I didn't become a nurse to feed people's addictions. Do *nurses* have the right to refuse

[Thankgodforativan]

(Disclaimer: So this turned out to be longer than I thought it would, and a bit of a rant. Sorry! But I think this is something that's relevant to all of us).

Some background: I work in a combined med surg ward, so we see a bit of everything. We have a young-ish girl, in her twenties, that has a VAC dressing in her leg following very deep self harm about two weeks ago. Her drug use has also given her 'meth mouth', and she's had at least one tooth removed about a week ago as well.

The issue is that she has a personality disorder, a history of aggression, is a known drug seeker and has had to have her VAC replaced twice now because she keeps sabotaging it - picking at it, poking and playing with it. Before it was put in she was seen physically pulling the edges of the wound apart with her hands also. She demands morphine roughly every hour for "ten out of ten" pain even though you can clearly see that she's not distressed in any way. She is charted for PRN morph and fentanyl, subcut (not allowed to have a cannula).

We always hear about the patients right to refuse; surely nurses have some way of objecting in a situation like this? Panadol (Tylenol), anti-inflammatories and endone all "don't do anything", even though it barely gets to two minutes after giving these before she buzzes and asks for "something better".

It's ridiculous; the patient knows she's playing us for fools and has said as much. Surely there comes a point where enough is enough and we stop giving in to people, especially people who don't want to help themselves. No wonder the state health system I work in is broke; It frustrates me to no end when we can't even afford more then one obs machine on the ward between thirty two patients, yet we will hand out expensive treatments to people who clearly don't want to get 'better', and dole out morphine like it's soda.

I know we need to cover pain relief somehow; I'm aware that vac dressings can be painful. But it's not like she can say we're not giving her anything at all. What are our options here? I'm not the only one with the same concern.

Sincerely, nurse who didn't become a nurse to be a drug dealer.

*edited for spelling.

[MrNurse(x2), ADN]

You work acute care, you will not fix their addiction, which probably stems from her psychological pain more than physical, hence the self harming. Medicating addicts does the same physiological good as giving a beta-blocker to a cardiac patient, it deters untoward effects. You may want to reevaluate your attitudes or your specialty, the majority of pts. under 70 are going to be a pain management nightmare due to drug use in their history and dilaudid use.

[skylark, BSN, RN]

Not sure why you think I should review my attitude or my specialty?

My point is that because this kid comes in every night we are feeding his addiction. He has refused all attempts at more appropriate management but just wants his free fix every night.

So we are, in effect, his supplier and therefore supporting his addiction.

Is this what healthcare is really about?

[BostonFNP, APRN]

Not sure why you think I should review my attitude or my specialty?

My point is that because this kid comes in every night we are feeding his addiction. He has refused all attempts at more appropriate management but just wants his free fix every night.

So we are, in effect, his supplier and therefore supporting his addiction.

Is this what healthcare is really about?

IDK, it's my opinion that unless you are writing the orders, you aren't feeding his addiction, you are just doing your job.

[jdub6]

So here is another question along the lines of the first one, interested to hear your take on it.

22 year old male, calls an ambulance EVERY NIGHT for sickle pain. Has never shown up for any appointment we make him for sickle clinic or pain management, so has never been formally diagnosed, and his retic count is normal every time.

Demands a stat shot of Dilaudid, then a second an hour alter and then 2 norco and then he skips out.

Returns for the same routine - every - - - darn - - - night.

If not our ER then one of the others in the city, he seems to rotate around, but the ambulance service say that they transport him every evening.

Being a large ER he can see a different doc every night of the week, and communication regarding frequent flyers is non-existent here, both in this dept and between other ERs.

Bear in mind also that he is on his cellphone the entire time, and that non-verbal signs of pain are not present, he is too busy watching netflix to discuss his medical needs.

He gets medicated on the basis that the pain is what the patient says it is.

So do we carry on like this, or do we refuse to treat him until he has been to clinic?

Answers please, this should be fun!

Very similar situation here...similar age male, sickle cell has been officially diagnosed and he does have a sickle cell doc although possibly only because he has actually been hospitalized in the past and thus a captive audience.

our hospital is literally the only one in the tri-county that is not affiliated with Huge Hospital System. several months ago he starts showing up way more often, usually via EMS from the bus stop where the busses from non-neighboring cities stop. It's easy to see his history of multiple ER visits multiple places and multiple dilaudid prescriptions from multiple providers all filled. He has given fake names for non existent sickle cell docs in the past.

Recently one of our docs got the real name and took the time to call. When the doc called back he thanked her for calling and said that this young man has been taking the long bus ride up to us lately because the sickle cell clinic has a standing care plan in Huge Hospital System for no narcotics and refer back to clinic unless signs of true crisis or unrelated painful condition are present.

Here's the thing....despite this being documented in his record (with a quote that "unless there is crisis or something like a broken bone, he shouldn't be getting narcotics from anyone other than me. I have openings in two days all day, he can call me tomorrow. But he generally prefers ERs to my clinic unless they approach him consistently. ") we still have 2 docs who give this pt multiple IV doses of dilaudid WITH Ativan AND benadryl (he tells the triage nurse that's what he will need and that's the first thing he says to the docs as well. )

This just feels like these docs are deliberately undoing the efforts of the specialists and local hospitals to curb this man's er use and also to have one provider managing his narcotics (before anyone mentions that this pt is avoiding withdrawal or the like, the sc clinic gives him po dilaudid- we can see it in his rx history.) I have no suggestions but can commiserate! I do feel that pts like this should be approached differently.

[jdub6]

Individuals who have a Substance Use Disorder particularly the substance which is physiologically and psychologically dependent, medically have no control over the physiological part of the dependence. That said, this patient is exhibiting in her behavior psychological symptoms associated with the physiological effects of the opioid she is physically dependent on (i.e manipulative behavior, obsession with the time the med is due, "sabotaging "). She has NO control over this. Period. No more than a person who has insulin dependent diabetes has control over their pancreas not being able to make insulin (physiological). The person with diabetes also has to make behavioral changes such as monitoring their food consumption and being active to aid in controlling their blood sugars. Opioid dependence is the same way. Every one of us are born with opioid receptors in our bodies to control pain and emotions, rewards etc. We have to have them to live the same as with insulin. When a person begins to take opioids, he/she starts to temporarily change the "picture" in the brain that naturally produces the opioids. The body can handle the temporary replacement, however, in the cases where the change is long term meaning the person continues taking the opioid for longer stretches of time (several months to years) then the body permanently changes that picture and depends mostly on that picture to "satisfy" the pain, emotion, reward, etc. This is the physiological effects of the opioid. No control is possible. It may seem so especially when the person shows behavioral signs that confuses the family and in this case, the nurse. This person must have this opioid or a replacement for the "original" picture that is in the brain such as another opioid. Please understand this concept and you all will better be able to "nurse" a person instead of "feed" a person with physiological dependence. if you wear glasses and can not see well without the glasses on, would you want someone to take your glasses from you and then tell you they are not giving them back to you at the same time they are asking you to read something for them?

Long time addict, now long time clean RN here...and my drug of choice was opioids and benzos....

Sorry but from experience I respectfully disagree. You cannot compare drug addiction or tolerance to diabetes. Did I lose control? Absolutely. Did i suffer consequences? Yes, years of my life and many treasured relationships and my finances were ruined. Was I well aware of my manipulative/ deceptive tactics and able to not use them when I had the motivation? Always. Was going through detox and fighting the cravings the hardest thing I have ever done? definitely. Did I need to biologically treat those cravings in order to succeed? Nope....it was all mental (although meds for detox sx helped immensely....none were opiates.)

I also have to say that my addiction took off when I was hospitalized with objective evidence of a very painful condition and given IV dilaudid with PO on dc. I knew at the time that I was manipulating providers into giving more at higher doses. But I convinced myself that I was just treating my pain. And that was true. Except at some point, either inpatient or at home where I quickly figured out how to crush and inject the pills so they would provide the rush I wanted, the pain was caused by withdrawal and not my condition. To this day I can't figure out where that change occurred but I know it did, and after that things got bad very fast (we're talking IV heroin and eventually cocaine as well, financial ruin, nearly dying.)

At the time I was mad and offended when anyone suggested anything other than dilaudid. even with years clean I still would go back and change that in a heartbeat...I desperately wish that I had been limited to lower doses or fewer refills at that point. I absolutely could have chosen to put it down at that time and it would have been so much easier. But the pain management propaganda gave me the perfect excuse.

Not that everyone is like me....but I have known many other addicts through the years and never saw an addiction that was 100% biological and 0% mental/ cognitive/ behavioral. Even active addicts, with an understanding audience, would agree.

[nursenikki1010]

Honestly. In this time of "patient satisfaction" the line between good healthcare and happy clients is too blurred. And if you've read any research we are losing nurses in droves due to this very frustration. Furthermore, the research suggests that the only way to combat this fatigue is to acknowledge that we have went too far with satisfying our patients and that we need to find better balance. Just a reminder that the evidence changes regularly. What you were taught in nursing school about patient labeling, etc... is not current. AND if you read the CDCs report that was released in late 2016 it states that the opioid epidemic can be directly tied to over prescribing. It also suggests that we stop routinely assessing pain unless there is a clear reason for a patient to be in pain. The CDC states that pain is not a vital sign and should not be treated as such. Also, if you look into why pain became a vital sign in the first place it was because Pfizer had just created a new opioid pain medication and they lobbied in Congress to have pain as a vital sign legislated. It was meant to only be applicable to cancer pain but Pfizer continued to lobby for it on all fronts when they saw how profitable their new medication was. There is a very clear history as to the abuse of these medications and to how prescribers have perpetuated that abuse. So, I believe it is absolutely within the nurses scope to question a doctors order based on these facts. Do no harm. Nonetheless, this takes quite a bit of energy and it's a lot easier to just give the med if it is safe.