Nurses Enabling Substance Abusers

zombienurse13 · Dec 22, 2014

Anyone?

elkpark · Dec 22, 2014

Umm, because the physicians order the meds and we are not really in a position to simply refuse to give them to people?

Years ago, I used to "fight the good fight" with these people, talk about alternative coping skills, relaxation techniques, blah, blah, blah, but I finally decided it's a waste of my time and energy if people aren't interested. As the cliche' goes, you can lead a horse to water, but you can't make him drink. If someone has been abusing benzos or whatever for a long time, and has no real interest in making any changes, my giving that individual one less Ativan or Xanax tablet is just "spitting in the ocean." In terms of the big picture, makes no difference -- so how much effort should I put into resisting doing what the client wants (and is entitled to, per the physician orders)??

If the physicians don't know any better or don't care, there's only so much the RNs can do.

classicdame, MSN, EdD · Dec 22, 2014

It is not up to the nurse to determine medication therapy. Surely you know how dangerous it is for someone to come off a high too quickly. If his vital signs were ok and the order was valid I say give it to him

You are not going to do any behavioral management (punishment) at this stage in his treatment.

zombienurse13 · Dec 22, 2014

I'm not trying to punish anyone, and just because it is on their PRN list does not mean we have to give it, like I said Nursing Judgement is a part of PRN's and me over medicating with narcotics or any nurse can put our nursing license at risk, for example what happens if I give 3 or 4 narcotics at one time and for some crazy reason that patient goes to bed and stops breathing. Do you think the doc is going to be questioned? No, because they didn't give the meds, they can prescribe all day long, but ultimately they don't administer, nurses do. Also, aren't we as nurses suppose to help follow the patients plan for detox? These detox patients come to us for help and restraint, it is not helping them to offer a buffet of narcotics, that just encourages them more to continue the abuse, and at our facility things like Ativan are for extreme agitation/anxiety not for just oh I'm a little bit anxious...we always have other non-narcotic anxiety meds to offer them to start with. I guess this is the problem, let's just give them the narcs so they continue to be addicted to it while they are at our facility then when they leave and the doc don't give them a script they will buy it off the street.....how is that helping our patients. Most nurses I know just give it to them so they either don't have to explain/educated the patient or just to get them out of their face. Which like I said makes it harder on the nurses who really watch what meds they give their patients and want to protect our license. It's always the same story: Well the other nurse gave me my Percocet, Xanax, Lyrica and Temazepam all at the sme time last night....What? Are u kidding, I don't do that kind of nursing in any setting, especially detox.

zombienurse13 · Dec 22, 2014

And no they are not entitled to those meds, it is based also on Clinical Judgement, these are not scheduled meds, and I have seen very few patients ever really detoxing or coming off of a "high too quickly" most of the patients I encounter are med seeking, they are easy to spot. I have had true detoxing patient's coming off of Alcohol & Xanax before, trust me I know what it looks like....those are the ones I wouldn't hesitate to give Ativan to, and honestly those are the ones that don't even ask for it. As far as opiates, we don't even have a detox protocol for opiates because the docs think there aren't many withdrawal symptoms or danger.

elkpark · Dec 22, 2014

... at our facility things like Ativan are for extreme agitation/anxiety not for just oh I'm a little bit anxious...we always have other non-narcotic anxiety meds to offer them to start with. I guess this is the problem, let's just give them the narcs so they continue to be addicted to it while they are at our facility then when they leave and the doc don't give them a script they will buy it off the street.....how is that helping our patients. Most nurses I know just give it to them so they either don't have to explain/educated the patient or just to get them out of their face. Which like I said makes it harder on the nurses who really watch what meds they give their patients and want to protect our license. It's always the same story: Well the other nurse gave me my Percocet, Xanax, Lyrica and Temazepam all at the sme time last night....What? Are u kidding, I don't do that kind of nursing in any setting, especially detox.

In my experience, people who have Ativan or Xanax ordered for "extreme" or "severe" agitation/anxiety who don't get it when they request it for "oh I'm a little bit anxious" quickly become extremely or severely agitated and anxious. Like I said, I spent many years doing what you are talking about; offering other non-benzo meds, trying to teach nonpharmcological mechanisms, etc., etc., etc., and none of it helped because the people weren't interested. They just got mad. For most of the people you are talking about, a few Valium or Xanax or Ativan tablets more or less just isn't going to make any difference.

And I think you're being a little melodramatic about people risking their licenses. I've never known a nurse who would give "Percocet, Xanax, Lyrica and temazepam" together. I've told lots of people over the years that I'm not comfortable giving X and Y together; they can choose which one they feel they need more urgently and take that one now, and I'll be happy to give them the other one in a couple hours.

If the physicians have ordered this stuff, and the clients know it and ask for it, it's v. hard for nurses to make a case for refusing to give it. A lot of the responsibility rests with the physicians, IMO. And if the physicians aren't taking the same approach to treating the client that you are, it's a waste of your time and effort.

THELIVINGWORST, ASN, RN · Dec 22, 2014

In my experience, people who have Ativan or Xanax ordered for "extreme" or "severe" agitation/anxiety who don't get it when they request it for "oh I'm a little bit anxious" quickly become extremely or severely agitated and anxious. Like I said, I spent many years doing what you are talking about; offering other non-benzo meds, trying to teach nonpharmcological mechanisms, etc., etc., etc., and none of it helped because the people weren't interested. They just got mad. For most of the people you are talking about, a few Valium or Xanax or Ativan tablets more or less just isn't going to make any difference.
And I think you're being a little melodramatic about people risking their licenses. I've never known a nurse who would give "Percocet, Xanax, Lyrica and temazepam" together. I've told lots of people over the years that I'm not comfortable giving X and Y together; they can choose which one they feel they need more urgently and take that one now, and I'll be happy to give them the other one in a couple hours.
If the physicians have ordered this stuff, and the clients know it and ask for it, it's v. hard for nurses to make a case for refusing to give it. A lot of the responsibility rests with the physicians, IMO. And if the physicians aren't taking the same approach to treating the client that you are, it's a waste of your time and effort.

I always say it's not my job to help you overcome your addiction. They are there to safely come down. And these patients are not narcotic naïve.

macawake, MSN · Dec 22, 2014

If the patient's physician has prescribed the medication and the patient requests it, I'll give it to them if their vital signs permit. I'm not the drug morality police. It bothers me that some nurses engage in a battle of wills and/or play power games. Nursing judgement means that you should form an opinion on whether or not it's safe to administer the medication, not to decide if you personally approve.

Fortunately since I work PACU and anesthesia I don't see much of nurses who "police" patients any more. I'm quite generous with powerful narcotic analgesics. My only goal is to keep my patients safe and comfortable, free of pain and anxiety. I would much rather medicate ten "drug seekers" unnecessarily than under-treat a single person in pain (physical or mental).

I've previously worked law enforcement and have dealt with thousands of drug addicts and seen all the misery addiction brings (both to the addict and to others). Because of my experience I'm utterly convinced that I'm not going to save or cure a single addict who's not motivated to quit, by withholding a PRN med.

It would just be a futile effort or petty power trip on my behalf. (Depending on my motivations for denying the patient the med).

Gooselady, BSN, RN · Dec 22, 2014

I agree with the other posters. I did chemical dependency nursing as a manager for four years besides caring for the constant stream of drug seeker/addicts in all other kinds of nursing.

This is a very tough position to be in, what with feeling your integrity on the line. Here's how I look at it, considering my past experiences. An addict will not go into recovery unless they are extremely motivated. A drug seeking patient is not motivated for sobriety. What needs to be in place for the goal of sobriety is not there, period, end of story.

All your very compassionate desire to help them get out of their addiction is good, but the patient cannot benefit from it. You are a part of their 'healing' or whatever for short periods of time, and one of many healthcare personel they've had the misfortune to meet. You are one in a million blurred faced in their life. You can have all the motivation and compassion in the world for that addict, but it is useless if they aren't motivated. You can't MAKE them get motivated by refusing PRNS or even by taking a 1:1 time and psychoanalyzing or do motivational interviewing with them IF they have no intention of tolerating the withdrawals for a sober future.

You are powerless, and their addiction is more powerful than anything you say or do. So basically, if the patient is drug seeking, and isn't motivated for sobriety, you might as well give him the PRN and stop stressing yourself about other nurses 'enabling' them. If the MD wrote the order, and the time frame is right, give it and get on with your day. You aren't HURTING the patient or preventing them from being motivated.

I've closely worked with both kinds, motivated and unmotivated. They overlap a little, but not by much. Motivated patients don't drug seek. You might find them curled in a ball or tearful and needy, but they don't ask for drugs. It's pretty cut and dried.

The first thing I'd do if I overheard a patient laughing about getting high is call the MD and let him/her know, and drop it. Whether the doc does or doesn't do anything is out of my scope of practice :)

The purpose of this? So you job satisfaction and team work can continue onward with less drama :) So your sense of personal integrity remains firm.

B52, ADN, BSN, MSN, RN · Dec 22, 2014

Be careful. Withholding Ativan, prn or scheduled, could lead to a tonic clonic seizure.

LadyFree28, BSN, LPN, RN · Dec 22, 2014

I always say it's not my job to help you overcome your addiction. They are there to safely come down. And these patients are not narcotic naïve.

THIS. :yes:

And THIS:

If the patient's physician has prescribed the medication and the patient requests it, I'll give it to them if their vital signs permit. I'm not the drug morality police. It bothers me that some nurses engage in a battle of wills and/or play power games. Nursing judgement means that you should form an opinion on whether or not it's safe to administer the medication, not to decide if you personally approve.

Nursing judgement is objective and not a personal opinion. :no:

Your "license may be on the line" if you decide I use "skewed nursing judgement" and THIS happens:

Be careful. Withholding Ativan, prn or scheduled, could lead to a tonic clonic seizure.