Narcotics administration

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.

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.

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.

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.

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.

"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.

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.

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.

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.

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.

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.

In my 17 years of nursing I have never once struggled with this issue. Taking care of patients, regardless of what they want or need, has no personal relevence to my life: I mean whether they take a tylenol or dilaudid, how much, and how often is not my personal business. My life is not affected in any way by what my patients take. Professionally, it is only relevent to the extent that I desire and am required to make sure the administration of a medication is not contraindicated or harmful. In fact I always found it quite useful to know that a patient would be wanting their medication on a "scheduled" prn basis...makes organizing my shift easier and I sleep better not having to worry whether or not my patients were comfortable! lol!

However, on a personal level, many of the comments on here are distressing to me. Over the past year I have made multiple trips to the ER, have been hospitalized at least 6 times, and ultimately had 2 surgeries. Over that period of time I developed quite a tolerance to opiod medications. A few times I heard the nurses in the hall saying that I was a drug seeker or an addict (I take nothing at home besides aspirin)...imagine their surprise when I had emergency surgery not once, but twice to save my life. I happen to be guilty of knowing exactly when my pain meds were "due" for several reasons: the half life of dilaudid is only about 2.5 hours give or take; the doses given were only enough to take the edge off the pain so in 2.5 hours the pain was back full force; I was in a constant state of dread worrying that (given the nurses attitudes) my pain wouldn't be controlled. I've learned to have an upfront honest discussions with the physicians and the nurses caring for me so they can understand my history and my tolerance.

I work in an ER setting now so I understand what ya'll are talking about when you discuss "frequent flyers" and I know about whom you are addressing when you talk about the "seekers". The way I look at it is this: that person made the effort to come to the hospital for SOME reason and it is my duty to treat them in terms of the physicians orders. Could be they want to get high BUT there is the same probability that they need treatment. One of my former charge nurses sent a supposed "seeker" away (EMTALA violation) who presented with a severe headache. She said "you might as well leave, we aren't even going to give you a tylenol let alone narcotics"...the guy died at a nearby hospital of a brain bleed.

Anyway, some people watch the clock because their pain really isn't being controlled as well as it should or they are afraid of getting behind and having worse pain. Either way, it shouldn't be anything personal to the nurses. Do your job, take it in stride, assess and document as appropriate and follow the physician orders. I fail to understand why nurses have such a negative view and take opioid administration so personally.