How do you deal with suspected addicts?

linearthinker, DNP, RN · Sep 17, 2011

I wouldn't worry about it. She has valid orders. Implement them as you are reasonably able. She can complain about you being 3 minutes late until the cows come home, who cares?

OCNRN63, RN · Sep 17, 2011

It is possible to sleep and still be in pain. Sleep is an escape mechanism.

cherrybreeze, ADN, RN · Sep 17, 2011

I had a Resident that threatened to sue/ call the state on the facility because she did not get her PRN dose of Oxy IR/ Vicodin RIGHT on schedule.
1. Resident says she is in 8/10 pain, and has been 'falling asleep but had to stay awake to get the next dose of pain meds' I re-educated about the pain scale and how w/ 8/10 pain you cant possibly be asleep and if you are asleep that's a good thingetc...
2. Resident pulls call bell right on schedule for PRN meds (all of them) and says she needs then NOW. When i am even 3 minutes late, she starts cursing and rolling around the bed.
3. Resident writes down all the doses and sets an alarm clock to wake her up during the night to get her PRN meds and then complains that she has had no sleep.
- How do you handle such a pt. One who has admitted to popping oxy before going to work. i'm documenting EVERYTHING that i do.
i understand that i am biased about this... its really frustrating and i need some advice on how to deal with this.

The bolded statement jumped out at me as not fitting the rest of the scenario. What do you mean?

As for the rest....I don't necessarily see the "suspected addict" that you do. I do see what could possibly be an undermedicated chronic pain patient. I know you'll probably disagree and say that they are not undermedicated due to taking their PRN's on schedule, but perhaps the dose is not high enough. If they've been on that dose for an extended length of time, it's going to become less effective. That's just the way it works. This sounds more to me like PSEUDOADDICTION.

Also, if this person needs their PRN's around the clock, perhaps it's time to discuss with the MD an order for an extended release med, such as a fentanyl patch, MS Contin, etc.

Pain does not disappear during sleep. Both my sister and her BF had fairly recent surgeries, and I encouraged them to awaken at night to take their meds, especially in the first few days. It's MUCH harder if you do manage to sleep for 8 hours, say, and then wake up with no meds at all in your system. It's best to avoid that, if you know you'll have pain.

As far as the behavior of yelling, threatening to sue, etc...well, that's just a difficult patient. Not much you can do to change those things. Continue to reassure them that you are doing the best that you can, and that you care that their pain is managed to the best of your ability. That alone can go a long way.

Not trying to be mean, and I'm also not saying that for sure you are wrong about this suspected "addiction," but it sounds like both you AND the resident need some reeducation regarding pain control.

samirish · Sep 17, 2011

I know ortho patients need to get AHEAD of the pain (they routinely need their pain meds on time around the clock even if they are able to sleep)..if not it can spiral out of control very quickly. However you didn't specify what kind of pain she is having. I wouldn't worry so much if your 3 min. late. I doubt highly you will get into trouble for that.

Maybe the doc needs to reevaluate the pt. to make sure she is getting appropriate pain relief in the first place? If you truly suspect she is drug seeking, can you possible request a psych eval?

RNdiva505 · Sep 17, 2011

I had a situation like that last night. Patient on 1 mg dilaudid q 3 hours was calling me around the clock. This morning when I was starting their IV I began, "please do not feel offended, but it does not seem like we are controlling your pain with the pain you are taking now. Do you have a history of taking any meds for pain control that we do not know about?" The patient said they weren't offended and yes they had multiple sx in which turn they have been on pain meds the last 13 years! Glad I asked cuz I was thinking they were a seeker, but turns out they had a tolerance. But we had a good nurse/patient relationship. I still felt weird asking.

Anywayz, knowing that she pops oxy before work would indicate she probably has a tolerance or just likes the feeling of zonking out. Sometimes I give them an option or ultimatium. Because if you continue to give her all those narcs she can get an ileus. I usually tell my seekers or patients who are tolerant to take a couple laps around the unit before they ask for their pain meds so keep their stomach active. :lol2: And when I see them taking their lap I know to get their meds ready.

You can not deny people pain medication if they are "in pain", but you can set limits. Like can I have my dilaudid with my phenergan. I usually ask why and when they say because it makes me nauseous ...I usally say well you can have crackers or call me when you feel nauseous! They can not argue with that and nor are you denying them anything. Or when they have anxiety meds and they request them for sleep I usually say are you anxious right now. They usually say it helps me with sleep and I usually say sorry the dr didn't order anything for sleep and I chart the scenerio.

Oh by the way at the hospital I work at if a patient is requesting pain meds and they can even keep their eyes open. I will refuse to give it due to obvious reasons. Plus look at their vitals if low bp, pulse, respirations you can definitely refuse to give (if these are outside their norm)!

You have a difficult situation, but finding wayz to safely and appropriately deny their request for something becomes easier.

Good luck to you!

Hospice Nurse LPN, BSN, RN · Sep 17, 2011

What kind of pain is your pt having? How long has she/he been on the current meds? How are they rating the pain 30 p giving PRN?

Some folks who have chronic pain are never fully relieved. Your pt could have possibly developed tolerance for the current med. Is it possible to have the doc review the meds? Just because a pt is sleeping, doesn't mean their pain is controlled. Sleep can be a way of coping w/ the pain. V/S that are wnl isn't always an indication that the pt isn't in pain. I've had pts on massive amts of pain meds and state the pain is 7 and needed something for breakthrouugh pain. The VS were wnl.

A pts pain is what they say it is. If there is an order for the med, why question if they need it or not. As nurses, we shouldn't withhold meds because we don't think they need it.

linearthinker, DNP, RN · Sep 17, 2011

The thing is (and I'm not just talking to the OP, but to anyone with these kind of issues at work) when it comes down to brass tacks, it doesn't matter a whit if the patient is an addict, a pseudo addict, just dependent, or a junkie. Just implement the order as it is written and stop worrying about someone possibly getting high, lol.

There is a good chance you are relieving real pain. Worst case an addict, who may not be a nice person, gets high. Even if that is the case, she is going to be easier to deal with if you just give it to her! No matter what, you aren't going to "fix" her or the underlying problem, you are just going to antagonize someone you already know to be a PITA. So administer drugs according to lawful orders and assume the best, and stop worrying about it.

allnurses Guide · Sep 17, 2011

OP-

I can see why you may have concerns about this patient. It's perfectly ok for you to bring this up for discussion. However, you do need to follow orders as they are written. Maybe you can bring up your concerns to your supervisor or to the patient's provider. She may be undermedicated and is terrified of being in pain. Perhaps it's the only thing she feels she has control of (getting her meds on time). And yes, she could be an addict or has been misusing pain meds. It's a difficult situation and no one wants to enable or contribute to someone's addiction, but the patient deserves to have her pain properly managed. Talk to your supervisor or a colleague about your concerns. Questioning these things helps us learn as nurses.

OCNRN63, RN · Sep 18, 2011

I had a situation like that last night. Patient on 1 mg dilaudid q 3 hours was calling me around the clock. This morning when I was starting their IV I began, "please do not feel offended, but it does not seem like we are controlling your pain with the pain you are taking now. Do you have a history of taking any meds for pain control that we do not know about?" The patient said they weren't offended and yes they had multiple sx in which turn they have been on pain meds the last 13 years! Glad I asked cuz I was thinking they were a seeker, but turns out they had a tolerance. But we had a good nurse/patient relationship. I still felt weird asking.
Anywayz, knowing that she pops oxy before work would indicate she probably has a tolerance or just likes the feeling of zonking out. Sometimes I give them an option or ultimatium. Because if you continue to give her all those narcs she can get an ileus. I usually tell my seekers or patients who are tolerant to take a couple laps around the unit before they ask for their pain meds so keep their stomach active. And when I see them taking their lap I know to get their meds ready.
You can not deny people pain medication if they are "in pain", but you can set limits. Like can I have my dilaudid with my phenergan. I usually ask why and when they say because it makes me nauseous ...I usally say well you can have crackers or call me when you feel nauseous! They can not argue with that and nor are you denying them anything. Or when they have anxiety meds and they request them for sleep I usually say are you anxious right now. They usually say it helps me with sleep and I usually say sorry the dr didn't order anything for sleep and I chart the scenerio.
Oh by the way at the hospital I work at if a patient is requesting pain meds and they can even keep their eyes open. I will refuse to give it due to obvious reasons. Plus look at their vitals if low bp, pulse, respirations you can definitely refuse to give (if these are outside their norm)!
You have a difficult situation, but finding wayz to safely and appropriately deny their request for something becomes easier.
Good luck to you!

If the meds are making them nauseated, give them the anti-emetic. If you're worried about sedation, then ask the doc about a different anti-emetic, like Zofran.

I would never force-march a patient around a unit before I medicated him for pain. People tend to do better with ambulation when their pain is under control, not acute.

If the patient needs something to help him sleep, notify the doc. Sleep is essential to healing. Personally, I'd give the anxiolytic and let them have the sleep they need, then address the issue with the doc.

canigraduate · Sep 18, 2011

I'm probably going to need a flameproof suit for this, but I can't help it. I just can't let this go without saying something in defense of addicts.

SO WHAT if they are addicted? Addiction is a physical dependence on a substance, right?

Doesn't that mean that they physically NEED whatever it is they are addicted to?

So, really, I think a lot of nurses are being unintentionally cruel when they withhold pain meds because they think the patient may be addicted. They are basically causing physical and psychological harm to a patient.

If she is breathing well, isn't snowed, and it helps her feel better, GIVE HER THE MEDICINE!!!

I get emotional over these discussions, I admit it. My father has severe pain from back, neck, and spinal cord injuries. He's a walkie-talkie, though, so no one believes him. He is often treated like a junkie. He rarely slept more than 4 or 5 hours at a time for the past couple of decades, because the pain gets so bad it wakes him up.

This year, he finally got to a pain specialist that believed him. He called me one morning at 0530, crying, because he slept through the night for the first time in almost 20 years and he woke up on his own, without having to reach for a pill bottle.

Please believe your patients when they say they hurt. If they aren't getting relief, try to work with them until they do. If they are using the pain medications to get high, then get them help, instead of judging them. It takes a lot of psychological pain to put up with all the rudeness, judging, and general crappy attitudes toward addicts.

xtxrn, ASN, RN · Sep 18, 2011

I had a Resident that threatened to sue/ call the state on the facility because she did not get her PRN dose of Oxy IR/ Vicodin RIGHT on schedule.
1. Resident says she is in 8/10 pain, and has been 'falling asleep but had to stay awake to get the next dose of pain meds' I re-educated about the pain scale and how w/ 8/10 pain you cant possibly be asleep and if you are asleep that's a good thingetc...
2. Resident pulls call bell right on schedule for PRN meds (all of them) and says she needs then NOW. When i am even 3 minutes late, she starts cursing and rolling around the bed.
3. Resident writes down all the doses and sets an alarm clock to wake her up during the night to get her PRN meds and then complains that she has had no sleep.
- How do you handle such a pt. One who has admitted to popping oxy before going to work. i'm documenting EVERYTHING that i do.
i understand that i am biased about this... its really frustrating and i need some advice on how to deal with this.

The behavioral stuff (rolling around the bed, threats, etc) can be what we have taught chronic pain patients to do. It's a widely held belief that pain patients are addicts....only about 1% of people given narcs become actual addicts (not the same as dependent or tolerant). Chronic pain patients have to accommodate our biases by doing what they need to do to avoid having the pain becoming so intense that it takes 3-4 times as long to get it under control....more than likely it's never "relief".

It's VERY real to be afraid of the pain...that's not the same as drug-seeking :) Vital signs in chronic pain patients are often normal, since being in a lot of pain is their new normal- the autonomic responses have compensated for the chronic stimuli. Severe pain can also cause vasovagal responses and severe, pre-syncopal drops in blood pressure.

All we have to go on is the patients' word, and the doctors' orders. :)