Narcotics administration

[schoolmack]

I work on a med-Surg floor where dilaudid is prescribed excessively. Especially to chronic drug seeking pts. We have joked that we think some of the pts are setting an alarm to wake themselves up so the can request more IV medication "when it is due" (actually when the time is up and they can get it again) Anyway, we have confirmed this as fact, and I have a problem administering pain medication to someone who is setting a clock to receive it, not because they are genuinely in pain.

What do you think? How would you handle it? These are frequent fliers and this is a very constant issue!

[wannabecnl]

One responder mentioned this, but I think it bears repeating: set a comfort goal with your patient. Research has shown some improvement in managing pain with various types of patients by asking them not one but 2 questions: "what is your pain on a scale from 0-10?" and then "where would you like that number to be (to be able to cough/ambulate/roll over, etc.)?" You can then educate them about pain control and point out that given their surgery or condition, it may not be realistic to get them to a zero, but maybe they would be happy going from an 8 to a 2... or an 8 to a 5. The number system is so subjective, and we can't really know what a 2, 5, or 8 means to individual people. Setting comfort goals helps to illuminate the patients' expectations and gives us something to shoot for. Patients are happy because they are involved with their care, and nurses are happy because they know what the patient wants.

I worked in the PACU as a student, where almost every patient comes out of the OR with orders for pain meds: fentanyl and oral analgesia if they are going home, and often Dilaudid and/or a PCA if they are staying. Our biggest concerns in the PACU are airway (so we don't want to go too heavy on the opioids while they are still waking up) and ability to cough and deep breathe (so pretty much anyone who has had abdominal or thoracic surgery is going to have to learn splinting and take some pain meds). Even when patients are loopy, you can have this conversation with them. Generally, if they can articulate a pain score, they can articulate a comfort goal.

I really think that setting comfort goals has the potential to increase satisfaction with care AND improve pain management. It may still not work for those who are looking to get high, but it might help address the pain needs of chronic pain sufferers and other cases when we just don't know what they are feeling.

[RNfaster]

I generally believe that most patients report pain accurately. I also have noticed some using narcotics for emotional pain or anxiety (and some of them have told me as much). I let the provider know what's going on in such cases.

I dilute narcotics and push slowly. I am shocked that management (as reported here) pressed some nurses to reduce dilution in order to increase patient satisfaction. I think safety should be paramount.

I have trouble with the patient that reports 10/10 pain and when offered the dilaudid, refuses it as the diphenhydramine push is not yet available...wanting to wait until both may be given together a couple hours later. That seems odd to me.

One other comment...for the cancer patient who set her cell phone so she could get pain meds through the night... It seems to me that a PCA with a continuous dose would have made her more comfortable... Wonder why the doctor didn't order that.

[LTCangel, ADN, BSN, LPN]

I once had a very wise Nurse Manager on my Orthopedic Unit who said during a staff meeting, "Give pain meds when they are due. We will not make them drug addicts in the 3-4 days they are here and we will not cure them if they are already drug addicts." I have always carried this advice in my mind since she gave it because it is true. I know I have encountered true drug addicts in my 16 yrs as a Nurse, but if they are suffering an acute condition then they are going to require MORE pain meds then the average person. It is not my job to judge but it IS my job to be the patient advocate and to give pain meds in a timely manner. Just Sayin'

[BrandonLPN, LPN]

As others have said, I don't really care if the patient isn't really in pain when they request a PRN narcotic. As long as they can safely handle it and there is a legal order for it, why not? It's not like me witholding a dose they don't really need is going to miraculously cure them of their addiction. You need to pick you battles.

[0402]

If it's available, and safe to give, I will give it, if the pt wants it. I redirect when a pt uses the word "due"- that is for scheduled meds. PRNs are available, if needed, at certain intervals. If a pt wants to set their cell phone, I don't really care- we tend to get good report from other nurses on these things, and I will note each time the med is "available" during my shift so that I can plan for it- I'm fine with that. I totally agree with the pp- we are not going to make them an addict, nor cure them of addiction. Safety is paramount and if that is maintained, then they will get the requested meds, as ordered. I will dilute meds appropriately, so that I can push it at a safe rate, and if they'd like to complain, they are welcome to speak with the charge nurse, the manager, the pain nurse, their doc or anyone else- I'm yet to lose that fight. Our hospital just instituted a policy that does not allow the administration of sedating IV meds together- they must be given at least 20 minutes apart. Gone are the days of "I want my dilaudid, benadryl, phenergan, and ativan together." I'm happy to print off the policy and show it, if need be. I do enjoy when the pt tells me that it would be so much easier on me, if I could just bring them at the same time.

This post reminds me of a recent issue we had on our floor. Pt was getting 1mg dilaudid q3h and 6.25mg phenergan q6h. Pt was "stoned," lethargic, slurring her words and nodding off, repeatedly (even trailing off in the middle of sentences); however, VSS. While speaking to the pt, I realized that her statements and behavior regarding her pain and nausea were inconsistent and "off" (some even inappropriate to the situation). After reviewing her hx (which included PTSD from a motor vehicle accident, as well as anxiety and depression), it seemed that she was dealing with psych issues that were being "medicated" by these narcotics/ sedating meds. I requested a psych consult, as an adjustment in her psych meds and/ or further therapy seemed like a better way to deal with what was going on, and I expressed my concern about her LOC and safety matters (she actually did have a fall at a different hospital when given the "magic 3" (dilaudid, benadryl and phenergan) as she requested). Instead of getting the psych consult, they upped her dilaudid to 1.5mg and doubled the phenergan because she told the dr the current doses weren't helping. She was DC'd 2 days later, with no further psych help, and I fully expect to see her very soon. My concern wasn't with the "drug seeking;" it was a safety issue, but what does the nurse know? I only spent 12 hrs at a time with her, talking to her and observing her. The Dr saw her for about 2 minutes. Thanks for letting me vent.

[ORoxyO]

I have had pts set their cell phones to go off every two hours. Did I give the meds, yep yep as long as it was safe..The last pt I had was a CA pt with mets to all major organs. They set their cell phone to wake them when pain meds were due.. Do I think she was in pain, of course, this was her way of keeping the pain under control. She died about 2 weeks after DC home. Some of the other nurses were upset about the alarm, but when you think about it, it makes sense to keep it under control.. Most seekers have some type of chronic pain issue also, it may not be CA but who's to say it isn't real.. I try very hard not to judge, I would hate to be so jaded that I left a person in true pain because I thought they were seeking. Not my job to police meds, if the PCP writes the order for it and it is safe to give, I give.

As someone who has had some pretty painful injuries...I can tell you my eyes were glued to my alarm clock to see when I could pop some more pills...and I took them as soon as my 4 hours were up. Being in pain sucks and when it's all you can think about you bet the clock it watched!

And the worst part is when you are hospitalized and you have to convince someone who doesn't believe you that you deserve your rightfully owed medication. I don't wish that on anyone.

[Jory, MSN, APRN, CNM]

A friend of mine just lost his license because of another nurse that refused to give pain meds to a drug addict and the mess that ensued after that. They restrained the patient on doc orders and got a ua for a drug screen..krazy the pain med should have just been given

Thank you for presenting a perfect example.

This is exactly why if the patient is alert and breathing...I would give the meds and send him on his way.

So your friend lost his license because of a drug seeker...who is probably still using.

[FMF Corpsman, MSN, RN]

Here is what I know. I have both chronic - diabetic neuropathy - and acute pain. I do what I can to keep my pain at bay. Gabapentin 600 mg q8hr will help me if I LOOK AT THE CLOCK and take it q8. If I am distracted and it gets to be 10 hrs, then my lower legs start burning and pinging, and another 1/2 hour goes by before the med helps.

Muscular and joint pains abound as well, and Ibu 800, or norco 5/325 will be my drug of choice depending on the time of day. And when I was in the hospital I waited 2 hours at one point to get my prescribed meds. My anger didn't help my pain, either.

I sometimes cry at home alone.

Merlee, I know your pain, intimately. I've traveled the road you are on for the past ten plus years. I am currently confined to a wheelchair because of numerous diagnoses. Cerebral Stenosis C-1 & 2, and Lumbar Spinal Stenosis L-1 through L-5. Along with the Diabetic Peripheral Neuropathy. At one point, I was on up to 800mg of MS po qd with 60mg MS po Q2 prn for breakthrough pain. I've been on Fentanyl Patches, Oxycodone, pretty much anything in the VA's orificenal for pain control. I finally got tired of the routine, decided it was time for a change, and told them I wanted to come off the narcotics. Typically, I was stuck with a stuck with a dr. that couldn't diagnose a bloody nose at a fistfight and he wanted to wean me off 25 mg q/3 months, and at that rate, I never would get off. I weaned myself off as tolerated and I was off everything within 6 months. It got a little hairy on occasion, but motivation works wonders. Now the problem is, I've ticked off the VA and they've decided not to give me anything for pain. My body has a problem with NSAIDS, it doesn't tolerate them, they don't relieve my pain, and if I stay on them I retain fluids to the point of going into CHF. So, that's a problem of sorts. The only thing the VA will prescribe is Lyrica, commonly used for Fibromyalgia patients. I take 250 mg over the course of a day, and it does nothing for me, so I live racked in pain. I try to do whatever I can to distract myself and sometimes it helps, sometimes it doesn't. Whenever I find myself getting in a cranky mood I try to go find something else to do, but I don't always recognize it in time. So, I do understand pain control, and even the lack thereof, just know you aren't crying alone.

[msjellybean]

I have trouble with the patient that reports 10/10 pain and when offered the dilaudid, refuses it as the diphenhydramine push is not yet available...wanting to wait until both may be given together a couple hours later. That seems odd to me.

This. We have a couple of frequent fliers that always have vague & non-descript complaints of pain, that once they're worked up don't show anything. One of them will wake up, ask whoever responds to his call light for more pain meds & then when I go to assess his pain, he's back asleep and darn near needs a sternal rub to wake. I also gave the benadryl to him once, diluted & put on the pump as a secondary to run over a couple of minutes. Not 20 seconds after walking out of the room, I heard the alarm on the pump going off. Walk in there & he's reeled the pump over to himself by the tubing, has the cartridge door open & is pushing the syringe full of medication into the line.

[turnforthenurse, MSN, NP]

I dilute narcotics and push slowly. I am shocked that management (as reported here) pressed some nurses to reduce dilution in order to increase patient satisfaction. I think safety should be paramount.

Or those who push the drug in fast...I have never had a patient ask me to do that but even if they did, I would refuse and educate them on WHY you don't just quickly push IV pain medications.

I have trouble with the patient that reports 10/10 pain and when offered the dilaudid, refuses it as the diphenhydramine push is not yet available...wanting to wait until both may be given together a couple hours later. That seems odd to me.

That is odd to me, too. I have had patients c/o 8/10 pain and I have offered their medication but sometimes they refuse for whatever reason. I offer other medications that isn't their "choice" and they still refuse. I just document, "pt c/o pain 8/10. Pain medication offered but patient refused at this time, stated, "..." to cover my butt.

[Meep,RN]

It has definitely crossed my mind that some of the alternate pain relief therapies have gone out the window such as meditation, massage etc. but really, who has time for that? Push the drug and let's go. Now, if I had patients like you and me and didn't want to be all screwed up on dilaudid then I would find the time... Also, you have to maintain your boundaries. If they understand the consequences and choose to continue down that path, you just have to protect your own sanity and go along with it with a smile on your face. You can really drive yourself crazy trying to save those that don't want saving.

[imintrouble, BSN, RN]

When I was a newer nurse the drug seekers disgusted me. Then I figured out the angst was all on my side. Since then I waste no time on trying to figure out who is playing me and who's not. I don't care.

If a PRN pain med is due, they get it. If it's not they wait, and I give it as soon as it's due. I don't make them wait. I don't drag my feet. I find that in this kind of environment, I don't have to endure the screaming, moaning or writhing that comes with someone attempting to convince me they're dying of pain. I like to believe the seeker and I come to an understanding. I don't play any games if they don't play any games.

Resp, BP and LOC have to be WNL before narcotics are given, of course.