IV pain meds standards??????

classicdame, MSN, EdD · Sep 13, 2012

your reasoning is faculty. For one thing, people who are frequent flyers will continue to come in. They will start having withdrawals. Another thing, maybe they have a chronic pain situation that is not being treated adequately (counseling, physical therapy, etc). My theory is that you are not going to have the time to do behavioral management. As long as the med is ordered and the vital signs are ok then give then medication. You cannot judge what someone else is going through and you cannot "fix" it.

psu_213, BSN, RN · Sep 13, 2012

I have a question. The other night I was taking to my house supervisorabout a patient who is a frequent flyer. He is a chronic non compliant patientwho always wants the narcs. This hospital doctors hands out the IV morphine and dilaudidlike it is candy. I told her this is notstandard practice and she said it was standard. According to our pharmacy we givemore than national average. I told her if the doctors stop handing out the IV narcs thenour drug seeking patients would go down to a minimum. How does your hospital dispense the IV narcsand for what. I had a patient who was admitted for toe pain (DM) and had aorder for dilaudid 2mg q2.

In the theory, what you are saying makes sense...however, not giving 'frequent fliers' pain meds will not stop them. Also where did you come up with "nonstandard practice?" I have been in many situations where docs have prescribed what I feel to be way more pain meds than necessary--that seems to be the standard practice. I have seen IV narcs prescribes for pretty much everything...even as 'trivial' as strep throat and sprained ankles.

Anna Flaxis, BSN, RN · Sep 13, 2012

I have a question.
How does your hospital dispense the IV narcs and for what?

We have an Acute Pain Protocol that follows the framework of the WHO analgesic ladder. With a few exceptions (peds, ICU, oncology for example), nearly everybody admitted to the hospital gets the protocol ordered by the admitting hospitalist.

People with chronically painful conditions who are admitted to the hospital will have their regular pain medications ordered as well as the APP for breakthrough pain.

Many people with chronic pain have pain contracts that are flagged in the EHR, so that when a care provider opens up the person's EMR, a screen pops up that notifies them that the pain contract exists. This is helpful for prescribers in establishing a plan for pain control for that person, and allows for better coordination of care between the hospital and the person's PCP.

There are a lot of reasons a person might be "noncompliant" with their plan of care. Many are undoctored, uninsured, have a mental health diagnosis, or lack the psychosocial tools to manage a complex chronic health condition. People that fit these descriptions need social worker involvement to help connect them with resources that will enable them to better care for themselves outside of the hospital. Unfortunately, such resources are scarce, and many people fall through the cracks.

jbluehorseh · Sep 13, 2012

I agree with what everybody is saying. However, when the patient does have everything he or she needs to be compliant then what. our case management make sure the patient has the resources he or she needs. There is a limit to what hospital can do when the patent goes home. the problem is the patient who is addicted to the pain meds are very difficult to treat because wedo not always know if the complaints are true or fake even after all diagnosis have been exhausted. It not just that fact that the doctors order pain meds, it the problem that the first line med is IV morphine or dilaudid. The po meds are not the first line medications. I never want to see patient in pain, but where should the limit be set. the pain med contract make good because the problem is stopped at hospital ER doors and if the patient needs to be admitted then the pain medication is managed from the start. Then the nurse does not have to give the patient IV dilaudid 4mg q2, prn around the clock plus scheduled MS content q12 with a host of other stuff.

NayRN · Sep 14, 2012

Again, it is not your job to decide if the patient's complaints of pain are real or fake. Your job is to administer analgesia within established parameters set by protocol and standards of practice (which are purely physiological)

For example, if your patient has IV dilaudid ordered q2, and their pulse ox is fine and their mental staus and respirations are fine, then it is your job to give the med and monitor for effectiveness.

Get social work involved, discuss the treatment with the doc (if possible) discuss other alternatives.

Their pain med contract is none of your affair. Document well. Practice within your scope, and if there are shifts where you end up giving a patient amounts of dilaudid that would put you and the rest of the hospital staff into a coma, just be sure that you monitor your patient closely. Move them closer to the nurse's station. Put a tele monitor on them. Put them on continuous pulse ox.

Yes it is very frustrating sometimes. It is also time consuming and inconvenient, but it is more so if you fight it. You will sleep much better if you realize that you are there to do a job, not to "fix" every problem that comes in the door. Just because you disagree with following the docs orders when there are no other contraindications doesn't make you right and the patient wrong. Choose your battles. It is what it is.

marmar1231 · Sep 14, 2012

As a nurse and Cancer patient I can tell you please don't judge. Before I was diagnosed with my Leukemia, I went to the ER several times for generalized pain. After awhile I was treated so badly that I just suffered the pain. That was until I was unable to walk and my Leukemia was detected in the ER finally. Til this day I still have this stigma of being a drug seeker with the ER doctors even though they KNOW I HAVE CANCER!! Pain is pain....don't question it or make the patient have to question it.

Imanurse01 · Sep 14, 2012

I have been "lurking" out here for quite awhile, but felt compelled to share my personal experience on frequent fliers who use a lot of IV narc's. This pt. repeatedly admitted for abd pain, had every workup known to modern medicine, including exp. surgery. No source of pain could ever be found. Always prescribed Dilaudid 2mg Q2 hr. IVP, then begging & screaming for it early. As Nurses we always dreaded her arrival, knowing we weren't helping her. She was non-compliant & would "sneak off" the unit after getting her Dilaudid, go outside & smoke until time for the next dose. We were told to document everytime she did that & we faithfully did so. The MD refused to listen to our concerns & angrily (!) told myself & another Charge RN to "just give it to her". In 10 months time, she was admitted 16 times. The last admit, she was found dead in a visitors bathroom, off the main lobby, about 45 min. after her last dose of IV Dilaudid. Her toxicology report was + for opoids, diazepenes & THC, & an old pill bottle with lots of different pills in it was found in her personal belongings. I was off duty when this happened, but the family is now engaged in litigation against the hospital & the MD.

Jory, MSN, APRN, CNM · Sep 14, 2012

The doctor's job is to prescribe and he is the one that will be held the most liable...that is why his malpractice insurance is tens of thousands and a nurses is less than $200 a year....it's because we are RARELY sued.

Your job is to communicate your concerns, give an objective opinion and chart appropriately. Your job is to give the medication in the correct location as ordered and to make sure that it is not a lethal dose.

That is where your liability ends...you'll just INCREASE your liability and get a reputation as a difficult nurse to work with if you start trying to "save" the frequent flyers.

In all due respect to Imanurse1...since you were off-duty, I would be wary if you got an accurate account of what is going on with that case. A doctor is not responsible if a patient lies about what they are taking and cannot be held responsible if an adult walks in, asks for drugs for pain, is assessed to need pain meds by the doctor...yet brings in more narcotics and takes them on top of what is given and the hospital has no knowledge of it.

Seriously...I would be willing to bet a whole paycheck that isn't the whole story. We cannot legally search their bags, we can't go into the bathroom with them, and I have been told that you cannot drug test them on arrival because of HIPAA.

If I got sued as a nurse under those circumstances, that is the one time that I wouldn't even stress over it.

tweetRN · Sep 14, 2012

As a nurse with chronic severe pain due to a botched foot surgery (6 other surgeries to try and fix some damage) this subject is one I'm passionate about so here is my 2 cents worth...While i do agree there are those frequent flyers that come seeking pain medicine only, it's not our job to decide if they are in pain or not. You can not tell by looking at a person if they are hurting. I walk around for 12 hours with a pain level of 7+ most days and those that do not know me or about my condition could never tell. And i can walk around on doses of pain medicine that would put you to sleep and no one knows. My point is, what was drilled in to our heads as students, "pain is what the patient says it is." So if the pain medicine is ordered and VS are stable give the med. And if you think the pt is drug seeking talk to the dr about it. It's important to build good rapport with your drs so you can have conversations like this. Maybe something is going on with the pt you aren't seeing. Maybe not. But talking to the dr will give you better understanding of why the meds are ordered the way they were. I've talked to drs about this many times, often times resulting in a change in the pain meds ordered. I find many times it's the er docs ordering the iv stuff not knowing the frequent flyers like the hospitalists do. Quit judging. That's not part of nursing.

mrcnstnc · Sep 14, 2012

Sadly I don't know if there is a "perfect" solution for the frequent flyers, the non compliant, the "drug" seekers. Pain is subjctive, and everyone's tolerance is different. And of course is it the old adage of which came first the chicken or the egg? Do medical professionals start the problem by over prescribing pain medication for conditions that may be treatable with ibuprofen or tylenol? Then scream bloody murder when they have an "addict" on their hands.Or is the person someone with an "addictive" tendancy in the first place, who really knows While these "types" of patients are at best frustrating and time consuming they are still our patients and while I agree ancillary staff such as social workers etc are benificial, who's to say they will comply with that, when they are in pain all they want is something to relieve it. We're human, we're nurses, and the tendancey to "judge" is compelling at times, we have a job to do, and if the Doc orders it give it. I battled this many times in my career, I've even worked with doctors and nurses who are addicted themselves. We can't change another we can only ask for the peace and serenity to accept the things we cannot change. There are support groups for people who deal with "addicts" maybe that would help to facilitate a better attitude on all our parts.

nerdtonurse?, BSN, RN · Sep 14, 2012

Just give the narcs. You're not going to change them, and they'll make your shift Hades if you don't. An addict will seek their drug/ETOH until they decide to stop, and nothing you do or don't do will change them.