IV Dilaudid problem patients!!!!!!!!!!!

chenoaspirit, ASN, RN · Feb 27, 2009

I had a patient just 2 days ago who would refuse pain meds when offered (he was surgery patient). I couldnt believe how stoic he was. BUT....yesterday he decided to try the pain med. He liked it, then asked for it again. He finally told me that his pain was a 0, he wasnt hurting, he just liked how it made him feel. So then he was asking for it every 3 hours. He then asked the doc for a script on discharge, the doc told him that most people dont need it for the type of surgery he had. He will be probably be leaving the hospital a different person than on admission. I hope he doesnt end up with a problem.

leslie :-D · Feb 27, 2009

I had a patient just 2 days ago who would refuse pain meds when offered (he was surgery patient). I couldnt believe how stoic he was. BUT....yesterday he decided to try the pain med. He liked it, then asked for it again. He finally told me that his pain was a 0, he wasnt hurting, he just liked how it made him feel. So then he was asking for it every 3 hours. He then asked the doc for a script on discharge, the doc told him that most people dont need it for the type of surgery he had. He will be probably be leaving the hospital a different person than on admission. I hope he doesnt end up with a problem.

lol, some folks don't even try to hide the fact that they love their buzz.

i'm sure he'll smarten up, for all the wrong reasons.

heh.

funny and sad at the same time.

leslie

hdhnurse · Feb 27, 2009

Dilaudid is highly over prescribed and it is a dangerous drug.....how many of you have had to narcan a pt. after dilaudid? In our facility we have done it several times.....for those of you who say not to question just give it. This is dangerous practice.

Drug seekers will lie, manipulate, steal and even self-medicate in between their allowed doses of dilaudid. I for one do not want to a party to such behavior or an enabler. I will medicate for pain but if something else is ordered I will try that first before moving on to dilaudid.

Every nurse should read up on dilaudid and the type of medication that it really is. The doses that are being given by the nurses on this forum are way above the recommended doses. Keep in mind that 1 mg of I.V. dilaudid is equal to 5 mg of I.V. morphine.

Take some time and do some research on this drug. Here's a link to get you started http://http://www.merck.com/mmpe/print/lexicomp/hydromorphone.html

hereigoagain · Feb 27, 2009

I never refused to push the Dilaudid (even if I did not agree with it and even the dr. didn't deep down, but the patient just wanted it so bad and the chaos that pts addicted to Dilaudid can make in an ER is just something else...so I do not blame the docs and I am not judging the pts pain either) and my point is...I had patients that just came to the ER saying that they take Dilaudid and they need some...just as plain as this and the tired doctor just gave it to them, so we can open up the ER for the real patients (yes, I said "real patients"), that needed help so bad (head bleeds, trauma, PE's etc. you name it). Everybody talks here how it is unfair to keep a patient from getting pain medication and that we can not judge someone else's pain...blah...blah...blah...but the reality is, when you see a patient who's whole life revolves around getting the next dose, you have to say something that might snap them out of the Dilaudid seeking madness. And again, please don't confuse the seekers with the patients that have trauma, cancer, fractures etc. Dilaudid seekers need a good dry out in a mental facility, so they can become regular people again, contributors to society (none of my Dilaudid seekers were working adults), enjoy their life and stop making their families life MISERABLE with their disease that's curable. And when they are too much deep into their didease to realize that their behaviour is distructive, who the hell is suppose to pay to their attention that they have an addiction problem, who else than us, the health care providers? So let's be honest and just say that we are burned out of trying to make them realize that they need help...it is not that we don't want to give it to them or whatever. I will continue to say something when I consider necessary. That is what I chose to do.

emtb2rn, BSN, RN, EMT-B · Feb 27, 2009

pt: "Can you push it fast? The last nurse did"

me: "No."

hdhnurse · Feb 27, 2009

Let me make another point.....Every patient that I admit to my floor I have to ask them if they are a smoker. It they say yes I am required to give them a smoking cessation packet. Smoking is an addiction....smoking kills and it is hard to quit.

So why am I trying to change a patients smoking behavior by addressing this addiction problem but when it comes to narcotic and prescription drug addiction no one wants to talk about it. It is not "politically correct" to inquire about a patient's drug use?

Drug addiction causes tons of other medical conditions and affects not just the drug addict but everyone around the addict.

We may not be able to change the behavior of the drug seeker but we can stop giving them the high that they want. In my research on Dilaudid I came across an article that said Dilaudid produced the same feelings as shooting up with heroin.

Yeah.....that's what I went to nursing school for....I am now your legal drug pimp!!! Just call me Nurse FeelGood.

eriksoln, BSN, RN · Feb 27, 2009

Let me make another point.....Every patient that I admit to my floor I have to ask them if they are a smoker. It they say yes I am required to give them a smoking cessation packet. Smoking is an addiction....smoking kills and it is hard to quit.
So why am I trying to change a patients smoking behavior by addressing this addiction problem but when it comes to narcotic and prescription drug addiction no one wants to talk about it. It is not "politically correct" to inquire about a patient's drug use?
Drug addiction causes tons of other medical conditions and affects not just the drug addict but everyone around the addict.
We may not be able to change the behavior of the drug seeker but we can stop giving them the high that they want. In my research on Dilaudid I came across an article that said Dilaudid produced the same feelings as shooting up with heroin.
Yeah.....that's what I went to nursing school for....I am now your legal drug pimp!!! Just call me Nurse FeelGood.

Most admission forms I've dealt with also have a section for "recreational" or "non-prescrbed" medications. Same as the smoking question, if they answer yes, consults and interventions are initiated.

Plus, and this is for everyone who feels burnt by the addicts who frequent the floor:

I think we can come to an understanding that no passive aggressive intervention you implement (holding meds, telling them face to face you think they have a problem, taking extra time to get the med, dilute the med. and give over an hour so there is no high etc) is going to make the addict sit bolt upright in bed and proclaim "Yes, I am a horrible person, I must change now, thank you Nurse Ratchet." They are going to change when they are ready and willing, not a second before, you are not powerfull enough to make it happen any sooner.

With that in mind, what scares me most about nurses who take it upon themselves to be so cavalier towards addicts is............in the back of my mind, I know their other patients are being neglected. More than anything else, if you let them, an addict can monopolise you. When you bear arms against them, you are letting them win. They will have you argueing about what you do and defending what you have done ALL DAY if you take this route. So, in your attempt to teach the addict a lesson, you really only accomplish upsetting other patients who need you and have to go without. Thats a shame.

leslie :-D · Feb 27, 2009

but regarding what you said being cattering to these pt's and many doc's and nurses do just that because its easy-- give them there dilaudid they will shut up for hr and two and the whole process starts all over again.
so, what are you really upset about?
that they require your attn every 1-2 hrs, or that they're addicts?
i am a non-judgemental nurse and a great one at that but yes i don't care about my job they can fire me if they want but i will not back down in making pt's and some docs realize that they have this addiction!!!!!!!!

i'm struggling with your self-perception of being non-judgemental.

so, you'd be ok if these folks all got pca's, requiring little to nothing of your time?

it is a valid grievance, when their demands exceed the actual time we have to give.

i'm just wondering if there'd be much less resentment if pca's were the godsends to these folks.

leslie

Roy Fokker, BSN, RN · Feb 27, 2009

I'd like to ask a few questions. I'm just interested in the responses. Please - no judgment, no 'implications' of anything. Just some questions and hopefully, I'll have some thoughtful answers :)

Q: How many nurses here have seen/believe it possible to have 10/10 pain (for example) - with no change, alteration, abnormality (and/or any combination thereoff) in the pts. vital signs? I'm obviously talking about AOx3 patient here.

Q: "Pain out of proportion to exam" is a valid, medical concern. How does this relate to "pain is whatever the patient feels/reports?"

Q: How many nurses here use qualifiers when describing the pain scale to patients (E.g.: "Mr. John Doe, how bad is your back pain? If I were to ask you to describe it on a scale of 0-10 with 0 being no pain and 10 being the pain you might feel if someone shot you in the chest or set your arm on fire, what number would you rate your back pain right now?")

Q: Follow up to the question above - is the use of such 'qualifiers' valid (or how about ethical?)

cheers,

eriksoln, BSN, RN · Feb 27, 2009

I'd like to ask a few questions. I'm just interested in the responses. Please - no judgment, no 'implications' of anything. Just some questions and hopefully, I'll have some thoughtful answers :)
Q: How many nurses here have seen/believe it possible to have 10/10 pain (for example) - with no change, alteration, abnormality (and/or any combination thereoff) in the pts. vital signs? I'm obviously talking about AOx3 patient here.
Q: "Pain out of proportion to exam" is a valid, medical concern. How does this relate to "pain is whatever the patient feels/reports?"
Q: How many nurses here use qualifiers when describing the pain scale to patients (E.g.: "Mr. John Doe, how bad is your back pain? If I were to ask you to describe it on a scale of 0-10 with 0 being no pain and 10 being the pain you might feel if someone shot you in the chest or set your arm on fire, what number would you rate your back pain right now?")
Q: Follow up to the question above - is the use of such 'qualifiers' valid (or how about ethical?)
cheers,

1. I totally think my food poisoning was a 10/10, but my vitals were fine.

2. "Pain is whatever the patient reports" still trumps all. The exam may have missed something or something will be revealed with pending test results.

3. I dont use qualifiers, but I do give more depth to the scores people are reporting. I go on to explain the pain scale has meaning, its not just something we jot down so JACHO has something to monitor (even thats about what its become). I tell my patients:

1-3 score is "tolerable" pain.

4-6 score is worsening pain, this is when you want to call me. If I intervene here, my intervention will be more effective.

7 if you have not called me, do so.

8-10 severe pain. My intervention will not be as effective for you. If you reach this point before meds are due again, the MD needs contacted. If you reach this point because you waited to tell me, I can intervene the same way I would when the score is lower, but it wont work as well.

heron, ASN, RN · Feb 27, 2009

Let me make another point.....Every patient that I admit to my floor I have to ask them if they are a smoker. It they say yes I am required to give them a smoking cessation packet. Smoking is an addiction....smoking kills and it is hard to quit.
So why am I trying to change a patients smoking behavior by addressing this addiction problem but when it comes to narcotic and prescription drug addiction no one wants to talk about it. It is not "politically correct" to inquire about a patient's drug use?
Drug addiction causes tons of other medical conditions and affects not just the drug addict but everyone around the addict.
We may not be able to change the behavior of the drug seeker but we can stop giving them the high that they want. In my research on Dilaudid I came across an article that said Dilaudid produced the same feelings as shooting up with heroin.
Yeah.....that's what I went to nursing school for....I am now your legal drug pimp!!! Just call me Nurse FeelGood.

I think the points that some of us are trying to make are:

You need to be sure about whether you're treating pain or addiction ... two separate, albeit frequently related, issues. Yes, addiction needs to be addressed with the pt and with the attending physician, but be clear about your goals of treatment.

Conflating addiction with the normal physiological action of a drug that creates tolerance and physiological dependence can lead to some very bad consequences for your patient. Tolerance does not equal addiction.

The fact that dilaudid creates a similar high to heroin should not come as a surprise ... they're both opioids, after all.

Getting into a power struggle over getting high is a losing proposition ... you are probably playing bad nurse to someone else's good nurse who will then give the poor thing what he wants. It's called staff-splitting.

Yes ... if an addict is hitting his bottom and you happen to be on hand to offer intervention, you can indeed support a healing process ... but that doesn't happen just because you decided it was time. It is reasonable to raise the subject when you can, on the off chance the pt might take you up on it. Just don't get so emotionally invested in a positive response. Be aware that when the pt says, "Oh, yes ... I want help" that there's a 50/50 chance that you are getting played ... being set up as the "good nurse".

Giving opioids to an opioid addict is not "playing drug pimp" ... it's preventing withdrawal ... trust me, you don't want to be dealing with withdrawal symptoms on top of whatever the pt is in the hospital for to begin with, which you're not monitoring because you're too concerned with his addiction. ( BTW, abdominal pain is a major symptom of opioid withdrawal ...). As for the pt getting high ... see the point above regarding power struggles.

None of this has anything to do with being PC ... and I'm really tired of having that phrase being trotted out everytime someone points out that the issue might be a bit more complex than you want to think ... and that there might be something wrong with the assumption that we, in our professional majesty, can control a pt's addiction.

Treating pain in an addicted patient is complicated and usually requires careful teamwork. You need to define your goals of treatment and come up with a plan that minimizes the openings for manipulation (ie no order changes in less than 24 or 48 hours, no "waffling" re administration times - a pca could help this, since lock-outs are programmed in, one and only one provider writing orders, etc.) Clonidine can be considered to cope with cravings. You need to get the doc and the rest of the staff on board ... and this is usually a challenge.

Just get your ego out of the mix ... otherwise, chances are you will be danced around O'Houlihan's barn and, guess what ... the addict will still be getting high!

heron, ASN, RN · Feb 27, 2009

I'd like to ask a few questions. I'm just interested in the responses. Please - no judgment, no 'implications' of anything. Just some questions and hopefully, I'll have some thoughtful answers :)
Q: How many nurses here have seen/believe it possible to have 10/10 pain (for example) - with no change, alteration, abnormality (and/or any combination thereoff) in the pts. vital signs? I'm obviously talking about AOx3 patient here.
Q: "Pain out of proportion to exam" is a valid, medical concern. How does this relate to "pain is whatever the patient feels/reports?"
Q: How many nurses here use qualifiers when describing the pain scale to patients (E.g.: "Mr. John Doe, how bad is your back pain? If I were to ask you to describe it on a scale of 0-10 with 0 being no pain and 10 being the pain you might feel if someone shot you in the chest or set your arm on fire, what number would you rate your back pain right now?")
Q: Follow up to the question above - is the use of such 'qualifiers' valid (or how about ethical?)
cheers,

Good questions ...

My late partner had chronic hip/back pain that she rated 8-10/10 ... you would never know it to look at her and I'd bet that her vitals never changed. Much depends on the individual's response and whether the pain is new/acute or chronic. I see a similar phenomenon among some of my hospice patients. People can adapt in amazing ways.

A point: it's been shown that people addicted to opioids have much lower levels of endorphins than non-addicts. Whether this is an effect of addiction or a cause is not known. The take-home message is that the addict's subjective experience of pain, both physical and emotional, is probably quite different from the non-addict's.

"Pain out of proportion to exam" is an important red flag that something else might be going on besides the presenting complaint ... drug seeking is right up there with histrionic personality disorder and other hidden agendas. It is not, however, definitive for addiction. Since there's no way to know for sure without reading the pt's mind, I still have to go with "pain is what the pt says it is".

Qualifiers with the rating scale are helpful ... it's a hard question for many to answer ... too abstract. How would it be unethical? Is the concern that the questioner is trying to "steer" the answer?