LTC Drug Addicts

fab4fan · Jun 17, 2003

Originally posted by kathi yudin
my last reply went to the wrong thread i think.. anyway.. it was said earlier that the residents are in long term care and are going to die anyway.. i agree with this but to a point.. the patient in question is only 67 y/o.. she still has a long time to live.. i also have chronic back pain... i went through the chymopapane injection yrs ago that failed.. i have 2 discs in my neck.. one at t2 and one at l5.. so ... i know pain.. i didn't work for yrs. because of it.. now.. i work as don at a long term care facility... i do understand pain.. we do pain management and do it well.. however.. 67 is toooo young... to be so addicted.. she needs help to control the pain.. to live with it and deal with it... let her control the pain rather then the other way round.. i am in pain daily.. right now my hips are killing me.. but.. i KNOW that i can't work if i use anything.. so.. i deal with it.. we need to work with our residents to help them through the tough times... psych is a good start..

People have a right to good pain control; if that means judicious use of opioids, then so be it. Sixty-seven is also a young age to condemn someone to days of unending pain.

For some people, "pain mgmt" means "learning how to suck it up and live with the pain." This is not true, and good pain mgmt professionals will be the first to say so. It is contrary to all of the current pain mgmt literature/information. I'm not even going to get into the "addiction" comment...addiction rarely happens when there is pain, and there is plenty of research to back that up.

It saddens me when I see comments like the ones quoted. It just goes to show that there are still a lot of nurses and doctors out there who need re-education on this issue. We cannot allow our personal prejudices to influence our care.

cargal · Jun 17, 2003

"I guess my biggest part of the post was wondering why doctors just accomodate these requests and not give her a pain patch then? "

My understanding from a hospice perspective on the patch is that they are expensive, difficult to titrate and may be more appropriate for some patients who are home care and have a difficult time understanding administration and dosing of other meds. MS contin is cheaper and better, easier to titrate and therefore more appropriate if there are no MSO4 allergies. Oxycontin is expensive. As a pharmacist told us recently, "it is neither unethical or unrealistic to examine the cost of pain medication when considering an appropriate drug."

Blessings,

gizzy76 · Jun 18, 2003

Thanks again for the great replies...I've worked with this woman more over the past week and have tried to open my mind more to her needs and issues. In fact, I even approached her yesterday in regards to a duragesic patch. She said that it was discussed with her doctor previously and he felt it would not be suitable for her in controlling her pain. I left it at that. She also said that her nightly 1 mg injection of morphine is sufficient to control her breakthru pain until 0500hrs when her 40mg of oxycontin is due.

Hate to do it...but I have to throw this in, in regards to this woman...

Some of our residents help fold the facecloths that come back in a sack from laundry. She was asked the other night if she would mind to help and she got all snotty and said,

"No, I'm NOT doing that, I'M retired!" And she was completely serious.

Some people are too much. Personally, I would have enjoyed the change of routine from sitting in my lounge chair continually watching television all day.

BillArnold1961 · Jun 18, 2003

We have a couple of residents like the one that you described and two of them are

angelbear · Jun 18, 2003

If I were retired and me or my insurance were paying for LTC I'd be danged if I'd fold laundry either. I am only 35 and I have already had my fill of folding laundry. The lounge chair and tv sound pretty dang good to me. I hope by the time I need LTC they have internet and I can still use it. That is what I am addicted to. And by the way if anyone cares I work 3rd shift and I would shoot you if you tried to make me get ready for bed at 6p or even 11p. When the time comes I do not want to be a 3rd or 1st shift get up I want 2nd to get me up. See what I mean? They have to conform their entire lives around LTC enviro. I say cut them some slack wherever possible. Hopping down off my soap box.

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · Jun 18, 2003

Originally posted by angelbear
... I hope by the time I need LTC they have internet and I can still use it. That is what I am addicted to. ...

My husband's grandmother is in a nursing home and wasn't I quite pleased that I saw that the facility is wired for internet. Each sunroom had a computer that any resident could use. There also is a computer room that had about 20 computers in it too.

Then they also had all there residents sitting in the hallway all lined up in their wheelchairs waiting for nothing. I hate that, but that is another thread.

ktwlpn, LPN · Jun 18, 2003

Originally posted by moonshadeau
My husband's grandmother is in a nursing home and wasn't I quite pleased that I saw that the facility is wired for internet. Each sunroom had a computer that any resident could use. There also is a computer room that had about 20 computers in it too.

Then they also had all there residents sitting in the hallway all lined up in their wheelchairs waiting for nothing. I hate that, but that is another thread.

We have many residents that sit in the hall in front of the nurse's station also-for various reasons.Approx 10 want to be there and most of the rest join them because they do not want to be alone...We purposely sit about 8 there daily for close observation-unless there is an activity going then we can not leave them in any of the other sitting rooms on the unit-too many falls and fisticuffs...In a perfect world we would have scheduled activities from 10 am until 8 pm 7 days a week -but I don't see that happening anytime soon...I also agree about folding laundry-I ,too am looking forward to NEVER doing another load-perhaps next time you can ask her to join the group just for the company-and offer everyone a cold drink,cup of tea or coffee...I think that maybe the staff now just do not like her-no matter what she says or does.....But we don't have to like our patients to give them the treatment that they deserve.(that's a good thing-I have known plenty that I would not SPIT on if they were on fire)BUt I gave them good care........

BillArnold1961 · Jun 21, 2003

I agree with angelbear, if the nursing home has an internet hookup, I'll be no problem to anyone....and also, they better not wake me up period, I'll get up on my own!!

pappyRN · Jun 22, 2003

Hello All,

What a great thread! Many points were made on which I'd like to offer my opinion.

I, too am a chronic pain patient from an ojt injury lifting a small patient on a vent. It has now been 8 years since my life completely changed and mostly NOT for the better. It's a long and complicated history of RSD-CRPS/TOS/DDD/DJD/CTS/TMJ/OA/GERD/IBS/FMS/CFIDS/MPS/POTS/AI/SI joint dysfunction, bursitis rt shoulder, bilat. trochanteric bursitis, rt brachial neuritis, rt femoral neuritis and possible SLE so you see why I won't get into my own complicated hx to explain why I require pain management.

I was thinking about some of the things that the staff finds offensive about this patient. I hope I can speak to some of them. I also have some comments regarding her physician.

In regards to her medication. I can tell you for sure that in almost all instances oxycontin and ms contin do NOT provide adequate pain coverage for twelve hrs. As a matter of fact the pharmaceutical house of Purdue -Frederick is being taken to task for an explanation and/or solution to this very real problem. It is way closer to 7-8 hours that is the duration of these 'contin' meds. It is not at all unusual to experience nausea, sweating, etc. when either of these drug levels start falling. It is becoming more the norm for patients to have their dosing changed to every EIGHT hours to avoid this situation. I know from my own experiences. It is a reason why many on this med every 12 hrs are calling for a prn probably around 7-10 hrs after the dose was given. It is also indicative of the patient clearly being UNDERmedicated with their maintenace med. The dose of her maintenace med should be adjusted to either give it q8 hrs or increase the q 12 hr dose. It would be much better for the pt if a q8h dosing was initiated. IMHO, it is extremely likely that she is requesting her 4pm med before the med nurse goes to the dining room for a med pass, because she is experiencing this med level drop off and taking a prn is just enough to both relieve her breakthru pain and prevent the withdrawal symptoms from physical tolerance. In addition, she very likely knows that by the time the dining room med pass is done she will have to wait for at least an hour before they can get to her. That would just be a behavior she learned from being a resident. When you are in pain the minutes seem like hours and if you also have very little to occupy your time for distraction, 1hr may seem eternal to her. It is also a behavior that alerts to the very real probability of "clock watching" which can happen when a pts meds are not adjusted to provide continuous, steady state coverage. These drop- offs may be what's making her request her meds on a rigid schedule. That's why it is so important that a pt' s maintenance dose is adequate and that it has been adjusted to accommodate for tolerance to the dose especially if it hasn't been adjusted in quite some time.

Someone said that it was also likely that she is aware of the staff's attitude about her. How right you are! I'm not even in an LTC and I have been on the hind end of attitude, opinions, intolerance etc. It is SO easy to tell when someone is not pleased with you. I am positive that she has endured not only "the look" from the staff, but has also overheard them.

In an attempt to try and 'get into her head' I was thinking about possible scenarios. I appreciate that a few may seem far-fetched but still they can be possibilities. I'm just trying to be devil's advocate for a while. In regards to her looking away when meds are brought to her and to her behaviors in general,

maybe she looks away for several reasons: she doesn't want to see "the look", she is about to cry and doesn't want you to see it, she tells stories because she feels she has to justify her need for the medication- it may have taken her so long to get her pain treated that she feels she has to have a story to legitimize her request, she may just be a drama queen with a flair to convince-her stories may seem perfectly plausible to her, maybe she feels guilty for needing them, maybe she fears appearing weak, she may be a rapid metabolizer and her level drops off because of it,she is proud and hates what her life has come to and on top of that she knows that staff doesn't approve of her need for her meds, and how about she may be AFRAID of what has happened to her, the staff is too busy to take the time to get to know her, it is humiliating to her to have to depend on everyone else to get her meds, the bedtime injection makes her drowsy more quickly and is just enough to fall asleep and therefore possibly not needing additional meds until her morning dose, maybe she is also afraid that her need for all this medication means she is addicted and she is worrying about that possibility because no one has taken the time to explain physical tolerance , pseudoaddiction from not being medicated either enough or undermedicated-withdrawal-TRUE addiction-and she starts feeling the withdrawal symptoms when the level drops off and that completely scares her that she is an addict, AND 100 other possibilities! I just think that it is important to realize that things like this situation can be very complex. It may have taken her YEARS to get to the point where anyone even remotely believes her about her pain for whatever reason including her spoiled child personality, so she is going to hang onto whatever relief she can get.

The possibilities are ENDLESS but I believe that it is most likely that she is experiencing level dropoffs and therefore pseudoaddiction AND that it is probable that her scenario is a combination of many instances that I listed. One other thing I should mention, don't forget about the stigmas from her era about addiction when you ponder behaviors. Pride was a big issue back then and one strived not to do anything that could potentially embarrass their family or themselves and that too, may be an explanation if she is afraid of her need for pain meds. This could also be as simple as her doctor has never sat down with her and discussed the goals and intricacies of pain management as we know it today. It is more likely that he has had a simple and quick patroninzing discussion with her and doesn't want to take the time to help her understand these goals and he just wants to order her meds with little or no discussion. He, too, may mistakenly believe that she is very near the end of her life-however 67 is young by many standards. Try approaching the physician in a non threatening wasy so he doesn't immediately get defensive about this sensitive subject. Ask him to tell you about Mrs.X in order to better care for her. Decide that someone is going to work with her on getting her to open up and establish an atmosphere of trust and communication. Who knows when you get through that outer shell she may be a very pleasant woman to you. Does she have family or friends that visit her?

I can not say it strongly enough- do NOT judge a person's pain by their outward appearance or on whether they are laughing etc. NO one with chronic pain has the energy to cry continuously for the rest of their lives. I have remarkable abilities to hide the fact that I am in pain. You see, when I have cried or grimaced etc. I get just as much flack and stupid comments like "suck it up. You are a strong person. You don't need to take pain pills. You just have to learn to live with this etc." So, you are darned if you do and darned if you don't. One person puts you down for crying and the other puts you down for NOT crying. What's the answer? BELIEVE the patient when they say they have pain. I try very hard not to cry because it is too energy draining but also because it makes my eyes swell and itch, my nose gets stuffy and I have to mouth breathe and I get a headache.

Have someone volunteer to take the time to get to know this patient. Give her a chance instead of taking the easy way out by giving her the pain meds and then rip on her behind her back and sometimes inexcusably within earshot of being overheard by her. Wouldn't you be afraid if your fate was to be dependent on people that you KNEW disapproved of you and your need for pain meds? I think it would be frightening to wonder what was going to happen to you when you realized they think you are a fraud AND have the power to withhold your meds from you. No wonder she wants to isolate herself. Perhaps she's also afraid that the staff will embarrass her in the dining room in front of all the other residents. Perhaps someone already has and that's what started her wanting to eat in her room. Could it be that looking at others in the same or even worse shape makes her afraid that she really is getting old although maybe inside she doesn't feel that way? Maybe it bothers her to be eating around others who look so old and sick and who have to be fed or cry out. And maybe she simply enjoys eating alone! I can think of numerous reasons and possibilities that could be going on in her head. Why should she have to suffer when we are perfectly capable of relieving her pain except for the attitude and/or lack of knowledge about pain management from the staff that she is PAYING to take care of her? She expects to be taken care of. That is where her money is going.She has the right to expect good care. She is not a prisoner and it is a violation of her rights to refuse her request to take her meals in the privacy of her room unless she has a condition that renders her a choking hazard. Remember, this is her HOME. Would you be happy if someone came into your home but wouldn't let you eat there and made you go to the neighbor's house for your meals? Would it be acceptable for you to be forced to have meals in your home with people you didn't even know except in passing? That's what it is like for those confined in an LTC. I don't care what is done in regards to decor, it would NEVER be like home for me or my Mom.

Every time I visit my Mom in the LTC where she is existing, I hear of yet another thing that was either denied or withheld from her. Things like-"you can NOT go to bed before 7pm in the evening. You HAVE to wait up until 6pm OR If we lay you down for a nap you HAVE to stay in bed for two hours!" So, she stays up in her w/c from 3pm until at least 8pm with NO change in position and she lays in BED crying because she wants to get up but knows they WON'T get her up since it is under two hours! This is done despite the reassurance from the admin and DON that she can NOT be forced to nap any longer than she wants and that she can retire for the evening at an hour of her choosing while understanding that she may have to wait a few minutes until her CNA is available.

I think one of the best ways to approach a subject in order to better understqnd is to think of how you would feel if she was YOUR Grandmother or Mother and the staff treated her the way you say they treated this woman with chronic pain. Shame on them if they are guilty of being so quick to judge. Until you have walked a mile in someone's shoes remember this may be one of THEM one day who has to put up with living every day of their lives maybe even several times per day, surrounded by people they know don't care for them or that accuse them falsely without proof. And why? Because of the misfortune to be dealing with chronic pain. I wonder if they have ANY idea what it feels like to be in burning pain so bad that they could barely stand to move or even wear clothes because it hurts to wear them? Are they aware of what it feels like to feel like they are on fire from a simple gentle breeze blowing across their arm or leg or wherever the pattern of pain is? How about imagining they are 85 years old andhaving to sit in a w/c for HOURS(6am-1pm) with NO change in position? All this is while they are made to sit on the hip that was fractured under their CNA's care because of her carelessness in giving appropriate care to a 85 y/o post CVA hemiplegic.

That's what it is like for my Mom.

I cry every time I see her and every time I have to leave her there. The administrator is psycho and the DON is her DAUGHTER! It is pointless to attend family care conferences. IT is all a bunch of lies to satisfy some need on paper. They are chronically understaffed. The owner thinks the administrator walks on water.

My sister and I pray every night that my Mom will pass peacefully in her sleep and this will all be over for her.

Can I understand about this woman in pain? Yes, but more than I ever wish I had to.

This was a great thread and in no way meant to be directed at you personally. I have been a pain long enough to try and get in this lady's head. While no one really can but her, I think I can get reasonably close.

Warm personal regards,

PappyRN

gizzy76 · Jun 22, 2003

thank you very much Pappy...you have opened my eyes even more to this situation...this woman's doctor is on an extended vacation right now and the doctor filling in for him has not even taken the time to see this woman at all in the past 6 months. I do plan on speaking with her doctor once he returns next month. Like I said before, I am trying to be more understanding of this woman. It's just so hard sometimes. My mother lives with fibromyalgia and always has different aches and pains and ailments. I'll admit that I may be slightly biased because of this...I am definitely trying to be more open though...It's a learning process for me...

I thank you again for your post...

kids · Jun 22, 2003

Wonderful post Pappy, you have raised some very good points.

nrw350 · Jun 22, 2003

Sounds like if I was in LTC, that I would want Pappy as my nurse lol! WAY TO GO PAPPY!