How do you deal with suspected addicts?

[OhioCCRN]

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.

[cherrybreeze, ADN, RN]

From the meds alone, it sounds like the 20-something is living with central pain, a specific type of chronic pain that occurs as a result of damage to the central nervous system.

I've been living with central pain for 33 years, and have had way too many experiences with HCP who don't believe I'm in pain or pass judgment on me and withhold pain medications because of lack of knowledge and personal bias:

• I've had quite a few doctors and nurses tell me that I couldn't possibly be in pain because I'm an incomplete tetraplegic and use a wheelchair. "You can't feel me touch you, so you can't possibly have unbearable burning, shooting and stabbing pains. Therefore, you're a drug-seeker."
  
• Certain areas of my body are affected by severe hyperpathia [increased response to painful stimuli] and allodynia [things that wouldn't usually hurt, like wearing shoes, trigger significant pain]. When I broke into tears after a nurse put a non-slip sock on me despite my repeated explanations about why I couldn't have that foot covered, she told me to 'quit being such a baby.'
  
• An ER doctor on duty when I came in for a tib/fib fracture in leg affected by hyperpathia and allodynia refused to give me any pain medication. The doctor told me to my face that I was a drug seeker and had likely deliberately injured myself to get a 'fix' because I told the triage nurse that I had central pain and take 80mg of Oxycontin BID plus oxycodone for breakthrough pain.
  
• I've recently had to switch from Oxycontin to a more affordable pain medication because the cost, even with insurance, was bankrupting me. The more affordable pain medication I'm on now is Dolophine, which is the brand name for methadone. Even though the script from my pain management doctor specifically states 'for pain', the pharmacist who's filled my prescriptions for opioid pain meds from this same doctor for the last seven years told me that it was 'illegal for him to dispense methadone to manage addiction, so I needed to go to the clinic'.
  

Seeing so many nurses who are already well-educated about chronic pain, pseudoaddiction, etc. and even more who are eager to learn to better help their patients is a beautiful thing.

I remember taking care of a para who had pain issues as well, and a lot of nurses did not believe that he had any due to his spinal injury. I don't claim to know everything there is to know about that subject, but common sense tells me that it can't possibly be "all or nothing".....that if you have such an injury, you automatically don't feel ANY pain/sensation of ANY sort. NOTHING is that cut and dried in this field!

My pain doc discussed methadone with me, for a long-acting med, due to the financial constraints of other meds....I just won't go down that route. Maybe it's shooting myself in the foot, since it IS cheap and it DOES work, but because of the stigma of methadone, I just won't go there. Shame on that pharmacist, that makes me mad.

Pharmacists can be tough: I accompanied my sis to the ER one weekend several years ago, for a stomach problem. She was given an Rx for a narcotic, so I took her to the pharmacy (the one I usually use as well) to fill it on our way home. Thankfully I was with her....the pharm tech called over the pharmacist, who was chomping at the bit to lecture and belittle me, and refuse to fill the script, because "I had just filled one for the same med a week earlier." Excuse me? Now, I can see where there could be SOME confusion: we're twins. Same first initial, middle initial, last name, and DOB. They didn't look closely at SOMETHING before assuming that I was trying to fill a double Rx. I cut her off, and told her to check the name again. At first she wouldn't even do it! So, in front of my sis (with whom I do not discuss my rx's) and everyone else standing there, she is accusing me of being an addict, basically. Their first thought is not, "we made a mistake," but "of course someone who uses pain meds chronically will try to manipulate the system."

My sister thought I over-reacted (which is funny in itself, because between the two of us, she is the...."b****y" one, LOL), but she doesn't understand. She hasn't had to deal with the label. It should never have even come UP, it was HER name on the Rx. If the two of us hadn't both been standing there, I wonder what would have happened (besides the pharmacist divulging MY medical info to my sister). We really are identical, so short of whipping out an ID (and who knows if even that would have mattered?), I bet they wouldn't have backed down. Very upsetting.

[canigraduate]

To those who suffer from chronic pain/know someone who does, i apologize for coming across in a way that offended you. Its been an eye opening experience to read the responses from those that have experienced it.

As a nurse you are expected to have NO judgments, biases or opinions. As a human being that is impossible. I am willing to acknowledge my biases and try to learn from them.

I no way did my original post imply that i was withholding PRN medication. I was concerned that the ammount of narcotics we were giving her were a lot... an example is 2 oxy IR, 1 Oxy SR and Vicodin all in a space of 1.5 hrs... as she had BOTH scheduled and PRN narcotics....

I have never had chronic pain thus i DON'T know how it feels and how you learn to cope with it. The posters that shared their personal experiences put this into perspective.

No offense taken whatsoever. You don't know what you don't know until you find out you didn't know it. (One of my grandfather's favorite sayings.)

I think it's awesome that you came here and talked about the situation. I'm sure this thread has given many readers a lot to think about, and hopefully has changed some attitudes.

So, thank you!

[canigraduate]

Addiction is a psychological phenomenon. The patient believes he must have the medication to survive. A patient who is physically dependent is one who suffers withdrawal symptoms when he does not receive the medication. Can the two occur together? Yes. Do they always go hand in hand? No.

Thanks for clarifying that for me. I guess I need to look up some definitions!

[pockunit, ADN, RN]

This is one of the hardest things for me to do as a nurse.

If I had pain on an 8/10 scale, I would be on the floor rolling and screaming. I have never had severe pain in my life, and can't imagine it, but because I have had pain, I find it to to believe some people when they tell me what their level is.

I have had 10/10 and I was not rolling around on the floor. I was doubled over, but not wailing or carrying on. Just because a pt is in pain doesn't mean you'll see over-the-top behavior with it. Everyone is different. My 4/10 might be your 10/10 and my reactions are not necessarily yours. You can't base your tx on how YOU would react to the pt's situation; it's not your place. It's not your body or your pain, it's theirs.

[pockunit, ADN, RN]

As a nurse you are expected to have NO judgments, biases or opinions. As a human being that is impossible. I am willing to acknowledge my biases and try to learn from them.

That isn't possible, you're right. As I see it, we're expected not to ACT on our biases or judgements.

[canigraduate]

This is one of the hardest things for me to do as a nurse.

If I had pain on an 8/10 scale, I would be on the floor rolling and screaming. I have never had severe pain in my life, and can't imagine it, but because I have had pain, I find it to to believe some people when they tell me what their level is.

Thank you for being honest. I, myself, have a very different reaction to pain than most. I withdraw instead of act out. About the only way you would be able to tell I am in severe pain is that my eyes tear up uncontrollably. My father is the same way. I can tell when his meds aren't working well because he starts clenching and relaxing his fist. That's the only physical sign he shows.

My mother, on the other hand, has some serious DQ tendencies. If she gets a splinter, she wails like you've slammed her fingers with a hammer, acts like she's been shot, and lets the whole world know that she's hurt and wants you to fix it RIGHT NOW.

[DookieMeisterRN]

From the meds alone, it sounds like the 20-something is living with central pain, a specific type of chronic pain that occurs as a result of damage to the central nervous system.

I've been living with central pain for 33 years, and have had way too many experiences with HCP who don't believe I'm in pain or pass judgment on me and withhold pain medications because of lack of knowledge and personal bias:

• I've had quite a few doctors and nurses tell me that I couldn't possibly be in pain because I'm an incomplete tetraplegic and use a wheelchair. "You can't feel me touch you, so you can't possibly have unbearable burning, shooting and stabbing pains. Therefore, you're a drug-seeker."
  
• Certain areas of my body are affected by severe hyperpathia [increased response to painful stimuli] and allodynia [things that wouldn't usually hurt, like wearing shoes, trigger significant pain]. When I broke into tears after a nurse put a non-slip sock on me despite my repeated explanations about why I couldn't have that foot covered, she told me to 'quit being such a baby.'
  
• An ER doctor on duty when I came in for a tib/fib fracture in leg affected by hyperpathia and allodynia refused to give me any pain medication. The doctor told me to my face that I was a drug seeker and had likely deliberately injured myself to get a 'fix' because I told the triage nurse that I had central pain and take 80mg of Oxycontin BID plus oxycodone for breakthrough pain.
  
• I've recently had to switch from Oxycontin to a more affordable pain medication because the cost, even with insurance, was bankrupting me. The more affordable pain medication I'm on now is Dolophine, which is the brand name for methadone. Even though the script from my pain management doctor specifically states 'for pain', the pharmacist who's filled my prescriptions for opioid pain meds from this same doctor for the last seven years told me that it was 'illegal for him to dispense methadone to manage addiction, so I needed to go to the clinic'.
  

Seeing so many nurses who are already well-educated about chronic pain, pseudoaddiction, etc. and even more who are eager to learn to better help their patients is a beautiful thing.

This is what AN is all about.

My pts pain is visceral? in origin I'm guessing since Crohns is what I believe started it coupled with numerous abd surgeries with many complications/prolonged hospital stays. I do know there is to a degree of psychological issues but I'm unsure if it began with ileostomies at a crucial developmental phase in this young mans life and/or chronic pain. Which came first, the chicken or the egg?

Thank you for sharing your personal story as it's another way to consider different types of pain. I've worked in many different specialties in my career except for neuro so your post is another point to ponder for future cases.

It's so sad that there are misconceptions related to pain management vs PITA pts. They (PITA pts) have really stigmatized those pts with legitimate pain and this has created (I believe) more psychological issues than the pain itself.

[ErinS, BSN, RN]

One of the hard things about being a nurse is that as a pt advocate we are constantly fighting for good pain control. Here are my thoughts:

1. I would call the MD and say "Mrs. Jones has had 40 mg of oxycontin, 60 mg of oxycodone, and 40 mg of hydrocodone in the last 24 hours. She is still reporting 8/10 pain. She is demonstrating that she has pain with agitation, anxiety, and irritability. Her respiratory function is normal. I think she would really benefit from an increase in her Oxycontin."

2. You may get a no, or a I am not comfortable with that from the MD. I would then recommend having a pain consultation. Remind the MD gently that this pt has threatened to sue, and you are very concerned about everyone's liability (pt's generally WIN lawsuits accusing providers of poor pain control).

3. It is scary to deal with high amounts of narcotics, but it is all relative. Pain control is a science. Some recommendations any time you are dealing with pain: if a pt is taking prn pain meds more than 3 times a day, they should be switched to a long acting (or have their long acting increased). They should be on some sort of pain adjuvant medication- like antidepressants or neurontin. Also, for the most part was should be aiming to provide pain control through the long acting. So if a pt is taking 40 mg of oxycontin a day, and 80 mg of oxycodone for breakthrough pain, we should probably go up to 120 mg of oxycontin in divided doses. Just some thoughts to keep in mind when trying to get new orders on pts.

Also, I learned early on that it is not worth trying to figure out who is an addict and who is not. I am far more worried about undertreating one person's pain, and so I think it is worth the risk that we are giving meds to addicts. I also tend to think that there are a lot less addicts than we think, and a lot more people with true chronic pain that is poorly managed. I work in hospice, so I think there is far less pressure on us to try to figure out who is drug seeking and who is not, but you would be SHOCKED at the pts we see referred who have a diagnosis of opioid addiction that stop showing those drug seeking behaviors when we get them on the correct pain regimen. Good luck!

[SnMrsSmiley]

pain is subjective. I have a pretty high pain tolerance and can be in severe pain and it not show to everyone. My husband on the other hand can be in minor pain and act like a total fool about it.

and remember too that a patient that is in pain is usually going to be crabby, combative, and insulting. Iv rarely seen anyone in pain that was sunshine and daisys lol. :)

as long as you are giving meds as ordered then you are covered. No worries.

[anotherone, BSN, RN]

This is one of the hardest things for me to do as a nurse.

If I had pain on an 8/10 scale, I would be on the floor rolling and screaming. I have never had severe pain in my life, and can't imagine it, but because I have had pain, I find it to to believe some people when they tell me what their level is.

I have had really bad pain in different areas and different types. At times i can barely talk, let alone role on the floor screaming.

[xtxrn, ASN, RN]

I remember taking care of a para who had pain issues as well, and a lot of nurses did not believe that he had any due to his spinal injury. I don't claim to know everything there is to know about that subject, but common sense tells me that it can't possibly be "all or nothing".....that if you have such an injury, you automatically don't feel ANY pain/sensation of ANY sort. NOTHING is that cut and dried in this field!

My pain doc discussed methadone with me, for a long-acting med, due to the financial constraints of other meds....I just won't go down that route. Maybe it's shooting myself in the foot, since it IS cheap and it DOES work, but because of the stigma of methadone, I just won't go there. Shame on that pharmacist, that makes me mad.

I had a para with a hip disarticulation who also had a dinner plate size decub in his sacral area that went to the bone. He was also on a methadone maintenance program, and his doc would NOT treat the pain from the decub. He lost mobility but not sensation. I'd go into the room when he wasn't expecting me (no time to drum up crocodile tears) and he'd be sobbing. I'd call the on-call docs to get him IV morphine on the weekends I worked (only worked weekends), but finally his MD put a stop to that, and I refused to take care of him after that. I would not participate in torturing this guy- who had some really intense wound care.

I've tried methadone for pain- and it is good....but I've also seen patients in drug rehab coming off of it- and their detoxes were the worst of any that came through the doors (this is the place Dr Phil sent people- well after my time there, but it's a good facility with a good reputation). It worked well, and I may go talk to that pain doc again (as long as he doesn't want to keep injecting my epidural and facet spaces- which lasts about as long as it takes to get home). My PCP is not all that comfortable with pain, though she has agreed to Ultram and Norco (in an amount that would last 2 weeks if I took it as often as the label said-- I ration it out like crazy, get each rx filled every month, and stockpile what I can- the knowledge that it's there helps a lot, and I can hold out a bit longer).

The detox from opiates is not lethal- but some of the symptoms can lead to dehydration and other electrolyte/flluid issues that can be risky; if there are pre-existing conditions- or undiagnosed conditions, there can be more complications. The folks on methadone just wished they'd go ahead and die. (Alcohol withdrawal, on the other hand, can cause death in and of itself). Rapid-detox from opiates is not the same as what 'normal' detox facilities do- and that can be extremely dangerous, and lethal.

[DookieMeisterRN]

Just for a chuckle I have to throw in that I floated the other day and had a young uncomplicated lap chole approaching her 2nd night of hospital stay. She kept asking for a fentanyl patch for pain control. For real?!? No, no, and no I'm not going to interrupt your surgeon in the OR to ask for the umpteenth time. Just take your 2 mg of IV dilaudid Q 2 hrs and hush up, you won't die tonight. In fact you look more put together than me!

Sorry, just a little vent.

ETA: The above was def a PITA and it was a very very long 4 hrs with this pt. When she wanted to know what pain meds she could take that wasn't oral I told her-to start with your surgeon will always order phenergan suppositories for the nausea (which is why she wanted a patch). Probably will D/C all opiates as your BT are absent and have nurses administer APAP supp PRN. Possibly you will need an NGT if you don't start passing flatus soon. Didn't hear another peep the last hour of my shift.

HaHa I am evil