(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.
I think it's ironic that your username is "Thank god for ativan" but you're apprehensive about giving prescribed controlled substances per order.
You aren't a drug dealer because you aren't personally profiting from the dispense of drugs. She has pain meds ordered and they're indicated.If she is engaging in self-sabotage, self-harm, med-seeking, she will suffer the consequences of those destructive behaviors regardless of whether or not you attempt to control her pain. I think its important here to remember what our job IS and what it is not.
at the ativan comment
As far as what our job is not....I think it IS our job to not only treat pain, but be part of the solution to the opioid epidemic as well.
I think if she has said that she is playing staff for fools, that that should be charted and discussed with the prescribing doctor. If the behavior is charted and discussed with the prescriber and THEN nothing comes of it, then, well, you did all you can do besides offer addiction literature (which I'm sure would be tossed out, but then you can at least know you did everything you could.)
I had a pt in physical rehab where we all knew he was addicted, he tried playing us for fools, then when he was discharged, he died of an overdose within a week of being home.
You cannot ethically refuse to give patient something that was prescribed by provider. Just as you cannot refuse to go into L&D room to assist a patient whose moral/social/sexual choices are in conflict with your own.
It's just a username friend. Meant to be a joke, ya know? Humor?
Incidentally, it comes from a framed picture we've had hanging in our nurses room for who knows how long now of Jesus that says 'and on the seventh day God created ativan'.
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?
A short hospital stay is not the place to try and treat somebody's addiction. It's not.
The OP asked if it was their right to withhold pain medication. It's not. The physician is the one who gets to judge the amount of pain a patient is in, not us.
Yes, addicts can be frustrating, but they still have pain!! Their tolerance is much higher, therefore, they need more of the me
If I truly thought the OP wanted to have an educated discussion, they could have worded their posts much differently. But stating I didn't become a nurse to become a drug dealer, shows the absolute disdain and bias this poster has.
I highly suggest spending some time working with addicts to get an understanding of addiction and the brain of an addict.
Specializes in Home health, Addictions, Detox, Psych and clinics..
I work in detox/addictions/mental health. It's no walk in the park. It can be quite challenging. Believe me. Patients with addictions to especially benzodiazepines, and opioids often require higher doses of pain meds to control their pain as their tolerance has become higher. When I've worked in other settings, if the medication is indicated, and SAFE to give, then i administer and assess. Hang in there, keep your head up. Everyone, including patients, have their own crosses to carry. :)
I used to feel similar to you until I experienced post partum depression after the birth of my 2 year old. I had no history of any mental disorders and had a stable home, involved husband, and support. I did everything right for the health of the baby and for me, but it still happened. I didn't turn to drugs or alcohol but I can tell you I can understand how someone would.
I am a naturally positive person but PPD was the darkest hole and it took me months to climb out of. While I was a difficult experience, it was the best life lesson I could have learned because it taught me that you never know what someone has gone through and what they are going through. It taught me empathy, humility, and while I may still find it frustrating at times to work with patients who are addicts, it does not suck my soul any longer because I truly feel for them because who would want to live like that?!?
I am assuming that my experience with PPD is only a sliver of what people with chronic mental illness or addiction go through and that tiny sliver was hell and it changed me and it made me think of doing things I never would have in a normal state. Meeting me now, I am level headed person, you would never know that 2 years ago I shut myself outside of my house on purpose at midnight while my husband was at work because I was afraid I was going to have a mental break, not know what I was doing, and hurt my kids. It feels like a dream that it even ever happened because I would take a bullet for my kids without hesitation.
Didn't mean for this to be so long and person but I am hoping you will see that addicts, people with mental illness, were at one time most likely "normal" people whose demons became too much to handle without self medicating. If you can't find empathy then just do not let if get to you, be a nurse, and give them their ordered medications. If you can't of that then perhaps a wellness field of nursing would suit you better. Good luck to you.
I hope you keep reading at least til you hear what I want to tell you-- and I promise, no high horse!!
I understand your frustration. I worked med-surg for 1 1/2 years after RN school and, even though I learned a lot, it was bang your head frustrating.
I too got very upset about the constant flow of Dilaudid to patients, many of which I knew were drug seeking. We had a few that were there so frequently that most nurses on the floor could do most of the admit paperwork without asking all those pesky history questions.
The PP's are correct, if there is a valid order & their vitals are ok- you have to give the meds. I finally pinpointed for myself, though, that more than giving the narcs, it was the manipulative behavior that usually goes with it that bothered me more. And, what took up the most time. The repeated calls to see if they could talk me into giving it early, to make sure I know it's due soon, is there anything else they can have, etc.
So, once I recognized that I had a patient that was going to want any & everything they could have the very second it was due, I would just level with them. I would tell them what was orddred & how often they could have it. That I will give it on time, never early. With many of them, they're so used to having to work the system to get it that if you're up front with them it reduces their anxiety & they're more cooperative & pleasant. Yes, you still have to give the meds, but this usually reduces the drama and time you spend fussing over nothing.
Just try to look at it as being no different- or less frustrating- than trying to educate diabetics or heart patients on diet and you walk in and find them eating a whole pie (chocolate or pizza)
And when you finally decide you're having more bad days than good at the bedside, then you switch to hospice where the folks really need the narcotics!!
"If you feel the medication isn't managing her symptoms well-enough, the patient is requesting/using medications inappropriately and/or the patient is constantly complaining about not getting the "right" medications, then notify her PCP so they can evaluate her and her medications. The PCP will decide if medication changes are necessary."
I agree with this 100%...but I have seen too many instances where the docs are just ignoring the patient's extreme use of pain meds while admitted to an inpatient service. I recently reviewed (third party) a chart where the patient was taking everything and anything written for her and "right on schedule". Two to three times nurses documented finding other narcotics (not prescribed for the patient) in the room, falling out of her handbag and on her bed. No one addressed this, no provider notes, nothing...not even a psych consult was ordered! She came in with a psych diagnosis and was already taking Xanax and Ativan outside of the hospital. (she was taking her husband's Percocets in the hospital) Oddly enough, the patient was admitted even though all her imaging and tests in the ED were negative. She had a managed Medicare policy which in some hospitals is an automatic admission $$$$$ (until they get denied) Pain should be treated but addiction should be addressed. If that patient were to overdose while in a hospital bed who do you think will be the first discipline to be blamed for negligence? Nurses!! I would be reporting this to administration and if they don't address it, then report it to the state. Protect your license!
Strongly suggest you educate yourself about addiction, mental illness, and pain management for addicts and people who are dependent. Learn the difference between addiction, habituation, and tolerance.
In this job, we are told that a patients pain is what they say it is... That being said, a drug user "GENERALLY" has a much higher tolerance for many pain Meds that we administer. Add that to her many other issues, IMO, it is not for us to decide that we need to hold her prescribed meds unless, like another poster stated, it is a safety issue.
Please understand that we are not judge/jury... we advocate for our patients, no matter who they are.
at the ativan comment 
Henryettaann
1 Post
How about instead of judging this poor girl you line up psych to do an evaluation and treat her!