I give in to drug seeking patients

allnurses Guide · Mar 8, 2011

Erin - I know the parameters for admission to hospice are widening, but my understanding would be that unless the patient initiates the desire to cut down the pain meds so they can be more mentally with it when family visits or something like that, trying to withdraw narcotics or in any way limit access to them to cure an addiction is not a consideration. I understand end-stage cancer patients can tolerate bucketloads of morphine and sometimes still be in pain. Does your facility try to wean terminal people off of narcotics because of fear they will become addicts?

rn/writer, RN · Mar 8, 2011

Erin - I know the parameters for admission to hospice are widening, but my understanding would be that unless the patient initiates the desire to cut down the pain meds so they can be more mentally with it when family visits or something like that, trying to withdraw narcotics or in any way limit access to them to cure an addiction is not a consideration. I understand end-stage cancer patients can tolerate bucketloads of morphine and sometimes still be in pain. Does your facility try to wean terminal people off of narcotics because of fear they will become addicts?

I don't want to speak for Erin, but I took her post to mean that they are giving the patient narcotics in sufficient amounts and at short enough intervals that her pain and her addiction are able to find some kind of balance. A delicate dance if ever there was one. This patient is fortunate to be in the hands of people who know what they're doing and who care enough to do it.

BabyLady, BSN, RN · Mar 8, 2011

I used to feel that way.
Until that same chronic back pain 30 something year old guy who has had a huge workup multiple times, has just shown up for the 3rd visit this week. He was just given a take home pack of Oxy's, a script, and shouldn't be back for back pain and certainly shouldn't be out of his pain meds, but oh yes, his prescription was stolen.... again.
yeah, right. Meanwhile, I have a patient who is having an MI, a child with RSV, vag bleeding patients.... blah blah blah.... easy to see why most of us call it like we experience it. For the obvious seeking behavior they display.

I look at it this way...I still get paid whether they receive the drugs or not...I do not have prescriptive authority and the person that gets their prescription records audited and can get them removed by the state is the physician...not me.

Patient should be seen in the ER in accordance with acuity. So the MI gets seen before the stumped toe that only "Lortab 5's" will work on and I wouldn't feel guilty about it.

MassED, BSN, RN · Mar 8, 2011

I look at it this way...I still get paid whether they receive the drugs or not...I do not have prescriptive authority and the person that gets their prescription records audited and can get them removed by the state is the physician...not me.
Patient should be seen in the ER in accordance with acuity. So the MI gets seen before the stumped toe that only "Lortab 5's" will work on and I wouldn't feel guilty about it.

that is true, but those chronic seekers suck the life right out of you and are constantly on the call light when you're with an acuity 2 (ESI system) that is a work up. It's the manipulative behavior that frustrates me to no end. Pain meds, fine, but the manipulation along with it is what I can do without.

allnurses Guide · Mar 8, 2011

I don't want to speak for Erin, but I took her post to mean that they are giving the patient narcotics in sufficient amounts and at short enough intervals that her pain and her addiction are able to find some kind of balance. A delicate dance if ever there was one. This patient is fortunate to be in the hands of people who know what they're doing and who care enough to do it.

I guess I don't know all the details of hospice care. I thought that if you are in hospice, it's because all available options for your recovery have not worked, so you aren't likely to be discharged as an addict. So what would be the purpose of treating an addiction? If that diagnosis is in the care plan, how would you know if your interventions were effective (as the goal for that is to abstain from the drug altogether). Just to take off the shellac, a successful treatment of addiction in a terminal patient would be to get clean and sober and then die.

If the patient initiates it they know up front their pain levels will increase - like a family visit, and yes then it would be a balance. If it's initiated by the nurses, it seems that all the patient education and teaching about withdrawal symptoms would sort of a barrier to that patient getting the pain meds they requested, or if they asked for more pain control, the nurse would have to find some other way to assess the patient''s pain level than the patient saying their pain isn't being controlled - again not sure why you'd need to consider anything else. The most frequent thing I hear from patients/family members when they transition to hospice is what a relief it is that they won't have to futz around with the need to (more plain language) negotiate and justify themselves to skeptical nurses. I guess if you have to be in hospice at all, you can at least expect that business to be over with.

Thanks for sharing your thoughts and sorry it was so long!!:)

rn/writer, RN · Mar 8, 2011

I guess I don't know all the details of hospice care. I thought that if you are in hospice, it's because all available options for your recovery have not worked, so you aren't likely to be discharged as an addict. So what would be the purpose of treating an addiction? If that diagnosis is in the care plan, how would you know if your interventions were effective (as the goal for that is to abstain from the drug altogether). Just to take off the shellac, a successful treatment of addiction in a terminal patient would be to get clean and sober and then die.
If the patient initiates it they know up front their pain levels will increase - like a family visit, and yes then it would be a balance. If it's initiated by the nurses, it seems that all the patient education and teaching about withdrawal symptoms would sort of a barrier to that patient getting the pain meds they requested, or if they asked for more pain control, the nurse would have to find some other way to assess the patient''s pain level than the patient saying their pain isn't being controlled - again not sure why you'd need to consider anything else. The most frequent thing I hear from patients/family members when they transition to hospice is what a relief it is that they won't have to futz around with the need to (more plain language) negotiate and justify themselves to skeptical nurses. I guess if you have to be in hospice at all, you can at least expect that business to be over with.
Thanks for sharing your thoughts and sorry it was so long!!:)

I wasn't addressing the addiction like it's something to be prevented. IMO it's absolutely insane for terminally ill patients to have to fight for their meds so they "won't get addicted." That's one of the purposes of hospice--to give patients a "place" where they don't have to explain the dynamics of medicating a dying patient properly. So what if they were addicted to begin with or become addicted/dependent toward the end. It's not as if they have to pass a drug screen for employment. You get it, but many don't.

I was speaking more about achieving a balance between effective pain relief and unintentional lethal overdose.

heron, ASN, RN · Mar 8, 2011

Even in hospice, you would have to deal with the addiction ... which is includes a set of behaviors geared towards obtaining more of the drug. Keeping an addict out of withdrawal is usually the goal rather than getting them "clean". Of course, if the addict wants to get clean before death - and I've met a couple that did - the hospice would try to work with that.

My end-stage AIDS patients back in the 90's were pretty much all addicts (we were a unit in a state public health hospital). The addiction and the pain were treated as two different, albeit possibly related problems. We kept them out of withdrawal with methadone and treated pain with morphine, both short and long acting. Nowadays, they would probably use suboxone or something, and morphine, dilaudid or methadone to treat the pain.

In any case, the key is establishing trust ... the patient must trust that staff will not allow her to be in pain OR undergo withdrawal. The hospice staff must trust that the patient is being honest about what she needs and why she needs it. It's the only way to control the behaviors that are part of the addiction syndrome.

ETA: to expand a bit Miranda's point ... dependance and addiction are two different things. That a terminal patient on opioids will undergo withdrawal symptoms if the opioid is stopped does not equal addiction, any more than a CHF patient is "addicted" to cardiac meds because s/he will decompensate if they are stopped. It's called tolerance and is a normal physiological response to the particular med.

Addiction, on the other hand, is the mis-use of psychoactive drugs for purposes other than that for which they were prescribed, in spite of negative life consequences. It usually involves the development of manipulative and dishonest behaviors in an effort to obtain the drug, either to get high or to stay out of withdrawal.

Just to confuse matters, there's pseudo-addiction, in which the patient uses behaviors typical of the addict to obtain treatment for inadequately controlled pain.

Definitely a fine balancing act.

rn/writer, RN · Mar 8, 2011

Thank you for doing such a wonderful job of explaining this. I take my hat off to those of you who do this intense kind of nursing. And I that some like you are available should me or mine ever need this kind of help. :up:

CoffeeRTC, BSN, RN · Mar 8, 2011

Bogs down the system on the floors too, dropping everything to give frequent pain meds, especially if you have multiple pts with frequent pain med orders. I like PCAs so the patient can administer his own meds, but MDs seem reluctant to order them for some reason.

This is nursing everywhere now. Thankfully, I'm not dealing with life and death like in the ER.

Sad, but I think most of my pts were set up for addiction. Our LTC is more of a short term rehab now with tons of rehab for knees, hips, wounds etc. Often times these people are coming to us with a long history of pain and taking large doses and frequent does of pain meds at home prior to surgery. After the surgery..pain is expected with therapy and normal healing process related to the procedures etc BUT, weeks after when the pain should be lessening...these folks are still wanting the large amounts of pain meds every xyx as ordered PRN......tolerance vs addiction????? When does it end.

heron, ASN, RN · Mar 8, 2011

This is nursing everywhere now. Thankfully, I'm not dealing with life and death like in the ER.
Sad, but I think most of my pts were set up for addiction. Our LTC is more of a short term rehab now with tons of rehab for knees, hips, wounds etc. Often times these people are coming to us with a long history of pain and taking large doses and frequent does of pain meds at home prior to surgery. After the surgery..pain is expected with therapy and normal healing process related to the procedures etc BUT, weeks after when the pain should be lessening...these folks are still wanting the large amounts of pain meds every xyx as ordered PRN......tolerance vs addiction????? When does it end.

Quite possibly both, depending on the patient. Sometimes we taper too fast and run into the early stages of withdrawal: anxiety, craving and agitation. The key is to try to discern with the patient what it is that we're treating ... is it the pain or the mood?

It's a particularly hard nut to crack in your setting, as you seldom have access to pain management specialists or the time for really intense care planning ...

nerdtonurse?, BSN, RN · Mar 8, 2011

I just had abdominal surgery (TAH, BSO), and was blown away by how willing people were to give me narcotics in large amounts! I got rid of the PCA within 12 hours, was walking the halls the next day after surgery, and home the day after that. I had 22 staples, stage 4 endometriosis where the surgeon had to "scrape" a lot of my intestines and remove adhesions and fibroids the size of grapefruit. Rather than expecting to be "pain free" I went for "enough med so that I could move" -- and move I did. Yes, it hurt, no it wasn't comfortable, and I'm still not "pain free" and I may never be. I only took limited amounts of narcotics the first 2 weeks, and I've been on nothing but Aleve and Advil since. I'm also up to walking a mile 3 weeks post surgery. Doc says I'm doing great, and he told the med students at my post op visit "this is the recovery you see when the patients get off the narcotics as soon as they can."

I don't want anyone to hurt, especially if they're osteo, onco, etc., and if they are hospice, I will keep you pain free if it's chemically possible to do it; worrying about addiction is crazy at that point. However, if you keep patients stoned to the point where it negatively impacts their recovery, you are not helping them get better, and that's what it's about. I've seen too many people die because they had real problems (MVA, back injuries, etc.) where the family took them home and didn't make them move because they hurt, and got the scripts increased for dilaudid everytime the patient said "ow." They come back on amazing amounts of narcotics with bowel obstructions, decubes the size of your hand, DVTs, still refusing to move, turn, deep breathe, they get pneumonia, end up on vents, and they die. When they didn't have to, from survivable conditions and accidents!

I can't help an addict....the addict has to decide to save himself, and I will move heaven and earth to get them a placement when then do. But I also think we need to teach post surgical and people with non-terminal painful conditions not to expect "pain free" and to understand that narcotics beyond what makes it possible for you to deep breathe, get up, walk, etc., make you worse, not better.

allnurses Guide · Mar 8, 2011

. . .I was speaking more about achieving a balance between effective pain relief and unintentional lethal overdose.

Exactly what occurred to me after I had written my tome, I was reticent to add more - I can see how your window narrows when there is a high baseline tolerance. Thanks. :)