I give in to drug seeking patients

cosmicsun · Mar 18, 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?

Absolutely. It has been made into the patient dictating their pain meds environment... I've even had nurses complain about a nurse on the previous shift that "she has no right to change the doctors' order." "The doctor ordered her meds and she's allowed to have them." The doctors need to change the way they are writing orders, but then again, they make money by having the patients in the hospital - bill Medicaid!

Who pays for Medicaid - us. The drug seekers bill is being paid by us.

stanleyrn · Mar 19, 2011

I hope you are just having a bad day and really don't mean this. If not, I truly feel sorry for your patients and I hope you are never my nurse.

Try spending some time in an emergency room and have the same patients come back day after day, break pain control contracts, and get up and leave when all you offer them is some norco 10s and not the dilaudid they were looking for.

cosmicsun · Mar 19, 2011

Absolutely. It has been made into the patient dictating their pain meds environment... I've even had nurses complain about a nurse on the previous shift that "she has no right to change the doctors' order." "The doctor ordered her meds and she's allowed to have them." The doctors need to change the way they are writing orders, but then again, they make money by having the patients in the hospital - bill Medicaid!
Who pays for Medicaid - us. The drug seekers bill is being paid by us.

I meant I've even had patients (not nurses - just about every nurse I know is familiar with drug seeking patients) complaint about a nurse in the form of "changing the doctor's order" etc. That's how it's been put, by more than one actually. They think it's on the med sheet so they are allowed to have it - PERIOD. (No question, no nursing evaluation, no nothing - and there is nothing anyone can do about it - apparently....)

MJJFan1, BSN, RN · Mar 19, 2011

I just get upset when q4 hours they are 9/10 pain. and then you catch them on rounds using their cell phones to wake them up q4 hours to ask for pain medication.

Bonnie Piper · Mar 19, 2011

[color=#191970]i give in to drug seeking patients

don't...that's what they want you to do. it is a proven fact that drug seeking is different than tolerance. patients that are legitimately in pain and have been on chronic pain medications will not be "seeking" drugs and will comply with the provider's regime. patients that have built up a "tolerance" to a drug, need a drug holiday so that the provider can re-assess the pain levels, and locations of pain and perhaps switch to a different narcotic.

patients that are new to the office and are "seeking" drugs should have other processes completed first. this should include a psychological screening for dependent behaviors, a urine drug screen and an agreement signed before the first prescription is written. an injection or procedure may be helpful in the meantime.

people that walk into your office and say that percocet or vicodin are the only things that work are seeking. personally i feel that vicodin should never be prescribed for chronic pain. there are plenty of other short acting narcotics available. long acting opioids (prevent the "highs") are much better to get the patient to return to their normal adls. they may need a short acting in between, but the goal should be to get as much coverage as possible with the long acting, so the short acting is only used for break through pain.

drug seekers can get drugs on the street and believe me, once you start prescribing to someone that doesn't need pain medicine...they will take what they want and sell the rest. people are desperate these days. also watch out for people that "hang around" the office or parking area...they may be watching to see if a patient gets a prescription, and may follow the patient to their house and may try to rob them of the prescription drugs.

inpatients are usually in acute pain, possibly from a fracture, surgery or other condition related pain. inpatient pain management is different than outpatient. whether controlled by pca or short-acting drugs, the patient has a right to have their pain controlled in order to be able to recover to go home. acute pain management and chronic pain management are very different.

drug seekers do not get my sympathy or cooperation. invite the dea in to speak at your group so that they can help you understand the bigger picture. it was an eye opener to our organization.

good luck!

heron, ASN, RN · Mar 19, 2011

To Bonnie Piper: how do you manage pseudo-addiction? It's not as rare as we want to think.

Bonnie Piper · Mar 19, 2011

Pseudoaddiction is very complicated. There is considerable evidence that it is a complication of tolerance. Drug holidays can also help determine whether it is tolerance or pseudoaddicton. There are procedures available that are controversial but can help. Example is ketamine therapy.

This is why it is so critical to start out right for the pain patient.

heron, ASN, RN · Mar 19, 2011

Agreed ... do you have a bibliography or reading list on the subject of pseudoaddiction? It's not dealt with often in the hospice literature. I gotta wonder whether there's a connection with opioid-related hyperalgesia as well as depression, anxiety and panic.

Bonnie Piper · Mar 19, 2011

A couple good resources are the book Bonica's Management of Pain By Jane C Ballantyne, Scott M Fishman, James P. Rathmell, the article Establishing a Diagnosis for Problematic Drug-Related Behavior

http://www.stoppain.org/pcd/content/addiction/establishing.asp and On the Meaning of "Drug Seeking"

Margo McCaffery, MS, RN, FAAN; Megan A. Grimm, MPH, CHES; Chris Pasero, MS, RN, FAAN; Betty Ferrell, PhD, FAAN; Gwen C. Uman, PhD in Pain Management Nursing 2005;6(4):122-136

MunoRN, RN · Mar 20, 2011

The premise that we shouldn't give in to drug seeking patients relies on us being reliably able to identify true drug seeking abusers, which is largely not the case. We too often misidentify behavior as drug seeking, and often even create the behavior we then attribute to drug seeking in our misguided attempts to avoid giving in to drug seekers in the first place. I think this drug seeker paranoia is a big factor in why we are actually pretty bad a pain control, which is too bad since pain control is so central to what nursing is.

Some common drug seeker myths:

Anyone who is asleep then wakes up complaining of pain is a drug seeker since they couldn't have been asleep with pain: Actually, patients will often sleep even with moderate to severe pain.

A patient who asks you to bring their prn pain meds when they are due is a drug seeker: Not only is this not an unreasonable request, it's actually law in the state of California for post-op patients. Vicoden and percocet are usually ordered every 4 hours for a reason, that's about how long they last. A patient will quickly learn that their pain will return in about 4 hours, and that it gets hard to catch up if they get behind on pain control. Patients only ask for pain treatment every 4 hours because we haven't been doing our jobs in re-assessing their pain about 4 hours after vicoden or percocet, which I've noticed is often because we believe doing so is essentially offering those meds, which is equal to "giving in" to them.

Patients who ask for pain meds when they are not yet in severe pain are drug seekers.: Basic premise of pain control: stay ahead of it rather than play catch-up. Keeping pain proactively controlled actually decreases overall opiate use and improves patient outcomes.

Patients who set their watch to remind them they are due for pain meds or call exactly to the minute they are due are drug seekers: This is more likely due to either inadequate pain control or because the patient has learned if he waits for the nurse to assess and treat his pain that his pain won't be treated appropriately. I have worked with many nurses, and seen nurses proclaim on this site, that Nurses aren't allowed to initiate the pain control process, the patient has to ask, then we accuse them of being drug seekers when they do just that.

linearthinker, DNP, RN · Mar 20, 2011

Last weekend there was a new locum moonlighting in our local ED. Word went out via facebook that there was a new doc in the ED and all the frequent flyers were in there, STAT. I heard he only gives pain meds IM though, so the joke was on them.

As to the premise of the OP, I believe in natural selection. Their addiction is their problem, not mine. I give what is ordered. Or used to, I don't work in that environment anymore. :)

Mudwoman · Mar 20, 2011

We have a board in each room that we can mark on. I put the times they can get their meds on the board. I tell them that I also have the times written down and will bring their meds to them when it is time UNLESS.........

I am busy and in the middle of something with another patient, and I will be there with their meds as soon as I am done.

They have respirations of 12 or less and per hospital protocol, I can't give a narcotic or any med that suppresses the respiratory system.

They have slurred speech or decreased level of orientation and again per hospital protocol.

Saves me from them constantly being on the call light asking if it is time yet.

I don't have to argue with them.

It isn't a fight that I have time for or care to engage in.

I am told by our Case Managers that pain management is no longer a reason to be hospitalized. Don't know how that is working.