Narcotics administration

FMF Corpsman, MSN, RN · Aug 27, 2012

I think that the medical profession in general have become too judgemental of the chronically ill in our society. The ill and disabled are far too often treated as disposable insignificant humans. I think that there should be a lot less judging and a lot more tolerance toward the chronically ill.
Of course there are those frequent flyers who we ALL know are seeking meds for the meds.....but we, as nurses need to be very careful to understand that the chronic nature if someones pain does not signify addiction and "seeking" behavior. I have a family member with metastatic CA to the bone......everywhere and a nurse recently worried about addiction to the pain meds.
My response to her was.....yes he maybe addicted to the meds and he will take that addiction to the grave with him!!! Of all the crazy things to say!!!!
This is a hot topic amongst nurses and MDs about the use of emergency rooms for pain.....pain clinics.......but my expereince has been that pain is way under treated due tothe assumption that someones pain isn't that bad and they are seeking.
It has no bearing on race and I think it is a reflectionof society itself on the uselessness of the chronically ill..
But we need to stick to the topic and not call each other names. We can agree to disagree without being disagreeable(Gerald Ford).
A reminder to everyone!!!!
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Lets please keep to topic.

Esme, I must say I agree with you whole-heartedly. I remember years ago when I was called to a floor when one of the Nurses refused to medicate a dying CA patient with the prn MS that was ordered, because she "was afraid it would suppress his respirations." The entire family was at his bedside and the family was requesting he be medicated. This gentleman was indeed circling the drain and he was a DNR. My assessment showed a man who was 94 years old, had metastatic CA, and was on his way out. I saw no reason for us to not make his transition a little easier. This nurse said I was hastening this gentleman's death. I didn't see it that way. She charted her observations and I charted mine. I was the House Supv. She was a floor nurse. He got the MS. He died the next afternoon, comfortable, surrounded by his family. As far as other patients are concerned, this is the pledge we all took when we became a Nurse.

"I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care.

I don't see anywhere in that pledge, where it says anything about judging or diagnosing anyone prior to medicating them with pharmaceuticals ordered by their physicians. It is our job to follow the orders of the Physicians, not make up our own. All too often these days we think everyone is "drug seeking," even to the point we don't give the average patient a chance to make his/her case for needing their prescription. Even in my own case where I was the one who effectuated the change from narcotics to OTC pain relief, if I go in and ask for pain relief for as much as severe dental pain, I am suspect, and usually denied the request. This isn't right and we are in fact denying our patients proper care, care they deserve, because of our own prejudices. Prejudices that go against the very oath we swore to uphold.

BrandonLPN, LPN · Aug 27, 2012

I'm a "jaded" nurse in most senses of the word. But one way I hope to never become jaded is in pain management. I'd much rather err on the side of giving pain meds to someone who doesn't really need them. Rather than withholding them from someone who really does.

arallenrn11 · Aug 27, 2012

Here's my opinion on this whole thing. Unless you are an RN employed in a drug treatment center or somewhere else that serves to treat drug addiction, your job is not to fix that problem. Your job is to keep your patients #1 safe and #2 happy. The average hospital stay is 3 days. That is not enough time to cure anybody's addiction. As stated before, so long as the dose or frequency isn't causing harm, give it when it's wanted. Your witthholding of pain medication based on your personal beliefs will not affect that person's addiction one way or another. All it will do is **** them off. And this is all assuming the person is an addict.

Dragonnurse1, ASN, RN · Aug 27, 2012

The concern regarding my first thread is being lost on the dosages of medicine mentioned. I struggle to continue to administer medication to pts setting alarm clocks to receive it vs those that are suffering and apprehensive to take meds.

With narcotics it is so easy to lose sight of the original question. As you can tell from the responses the use of pain meds certainly breaks nurses into 2 different camps. I have been on both sides of this issue, as a nurse and as a patient, and I can tell you this. Perhaps the patient has been on long term pain medications at home and they have found that by making sure they take their doses on time the pain stays at a manageable level. Being admitted takes the control away from the patient and they feel helpless. Setting their alarm may be what they do at home to make sure they do not miss a dose so they continue the practice at the hospital. It is so easy for nurses to look down on patients that need narcotics but wait until you become a patient needing those same drugs. I may not set my alarm but I do keep track of the time and I go no where without my pills. (I am on 4 Lortab 10's per day plus 2 Zanaflex at night) It is easier to maintain than to try to reduce the pain.

Poochiewoochie · Aug 27, 2012

It is our job to follow the orders of the Physicians, not make up our own. All too often these days we think everyone is “drug seeking,” even to the point we don’t give the average patient a chance to make his/her case for needing their prescription.

Thank you so much for stating this. As someone who WAS treated like a drug seeker in the ER last year when I went there for excruciating pain from 2 herniated disks in my neck I applaud you for taking this attitude.

As for the OP, I'm sorry that you feel the need to judge the chronic pain patients as drug seekers. In my case the first thing the doctors did was prescribe narcotic pain meds(which did nothing for the pain-I finally had surgery earlier this year after suffering for 7 months) It's no wonder people are addicted to these types of pain meds when doctors are so willing to prescribe them. So don't blame the chronic pain patients for being addicted to medication that is being prescribed to them. After a while they build up a tolerance. Shame on any medical professional who would withhold pain medication from a patient who has just had surgery. I've been there and when someone tells you they are in pain after surgery believe them. People have different ways of coping with pain so your idea of a "10" and how someone should be acting when they say they have a "10" on the pain scale should not come into play when accessing a patient.

I always say you need to walk a mile in someone elses shoes before you know what they have been through or are going through so don't be so quick to judge a chronic pain patient unless you've had to suffer with chronic pain. You're nurses, no one made you judge and jury.

ETA:When I was prescribed narcotic pain meds I was told to "keep ahead of the pain". That is what those patients are doing who have set their phones and other devices to go off at a certain time. It's to make sure they take their medication so they can keep the pain under control.

Tree5981, ADN, BSN, MSN · Aug 27, 2012

I don't understand the point of withholding pain medication. I once asked a hospice pharmacist "so if they are a drug addict would you still withhold giving them pain medication?" and he replied "no". And I 100% agree. What would be the point? I wouldn't want the patient to go through withdrawal. I don't see the point of purposely trying to torture the patient. Even if they were addicted, withdrawal has significant side effects as we all know. And if its killing the patient you are worried about, it takes a significant dose of morphine to do so. As a previous poster mention 2mg of morphine and 8 mg of dilaudid isn't that much.

Been there,done that, ASN, RN · Aug 27, 2012

"I work on a med-Surg floor where dilaudid is prescribed excessively."

This is not your nursing concern. Administer the medication as prescribed.. . do NOT try to change the PRESCRIBED schedule.. or interject you nursing (or personal ) judgement. Your shift will run sooo .. much smoothly.

FMF Corpsman, MSN, RN · Aug 27, 2012

I have a hard time with the drug seekers like a lot of other nurses. Some things that help me out:
If it is ordered and the patient is requesting it they get it IF it is due. I always go over the pain scale with patients. If they tell me their pain is a 10/10 I correlate that with mild, moderate, severely, extremely severe. I had a patient who kept telling me her pain was a 4 and it turns out she was actually experiencing mild pain. Well that would be a 2 or 3 so it required reeducation on the pain scale.
If a patient has norco and iv pain meds ordered and they are refusing the po I tell the doc. A lot of times that will have the doctor getting rid of the dilaudid/morphine.
If you are taking vicodin/norco at home and you are not in the hospital for an exacerbation of a pain crisis I really don't understand why you are requiring dilaudid just because you are in the hospital. If your pain is at the level it is when it is at home and you are at your goal we are all good.
People who have chronic pain do cry when their pain is so out of control. People who say that doesn't happen...well everyone is different.
Many (not all) patients with chronic pain need limits so they are not monopolizing all of your time. I let them know when there next meds are due. I find it extremely frustrating when they go on the call light 1 hour or more before they know their next pain med is due. I don't understand why they do it and there is nothing I can do about the timing of the pain medication. It is ordered by the doctor and If they are getting their dilaudid every 3 hours well I don't need you to start calling me 1 hour, 45 minutes, 30 minutes, 15 minutes before you can have your dose. I will give it to you 3 hours after you had your last dose because that is then it is ordered. Many of these patients have an extensive psych history and are on multiple psych meds. Sorry but these are things that make me go hmmm. These people need to find other methods of pain control besides iv narcotics. They really need to open their minds to other methods of pain relief.
I believe we as nurses should second guess a pain regimen with a doctor. As nurses we receive much more education than they do. Ordering morphine/dilaudid q6h is ridiculous when it has a short half life. I recently went to a conference and learned doctors are lucky if they get 1 hour of pain education in school.

I pretty much disagree with everything you wrote. I don’t believe it is your job to second-guess the Physician in as far as anything s/he does. If you are having that difficult of a time with following the Physician’s orders, perhaps you need to transfer to a less taxing area of the facility, where the Physicians orders are a bit more mundane and won’t arouse such phlegmatic difficulty. You are a Registered Nurse on a floor in a Hospital. Unless I’ve misread, that doesn’t make you a distinct part of the Pain Team, responsible for deciding his or her Pain Regimen and unless his or her Doctor has specifically asked for your input on the matter, it really isn’t any of your business, with the exception of following the medication orders on whatever shift you might happen to be working. People/Patients experience pain in very different ways. Pain is strictly personal. What hurts you, I may be able to flick off without so much as a thought. On the other hand, I may be devastated.

My big reference has always been, Labor and Delivery. I say that if men were consigned with the job of delivering children instead of women, there would be far less children because it would likely be only one child per family. I don’t see too many men going through the pain and agony of labor and delivery more than once. And yet there are some women who say that their pain was minimal. You tell me how to get a 6 or 7-pound baby through the birth canal and out that little bitty hole without pain or with minimal pain. While it may be your job to assess pain levels and the effects of medications, it isn’t your job to decide the worthiness of your patient to receive the medication already ordered by his Physicians. You took a pledge as a Nurse to “aid the Physician in his work and devote yourself to the welfare of those entrusted to your care.” You started off your post with “I have a hard time with the drug seekers” How is it exactly that you differentiate between the drug seekers and the actual patients in need of pain meds? Or are they all drug seekers in your view? Pain is pain regardless whether it is real or imagined and if a person is an addict, then the drugs they seek are in fact a medication they indeed need, especially if they are addicted to opiates. If you have never witnessed the withdrawal of an opioid addict, it isn’t pretty and is quite dangerous and life threatening. By being judgmental you are taking that patients life into your hands and you should be certain that’s what you want to do before you do it.

Poochiewoochie · Aug 27, 2012

You started off your post with “I have a hard time with the drug seekers” How is it exactly that you differentiate between the drug seekers and the actual patients in need of pain meds? Or are they all drug seekers in your view?

That's the problem-everyone is a drug seeker to some nurses and other medical professionals.

Someone said on another thread about pain medication that no one dies from pain. That is wrong. People in chronic pain have been known to commit suicide because they can not get any relief. I know the thought crossed my mind last year when I was in pain 24/7. I spent my days in my bedroom with a heating pad, crying because my pain was so bad. I couldn't sleep in a bed at night-the little things that most people take for granted become a labor for people who are in constant pain. So why shouldn't they be watching the clock to see when their next relief from it is.

Like I said before, unless you've been there you have no idea what it's like to live with chronic pain.

Tree5981, ADN, BSN, MSN · Aug 27, 2012

I pretty much disagree with everything you wrote. I don’t believe it is your job to second-guess the Physician in as far as anything s/he does. If you are having that difficult of a time with following the Physician’s orders, perhaps you need to transfer to a less taxing area of the facility, where the Physicians orders are a bit more mundane and won’t arouse such phlegmatic difficulty. You are a Registered Nurse on a floor in a Hospital. Unless I’ve misread, that doesn’t make you a distinct part of the Pain Team, responsible for deciding his or her Pain Regimen and unless his or her Doctor has specifically asked for your input on the matter, it really isn’t any of your business, with the exception of following the medication orders on whatever shift you might happen to be working. People/Patients experience pain in very different ways. Pain is strictly personal. What hurts you, I may be able to flick off without so much as a thought. On the other hand, I may be devastated.

My big reference has always been, Labor and Delivery. I say that if men were consigned with the job of delivering children instead of women, there would be far less children because it would likely be only one child per family. I don’t see too many men going through the pain and agony of labor and delivery more than once. And yet there are some women who say that their pain was minimal. You tell me how to get a 6 or 7-pound baby through the birth canal and out that little bitty hole without pain or with minimal pain. While it may be your job to assess pain levels and the effects of medications, it isn’t your job to decide the worthiness of your patient to receive the medication already ordered by his Physicians. You took a pledge as a Nurse to “aid the Physician in his work and devote yourself to the welfare of those entrusted to your care.” You started off your post with “I have a hard time with the drug seekers” How is it exactly that you differentiate between the drug seekers and the actual patients in need of pain meds? Or are they all drug seekers in your view? Pain is pain regardless whether it is real or imagined and if a person is an addict, then the drugs they seek are in fact a medication they indeed need, especially if they are addicted to opiates. If you have never witnessed the withdrawal of an opioid addict, it isn’t pretty and is quite dangerous and life threatening. By being judgmental you are taking that patients life into your hands and you should be certain that’s what you want to do before you do it.

I agree with this completely. And to add...she states "Many (not all) patients with chronic pain need limits so they don't monopolize your time". Say what??!! Patients with chronic pain shouldn't be limited! If anything, you should let the physician know that the medications they are getting are not working! Maybe suggest a longer acting pain medication. We as nurses should let the physician know if the current pain regimen is not working for the patient. They may A) be on the wrong med or B) need a change of dosing.

Tree5981, ADN, BSN, MSN · Aug 27, 2012

I pretty much disagree with everything you wrote. I don’t believe it is your job to second-guess the Physician in as far as anything s/he does. If you are having that difficult of a time with following the Physician’s orders, perhaps you need to transfer to a less taxing area of the facility, where the Physicians orders are a bit more mundane and won’t arouse such phlegmatic difficulty. You are a Registered Nurse on a floor in a Hospital. Unless I’ve misread, that doesn’t make you a distinct part of the Pain Team, responsible for deciding his or her Pain Regimen and unless his or her Doctor has specifically asked for your input on the matter, it really isn’t any of your business, with the exception of following the medication orders on whatever shift you might happen to be working. People/Patients experience pain in very different ways. Pain is strictly personal. What hurts you, I may be able to flick off without so much as a thought. On the other hand, I may be devastated.

My big reference has always been, Labor and Delivery. I say that if men were consigned with the job of delivering children instead of women, there would be far less children because it would likely be only one child per family. I don’t see too many men going through the pain and agony of labor and delivery more than once. And yet there are some women who say that their pain was minimal. You tell me how to get a 6 or 7-pound baby through the birth canal and out that little bitty hole without pain or with minimal pain. While it may be your job to assess pain levels and the effects of medications, it isn’t your job to decide the worthiness of your patient to receive the medication already ordered by his Physicians. You took a pledge as a Nurse to “aid the Physician in his work and devote yourself to the welfare of those entrusted to your care.” You started off your post with “I have a hard time with the drug seekers” How is it exactly that you differentiate between the drug seekers and the actual patients in need of pain meds? Or are they all drug seekers in your view? Pain is pain regardless whether it is real or imagined and if a person is an addict, then the drugs they seek are in fact a medication they indeed need, especially if they are addicted to opiates. If you have never witnessed the withdrawal of an opioid addict, it isn’t pretty and is quite dangerous and life threatening. By being judgmental you are taking that patients life into your hands and you should be certain that’s what you want to do before you do it.

I agree with this completely. And to add...she states "Many (not all) patients with chronic pain need limits so they don't monopolize your time". Say what??!! Patients with chronic pain shouldn't be limited! If anything, you should let the physician know that the medications they are getting are not working! Maybe suggest a longer acting pain medication. We as nurses should let the physician know if the current pain regimen is not working for the patient. They may A) be on the wrong med or B) need a change of dosing.

joanna73, BSN, RN · Aug 27, 2012

Pain is subjective, so it's never up to the health care provider to judge whether the patient is "drug seeking". As long as their vitals are within normal limits, I'm not concerned. Furthermore, in order to avoid breakthrough pain, it is best practise to administer pain meds round the clock. If the patient can receive their narcotic q6h, and they request it q6h, I give it. Of course, I will do an assessment, and ask them to rate their pain also. Remember that mild pain to you or me could be excruciating to another.