Prescription pain meds and their abuse by pt's.

P_RN, ADN, RN · Apr 21, 2002

Frankly as long as a patient says they are in pain and needs their pain medicine I will give it to them. We do not prescribe, we do not dispense, we ADMINISTER. It is not up to me to make that judgement.

This has been discussed here many, many times . This is one thread from exactly one year ago.

https://allnurses.com/forums/showthread.php?s=&threadid=7225&highlight=drug+seek%2A

Stormy62 · Apr 21, 2002

I agree we do not prescribe or dispense. I will check out the link you mentioned. Thank you for posting it. But you are missing my point. I will try to explain using an example.

Say I am a 30 y/o f with chronic back pain. MRI shows no evidence of herniation and is in fact WNL. I am on Oxycontin BID. I received a prescription for 60 Oxycontin on Monday. Friday I return to the doctor wanting an early refill (I should have used 10 of those 60 Oxy but am out)...i tell you, the nurse that I "lost them" or that a friend spent the night and "stole" them....you get my meaning here.

I KNOW i am not the one making the decision to prescribe or dispense. That wasn't my question. I want to know how you deal internally with the emotions or feelings you have about the patients blatent abuse and lies.

Fgr8Out · Apr 22, 2002

I'm with P_RN, Stormy. For some reason, Nurses continue to allow themselves to feel like they are being manipulated, "played", taken advantage of, etc... when dealing with a patient whose pain is apparently not being well managed.

Tolerance to medications can and does happen. And opioids do not have a ceiling like other forms of pain medications. Also, there are some types of pain that just have a hard time being treated, including neuropathy.

How do YOU deal with your emotions and feelings in these situations? You let it go... you remind yourself of the alternatives you're offering to the patient, and realized that ultimately it is the Patient who has to make the decision... assuming the Physician doesn't step in and just stop refilling the Rx. Nothing good is accomplished with your emotions, and in fact, it can be detrimental for you.

It's good you're concerned about the amount of narcotics your patient is taking, but as nurses we need to stop feeling like we can control our patients any better than we can control anything else.

Peace:)

Stormy62 · Apr 22, 2002

Lori,

You made a very good point. You are right. Other than offering alternatives, the patients abuse of the medication is not anything I can control. My job is to be sure the patient is informed of pain relief measures including alternatives to opiod therapy- not to control their chosen method of pain control....thank you both for your input.

NICU_Nurse, BSN, RN · Apr 22, 2002

My husband began suffering from back pain about two years ago. It was unbearable for him, he could not sit or lie down; the only way to temporarily alleviate it was by walking (he ended up losing his job, but that's another story). He went to two different orthopedists who told him the same thing- they didn't see anything wrong. He was turned down by the HMO for an MRI (yet another story- fricking hmo's...) but they took numerous xrays and swore that it was nothing. After suffering for four months and crying every night, with me having to help him bathe and dress and sit and stand and walk and even wipe his butt on the toilet for him because he couldn't reach his arms backwards, they finally began a trial of epidurals. After a lumbar puncture and three epidurals, still nothing. This whole time he was on Vicodin and Percocet, alternating between the two at the doctor's whimsy. They would give him a prescription for, say, twenty pills PRN that were supposed to be taken 1-2 q4 AS NEEDED. He would run out in three days-4 days, max. Sometimes he was taking two pills q4 all day long trying to maintain even a smidge of relief, and let me tell you, those pills barely took the edge off. Even though he was medicated fully, he would still be grimacing with every breath and sweating like a dog when he moved. Excruciating pain. I would call the office and beg them for another prescription or a refill and they would be SHOCKED and in DISBELIEF that he was running out so fast. Oh, sir, those are PRN- you only take them when you absolutely HAVE to. Hello, people, didn't we take a lecture in school on therapeutic med levels????? It was horrible. Once they refused to give him any more because they said they could get in legal trouble (snicker) and claimed he was addicted to the medication and not in actual pain. Well, I took two hours to get him up and dressed and we hobbled his weeping ass right on in the office and made them look him in the eye and dared them to deny him medication one more time. It never happened again, thank God. However, he suffered immense pain making that trip and it was, in my opinion, completely unnecessary. Now, he never claimed to have 'lost' the pills- we told them straight out he had taken every last one of them. Only when we petitioned the HMO did he get an MRI and guess what? Oh, now we see it, haha, whoops, you have a degenerative disc condition and no cartilidge between four of your lumbar vertebrae and whoops, what's that sliver of bone poking out there into your spinal column? Didn't see that on the X-Ray, haha, sorry. I am a nurse. I am there to ensure that my patients are pain free and comfortable, or at least as comfortable as possible, while they are in my care. I don't care if they even have a history of poly-drug abuse; they wouldn't be hospitalized if there wasn't something wrong. While they are in my charge, drug hx be damned, because I will medicate at the first time I see even a hint of pain. I will not wait until my patient is crying before I take action. Proactive medication does wonders. Easier to maintain a therapeutic level in the bloodstream, enables patients to participate in physical activity more easily, helps them to HEAL FASTER because being in pain wreaks havoc on your immune system. My LAST concern is contributing to an addiction; it is a concern, but not the most important one. In my opinion, anyway. :>P

Oh, something else I thought of. I have a friend who's father just died of lung cancer. He had a number of bottles of all types of pain relief, Ativan patches, you name it, in the medicine cabinet. She walked in to the bathroom one morning and caught her sister, who had snuck in the house unannounced, stealing pills from each bottle and sticking them in her pants pocket. Having someone steal your medication is not that far fetched- you'd be amazed how people are when it comes to pain pills. It seems sometimes there are no boundaries to be crossed. I dated a guy who used to skim heavy-duty sleeping pills from his ex-girlfriend. It's not uncommon. Also, I thought of this. I don't know where you work, but I work at a charity hospital that caters to the homeless, underpriveleged, and indigent population. They frequently recieve a free prescription on their way out of the hospital, only to be robbed by other homeless people or whatever out on the street. Guess who shows up the next day? They're not ALL lying. Not ALL of them. How do WE know which are telling the truth? To a grand degree, we must simply assume that they are telling the truth. If you think about it, it's not really farfetched. If someone will steal PRESCRIPTION glasses from another man off the street, glasses in a PERSONALLY DETERMINED PRESCRIPTION for that person, what makes us think that the pills won't go like lightning? Just something to think about. I mean, we send moms home with boxes of formula for their babies and they SELL IT to buy food. There are very poor people out there, and some of them, unfortunately, have to choose the lesser of the two evils in order to survive.

And one last thing... If my patient DOES have a history of drug abuse, you know what? The first thing I'm thinking of is TOLERANCE. If they frequently do heroin or crack, what's a measly vicodin going to do if they are genuinely in pain? Under medical supervision, of course, they should be getting almost liberal amounts of pain medication, unlike a four foot tall grandmother who hasn't done a drug in her life, you see what I'm saying? It may sound sort of harsh, but addiction isn't my problem- it's theirs. If they truly are addicted, they need treatment, but if they truly are in pain, they need medication FIRST, treatment later.

NICU_Nurse, BSN, RN · Apr 22, 2002

I hope you understand my point- don't want to tread on sensitive toes. ;>)

Agnus · Apr 22, 2002

I think I understand your feelings. Sometimes after caring for someone for a long time on tons of pain meds it finally gets to me and I ask another nures to take this patient for a while. I need a short break from the frustration of dealing with this patient. Then I am often able to return to care for them again, another day with a clear head and good attitude.

On an intelectual level we understand the situation. However, we do have our emoational limits. Acknowledge then and when you find yourself becomming ineffective and focusing on your own anger or frustration it is time to let another nurse temporarly relieve you from this patient.

ceecel.dee, MSN, RN · Apr 22, 2002

Please don't undertreat or misbelieve a patients c/o pain.

The doc can worry about how/why/if/when the pt. uses his Rx. (that's why he makes the big bucks!)

Fgr8Out · Apr 23, 2002

Kristi,

While I can tell you're venting, I completely agree with your bottom line... Treat the patients pain, ANY patients pain.

So sorry to hear of your husbands painful example. I hope he's doing better.

Peace:)

hogan4736, BSN, RN · Apr 23, 2002

Originally posted by KristiWhite2377
I hope you understand my point- don't want to tread on sensitive toes. ;>)

Understood.

For every story like yours, there's ALWAYS another that illustrates the lying and manipulation that other patients exhibit. (I know of two policeman that travel to our two other urgent cares (one is 12 miles away, and the other 35 miles away...both far out of their jurisdiction and far from home). Three urgent cares in three CONSECUTIVE days for 20 percocets each day IS A PROBLEM!!!

Should we judge? No, but we can't always help it.

But I'll argue taking EVERYONE at face value is what landed many in the depths of addiction!!

We should always be on our toes, and what if we took someone for his/her word and he/she overdosed that night? Are we not POSSIBLY liable?

It's a tough call. Judging everyone certainly isn't the answer, but giving pills blindly is NOT the answer either...I'm sorry. We are trained to educate, and I WON'T lax on that point ever.

How do we know that the patient may not know he/she is becoming addicted? (I had a patient return to our clinic after myself AND the doc confronted him about his behavior. He THANKED us for catching him!!!!!!!!!!!!!!!!!)

P_RN and ceecel.dee...We shouldn't judge, you are correct, but let's not forget, we also can identify potential abuse, and should IN CONJUNCTION w/ the doc teach EVERY patient EVERY time. It's our responsibility.

we are human...

fergus51 · Apr 23, 2002

This is so hard. There was a woman here on the news a few months ago who was dying of cancer and weaned herself off her pain meds because she was worried about addiction. She then went to the hospital when she finallycouldn't take the pain anymore where she was given more pain meds and sent home. I guess she still didn't want to take them and died in agony. Her family was furious that she wasn't admitted to the hospital (where they would have given her the same meds as at home). I think people are way too scared off addiction, and need to know the difference between addiction and physical dependence.

I have no idea how to deal with patients who seem to be "drug seeking". Fortunately I work L&D, so I am pretty sure the pain is real, and when I float to med-surg I don't know what else to do other than give them their meds if they ask for them. If it says PRN, or q1-2h, then that's what they'll get if they ask for it, unless it is discussed with the nurse manager and doc and they decide it's time to try something else.