Lady keeps "losing her pain patches"

[Blackcat99]

I work in a nursing home. There is a lady who is suppose to get a Fentanyl 100 pain patch every 3 days. However, it seems that every other day she is "losing her pain patch" and is always asking for a "new pain patch" because she "lost the patch"

What do you think is going on with this lady? Do you think she is abusing her pain patches?

[Jewelsforme]

1. Put the patch between shoulder blades. Invest $34 for a box of 100 Tegaderm (sheesh to your facility for not doing this already). Still disappearing?

2. Get one member of administration to implement 'fake' this room is now under video observation for illegal drug activity. No longer disappearing? Was an employee. Still disappearing? Keep video monitoring notice in place, and

3. Implement security cameras, cheap on EBay, store to chip and playback on day of patch disappearance. You will catch the thief. Not a violation of HIPAA if protection of patient from abuse. This is abuse if it is happening.

[heron, ASN, RN]

Alternatively, re-evaluate both her pain control and the underlying condition causing it.

[Tenebrae, BSN, RN]

Why does she need the pain patch?

If she is needing regular analgesia, on top of the fentanyl patch it would suggest to me that the 100cg patch may not be addressing her pain properly

As for them falling off. I've had it happen on numerous occasions to different patients at different times. I would be questioning whats going on

[edmia, BSN, RN]

All good suggestions. I just wanted to point out that Fentanyl is a fat soluble drug and needs to have some subcutaneous fat to be placed on in order for the drug to deliver well. If you're slapping that patch on a bony surface, she's not getting her full dose.

Sent from my iPhone -- blame all errors on spellcheck

[twinmommy+2, ADN, BSN, MSN]

I don't think it's a bad idea to assume that there is some diversion going on until it can be proved otherwise. No-one wants to think badly of other people but if it is true, either someone else is taking it which is abuse, or she is diverting in which case something needs to change as far as what is prescribed (getting her off the patch).

[heron, ASN, RN]

@twinmommy: I would respectfully disagree, based only on the information shared here. Diversion is certainly part of the differential diagnosis but to consider it the only possibility, or even the most likely one, without investigating further, is pretty poor nursing. It can also become a risk management issue.

[ixchel]

If the patch is applied and then disappears completely, I hate to suggest it, but I've learned from a couple of recent ODs that people have been chewing their fent patches. A previous poster mentioned under-controlled pain - if this patient was always compliant before and suddenly is having issues, perhaps adjustments need to be made. Or, perhaps she's reached a tipping point at which addictions consults may be needed so that the patient may safely have a new pain management plan.

[heron, ASN, RN]

@ixchel: I agree but would first consider that maybe the underlying condition that caused the pain might be getting worse.

I've seen end-stage cancer patients on doses as high as 500 mcg Q2days as a result of tolerance plus advancing disease.

Then there's a real zebra: opioid-related hyperalgesia.

My point being that it's a lot more complicated than just "If her pain is not relieved by this drug at this dose, then she must be lying about her pain to get stoned."

We're really saying the same thing: a thorough reassessment is in order.

[WinterLilac]

Brilliant response! Evidence of critical thinking and advocating for this patient. I like the way you think heron. Thanks for this thoughtful response, it has reminded me to utilise critical thinking techniques.