Nurses Enabling Substance Abusers

Published

For the life of me I can't understand why some Nurses continue to give Substance Abusing, Med Seeking Patients Ativan when there are other alternatives in place. I was charging this morning when the Med Nurse gave a patient who is already receiving Ativan 1mg & Methadone 20mg scheduled an additional dose of Ativan 1mg??? First of all he was admitted for detox and the doctor kept him on the Methadone? and he was schedule an Ativan taper so he would not have withdraws, fine I get it, but then we overheard him telling someone on the phone that he was detoxing and getting high at the same time and it was great, and the med nurse knew this, yet continued to give him more.....why? I don't get it, please someone enlighten me. It is a battle for the nurses who actually try to follow protocol with meds/narcotics as to not continue their addiction and protect our nursing license. This is just one of many examples I could post on here. Please stop giving these patients narcotics, just because it is on their profile does not mean we should hand it out like candy, remember Nursing Judgement and observation.

My hospital was in the news this last year because a patient in detox from alcohol was found dead, after obviously having seized and seized until he had a cardiac arrest.

Some number of staff were let go immediately (can you imagine being one of them?). Then on further examination, they shut the whole chemical dependency unit down. I don't know if it's been reopened or not. I was working medical oncology at the time, and the WHOLE hospital was under the state's gun for improving our CIWA charting, which apparently wasn't up to par.

The medication he didn't get? Ativan.

I know how CD nurses are, and need to be, doling out meds to addicts. I don't know any of the details of what happened, but I'll guarantee you it is less likely that the patient was simply ignored and more likely he didn't meet criteria for Ativan according to CIWA. It can be confusing as some folks don't actively withdraw for two or three days past the last drink. By then, they should be doing better, needing less, right?

I know the OP's situation was different, she/he was not coping with a patient in acute medical withdrawal.

But the two scenarios dovetail together in a very scary way, and as a nurse, you can get SO fed up by addict's and their behavior that you start making mistakes, you get into a power struggle with them and YOU WILL LOSE. It's best to not go there at all. Give the med, chart why and the response, call the doc -- but don't make THOSE kinds of decisions on your own. Even if you are right -- and you undoubtedly are 'right', the patient is drug seeking -- this is a rabbit hole and you don't want to end up in Wonderland.

Up Vote Up Vote ×
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
My hospital was in the news this last year because a patient in detox from alcohol was found dead...the WHOLE hospital was under the state's gun for improving our CIWA charting...The medication he didn't get? Ativan...

Can you tell me a little more? Was the unit a medical unit?

I asked because I sometimes float to a non medical psych unit where we have Pts on ciwa protocol.

Did the nurses not do CIWA assessment accurately? (Which I've seen)

Or was the facilities ciwa policy followed but simply wasn't in depth enough to catch the impending problem?

Up Vote Up Vote ×
Specializes in Trauma Surgical ICU.

Drug seeking but detoxing just don't go in the same sentence. If they are drug seeking then they have not decided to detox themselves or they wouldn't be seeking. Right ?? Also OP if they are truly there to detox why so many different narcs etc. ?? Doesn't sound like detox to me.

Up Vote Up Vote ×

Here's the thing. Addiction is a disease process and not a character defect.

So to get to the point in one's practice that the "thought" of medicating is repulsive is a personal judgment surpassing a clinical one.

Withdrawing off of narcotics is a difficult process that can cause a multitude of symptoms, some of which can be dangerous to a patient.

Methadone is a therapeutic substitute for heroin. At the correct dose, it can and does allow a patient to function. If one is not quite there yet, Ativan prevents the stuff that incident reports are made of. Like seizures. Like cardiac arrest. Like a stroke if one's BP goes through the roof.

Those things that an excuse of "well for the love of all things, the patient was ON methadone, HAD Ativan.....what more do they want???? I am sorry this patient seized, but really, we were just perpetuating the addiction".

Uh, NO, you are NOT perpetuating an addiction. You are medicating in the hopes that methadone will be at a therapeutic and functional dose, and topping with Ativan so the patient has no potentially fatal issues.

If prn's are an issue, it could take some education on why prn's are indicated and when. However, if documentation supports a prn, it supports a prn, regardless of why the patient is there.

I am not sure that there's any nurse who just shoots up the Ativan in hopes that the patient stays high. However, if after assessing and if the patient continues with c/o any number of withdrawal issues, a prn could be warranted. Which is, in fact. warranted for a whole lot of other clinical pictures than just a withdrawal protocol.

Addicts can and do say any number of things on the phone to a friend, including "bring me some junk". So do many, many other patients that are not addicts. If any person detoxing is not progressing as an MD would want, then is the time to advocate for an alternate level of care (ie: a facility that specializes in addiction) or a meeting with other disciplines to discuss where they go from here and what the plan of care needs to be.

A prudent nurse wouldn't think of holding a prn dose of pain medication for a days out post op who is still complaining of pain. Even if the thought process is that they should not be in acute pain at the point in recovery. This is the MD's call, and is an order. The same applies for an addict who is actively withdrawing.

If this is not something that is working towards a functional goal, then you, OP, as charge needs to have a multi-discipline meeting to discuss the case. Without judgment.

Up Vote Up Vote ×
Specializes in Behavioral Health/Substance Abuse.

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.

Not only this, but also the fact that the almighty Press Ganey rules most hospitals, and if those patients aren't getting the meds they want....well, then they tend to give lower scores. Like Elkpark, I tried to "fight the good fight" as well, using vitals/assessment as basis on whether or not to give the PRN medication....then I landed a write up for not giving enough PRN medications. I stopped fighting it at that point. If the patient was stable and not sedated, they got it as long as it was safe. Did I agree? No. This led to a resentment of my job and just exactly what was my role as a nurse to that hospital.

Up Vote Up Vote ×
Can you tell me a little more? Was the unit a medical unit?

I asked because I sometimes float to a non medical psych unit where we have Pts on ciwa protocol.

Did the nurses not do CIWA assessment accurately? (Which I've seen)

Or was the facilities ciwa policy followed but simply wasn't in depth enough to catch the impending problem?

It's a detox/rehab that is not on location, but is 'part' of the hospital. There's a psych unit on the same campus. Patients must be medically stable to do the detox at the rehab, or else they end up on MY floor if there were complications or it was too risky.

Because the CIWA charting was sub par, and what you don't chart doesn't happen, the major part of the 'slap' from the state was about CIWA use and charting. What they really DID or didn't do, that wasn't made public. Frankly I didn't want to know, it was horrible enough.

Up Vote Up Vote ×
Not only this, but also the fact that the almighty Press Ganey rules most hospitals, and if those patients aren't getting the meds they want....well, then they tend to give lower scores. Like Elkpark, I tried to "fight the good fight" as well, using vitals/assessment as basis on whether or not to give the PRN medication....then I landed a write up for not giving enough PRN medications. I stopped fighting it at that point. If the patient was stable and not sedated, they got it as long as it was safe. Did I agree? No. This led to a resentment of my job and just exactly what was my role as a nurse to that hospital.

If the patient isn't motivated for sobriety, you aren't hurting them by safely giving ordered PRNs. You aren't defeating their purpose for hospitalization. It's not even illegal to be an addict, so their behavior is distasteful and creepy but not 'wrong'. Feeling so resentful and questioning your role as a nurse -- time to move on. That's no way to live. Life is too short!

Up Vote Up Vote ×
Specializes in orthopedic/trauma, Informatics, diabetes.

I work in ortho and our pain meds are prn. Does that mean I don't give them?? No. I get frustrated at sickle cell pts, because they are on SO much medication I don't understand how they function, but I have never had a SS crisis and am not going to judge their pain. I am there to treat them with ordered medications. We have drug seekers, but having someone who is addicted, cooped up in a hospital room, I am going to give that prn dose if it looks like they need it

Up Vote Up Vote ×
Drug seeking but detoxing just don't go in the same sentence. If they are drug seeking then they have not decided to detox themselves or they wouldn't be seeking. Right ?? Also OP if they are truly there to detox why so many different narcs etc. ?? Doesn't sound like detox to me.

I have had patients that come to the ED hammered out of their minds drunk, because they know they will be admitted, and placed on an Ativan taper for detox. When the Ativan dosages start to get lowered, they leave AMA. This has happened way too many times for me to count. They might technically be detoxing, but they come for the free cable and the Ativan.

Up Vote Up Vote ×

I'm not saying I agree or disagree with the replys and yes I have followed Nurses who give MULTIPLE Narcs, it's like they don't care, and like I said I've done this for years, and anyone especially the Etoh abusers need Ativan, and the patients I'm referring to are already on scheduled Ativan, they are not being stopped cold turkey by no means, of course I don't want a patient to have a seizure.....and like I said most of the time we as nurses can tell when someone needs that extra dose of Ativan, I don't hesitate to give it....but it's the nurses that take no precaution and care about what they give patients that falls back on us that do...that is all I am saying.....oh and the fact that most of these patients are Voluntary and did come in for help, and yes we as nurses took an oath to help these people, we don't just hand out meds....I'm very surprised at the comments regarding it's not our job, or we shouldn't worry about it??? Last time I checked we took a oath to help people, drug detoxers come to us for help and that discipline otherwise they would just stay on the street getting high 24/7....

Up Vote Up Vote ×
I'm not saying I agree or disagree with the replys and yes I have followed Nurses who give MULTIPLE Narcs, it's like they don't care, and like I said I've done this for years, and anyone especially the Etoh abusers need Ativan, and the patients I'm referring to are already on scheduled Ativan, they are not being stopped cold turkey by no means, of course I don't want a patient to have a seizure.....and like I said most of the time we as nurses can tell when someone needs that extra dose of Ativan, I don't hesitate to give it....but it's the nurses that take no precaution and care about what they give patients that falls back on us that do...that is all I am saying.....oh and the fact that most of these patients are Voluntary and did come in for help, and yes we as nurses took an oath to help these people, we don't just hand out meds....I'm very surprised at the comments regarding it's not our job, or we shouldn't worry about it??? Last time I checked we took a oath to help people, drug detoxers come to us for help and that discipline otherwise they would just stay on the street getting high 24/7....

Kind of playing devil's advocate here...

People in the hospital for ETOH detox are there due to alcohol abuse, they're not there to have a benzo addiction treated. Similarly, even if a patient is drug seeking, if they're not in the hospital for drug rehab purposes, it's not up to the nurse to decide if they're pain is legitimate or not. Nurses shouldn't be withholding PRN meds based on some kind of principle.

If you truly think a PRN medication is ordered too frequently, or that the patient is taking advantage of the nurses, the best course of action is to get the orders changed.

Up Vote Up Vote ×
Specializes in Trauma Surgical ICU.
I have had patients that come to the ED hammered out of their minds drunk, because they know they will be admitted, and placed on an Ativan taper for detox. When the Ativan dosages start to get lowered, they leave AMA. This has happened way too many times for me to count. They might technically be detoxing, but they come for the free cable and the Ativan.

That was my point. Maybe detoxing is not the right word. Rehab may be a better word. What you describe is what I'm talking about. If it's ordered and safe, I give. I refuse to be the gate keeper.

Up Vote Up Vote ×
+ Join the Discussion