I give in to drug seeking patients

rn/writer, RN · Mar 8, 2011

We live in such a get-rid-of-all-pain-as-quickly-as-possible society that patients really do expect to be pain free. Maybe if they were given better information--that you will get enough relief to help you move but you probably won't feel perfect for a little while--they wouldn't be so alarmed when some lower level pain still exists.

When we create this false expectation by not preparing people for reality, we foster the idea that something must be wrong if they don't feel 100% by POD 2.

That said, I'm not going to play tug-of-war. If something is ordered for pain and it's time, I educate the patients and then give them their meds.

Horseshoe, BSN, RN · Mar 9, 2011

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.

Bravo. It's absolutely amazing to me how many nurses have zero understanding of the distinction between dependence and addiction.

creativemom, BSN, RN · Mar 16, 2011

:eek: I'm just shocked here to hear the reasons why RN's just "give in" with drug seekers.

I agree on the one hand that with long-term narcotic use that their bodies will develop a "tolerance" therefore their pain may require more medication to satisfy the body in order to feel less pain. But then my question is when do you stop? When do you try to get the patient to come off of these meds?

I work on a colorectal floor. Because of narcotics they end up on our floor with resections due to "narcotic bowel" whereby the bowels won't move any more due to getting all those pain meds and had the RN's from other floors tried other therapies and/or to wean them from drug dependence they wouldn't end up on our floor with resections after resections due to the dead bowels.

I dunno. It's a hard call. There are some patients that are in chronic pain that need to be in pain management therapies like we have at our hospital that uses a whole multiple of things to help manage their chronic pain.

But then there are truly drug seekers and with our experience we can tell who they are. I'm not saying to not deal with their pain issues, all I'm saying is that you are not doing them a favor by giving them all they can get + some. You're then being a legal drug dealer. Treat the pain and try to push for them to get into rehab and pain management.

Believe me, we do this and in the end they go from Jekyll and Hyde :uhoh3: to Mr and Mrs THANK YOU :yeah:for getting me off of those pain meds. I feel better, I am living life now type of people. :up:

Otherwise they end up on our colorectal floor and that's sad...

tthor5220 · Mar 16, 2011

Drummed into your head "pain is the 5th vital sign" and "pain is whatever the patient says it is for them" Right? Isn't that the gospel truth? Or is it gray and cloudy on the horizon?

rn/writer, RN · Mar 16, 2011

I'm just shocked here to hear the reasons why RN's just "give in" with drug seekers.
I agree on the one hand that with long-term narcotic use that their bodies will develop a "tolerance" therefore their pain may require more medication to satisfy the body in order to feel less pain. But then my question is when do you stop? When do you try to get the patient to come off of these meds?
I work on a colorectal floor. Because of narcotics they end up on our floor with resections due to "narcotic bowel" whereby the bowels won't move any more due to getting all those pain meds and had the RN's from other floors tried other therapies and/or to wean them from drug dependence they wouldn't end up on our floor with resections after resections due to the dead bowels.
I dunno. It's a hard call. There are some patients that are in chronic pain that need to be in pain management therapies like we have at our hospital that uses a whole multiple of things to help manage their chronic pain.
But then there are truly drug seekers and with our experience we can tell who they are. I'm not saying to not deal with their pain issues, all I'm saying is that you are not doing them a favor by giving them all they can get + some. You're then being a legal drug dealer. Treat the pain and try to push for them to get into rehab and pain management.
Believe me, we do this and in the end they go from Jekyll and Hyde to Mr and Mrs THANK YOU :yeah:for getting me off of those pain meds. I feel better, I am living life now type of people.
Otherwise they end up on our colorectal floor and that's sad...

How about giving this pep talk to the docs who are ordering the meds? If narcotics are ordered and the patient says they're in pain above 3/10 and we don't give what is avalable, WE are the ones who get in trouble. Hospitals can be fined heavily for not treating pain properly, and who do you think they will hold responsible?

There needs to be a much greater understanding of how pain works and what meds should be administered when. Not just for the staff but for patients and family members as well. Until that happens, what are nurses supposed to do? Risk getting dinged themselves or getting the hospital in trouble for not addressing serious pain? Arm wrestling with the docs who order too much or too little? Trying to reason with patients and their entourages who see us as the obstacle between them and the relief they seek?

This isn't a one-person, or even a one-discipline, problem. It isn't fair for the powers that be to demand that nurses take pain seriously and treat it quickly and then scold them when they do. A complex problem like telling the addicts from the ones who are dependent from the ones who could become addicted or dependent requires a solid team approach and goals and guidelines that are much more well developed than most of us deal with.

We can try to coax our patients to work with us, but in the end, if they don't, we are pretty much required to give them what they ask for.

If this isn't not the ideal, I'd be happy to listen to better ideas.

cosmicsun · Mar 16, 2011

My experience is drug seekers know what they are allowed to have and when they can have it. And, they ask, how often can I have that. I don't even bother anymore to try to save them from themselves or resist. Otherwise, you will have a patient complaint filed against you. The customer is always right....

heron, ASN, RN · Mar 16, 2011

Disagree that preventing bowel complications is all on the docs ... being on the lookout for untoward side effects is most definitely a nursing task. How about getting a bowel program ordered whenever narcs are ordered? Pretty much all of us know watch potassium levels when lasix is ordered, why not bowel function when narcs are ordered? BTW, I never heard of "narcotic bowel" ... do you perhaps mean "necrotic bowel"? Have never worked specifically in colo-rectal per se, so I could be wrong.

Having worked in hospice for a while, I'm pretty familiar with the progression of events from the order for narcs to bowel obstruction and I know that someone, or many someones, didn't pay attention.

On another note, no-one is advocating blindly feeding opioids to patients. What we're trying to point out is that labelling someone a "seeker" takes a little more critical thinking and knowledge than is customarily exercised, leading to a good deal of unnecessary (and legally actionable!) suffering, both emotional and physical.

rn/writer, RN · Mar 16, 2011

What we're trying to point out is that labelling someone a "seeker" takes a little more critical thinking and knowledge than is customarily exercised, leading to a good deal of unnecessary (and legally actionable!) suffering, both emotional and physical.

This is part of what I was trying to say, but you said it much better.

I get the "narcotic bowel" reference. Patients can develop an ileus primarily r/t opiate usage.

heron, ASN, RN · Mar 16, 2011

I get the reference, too ... just have never heard that particular dx.

tandlsmom · Mar 16, 2011

I don't think it is our place to judge anyone on their pain level. I am an RN and I have suffered for many years with migraine headaches. They can be excruciating, causing nausea and vomiting. The most frustrating thing to me was going to the ER, and sensing that they were not willing to give me pain meds because of their thoughts on "drug seekers". I truly hate hearing that term and I feel it can cause very discriminating views about our patients. I am now 50+ yrs old and seldom have any more headaches. Was I a drug seeker???

Up2nogood RN, RN · Mar 16, 2011

I get the reference, too ... just have never heard that particular dx.

I have heard a few of our surgeons use the term narcotic bowel in the progress notes but official dx would be bowel obstruction of course. It's a vicious cycle with our young 20 something crohn's, ulcerative colitis patients. Some are in every few months at least with obstructions....anywhere from 4-8mg dilaudid IV Q 1 hr PRN, npo, ngt, tpn, surgery for LOA, increase the pain meds post op. Some will adamantly refuse the pca because of course we know the real reason is the bolus isn't tbe same as that 4 mg but I hear the craziest things and it just pi$$e$ me off that the pt thinks I'm that stupid.

All I can do is encourage to wean off and suggest maybe tbe reason you haven't had a bm in 3 weeks is perhaps all the pain meds? These kids have really educated themselves on their disease but turn a blind eye to how narcotics adversely affects their bodies. Most are still in their adolescent phase when their disease emerged. The patient and usually mother can be extremly difficult to even reason with. I say less narcotics and more psychotherapy. And the surgeons? They go along with the pt usually to avoid a phone call at 0300 from the nurses.

Up2nogood RN, RN · Mar 16, 2011

Just wanted to add, on my unit we don't use the term 'drug seeker'. If there is a tolerance obviously they have some sort of issue but it's really not fair to judge without walking in that patients shoes.