    My solution, which doesnt apply to all pts by any means, was to point out to the MD that this happens every night at 12AM. She dc'd most of the prn narcs, changed them to set schedule dosage at 12AM, and lowered the strength of PRN pain narcs.

    I don't deny my pt had pain or breathing difficulty, but it is frustrating to watch him put on a huge show of pain and coughing, then 2 minutes after he gets his narcs he is smiling, feet up on the bedside table telling me now to go find him a soda and something to eat with absolutely no symptoms of pain at all.

    All I can do is educate the pt on his medicines, his dosage schedules, and try non-narcotic interventions as a first line attempt (and boy does he hate those). But I figure the MD knows their orders, I feel responsible enough to check and follow them or ask for clarification when needed, and bottom line the pt's pain is what he says it is and as long as I have educated him and tried non-narc attempts first I have done right. At the end of the night afterwall I am not an substance abuse nurse.

    Now, you want to really get me started..its not the drug seeking pts that get me..it's the pts that are undertreated for pain who won't ask for anything or even if they do the MD just won't prescribe anything stronger then tylenol.
  11. by   Up2nogood RN
    You should have informed your pt of the new protocol for all pts who present with CP- an enema. He most likely would not have CP anymore.
  12. by   hherrn
    Quote from Hospice Nurse LPN
    I just want to add that a pts pain is what they say it is. It's not up to me to decide if they have pain or not and what the intensity of the pain is.

    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."

    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.

    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?

    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.

    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.

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

    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.
  13. by   heron
    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.
  14. by   usalsfyre
    Quote from hherrn
    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.....

    Quote from hherrn
    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.

    Quote from hherrn
    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.

    Quote from hherrn
    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.

    Quote from hherrn
    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?

    Quote from hherrn
    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?

    Quote from hherrn
    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.

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