Nursing Interventions for drug seekers in the ED

SionainnRN · Feb 16, 2014

Why would you make the pt show you their mouth? What is that going to do other than antagonize the pt? I work in a large urban hospital and we have a majority of pts who are drug seekers. You treat the pain. Pain is what they say it is. Generally the more upfront the pt is about what they want, the easier it is on everyone. If the come in saying they have chronic pain and are out of meds, we'll hook them up with a small script. They come in whaling and moaning that they have the worst headache if their life, or worse belly pain ever, they get a million dollar work up and based on the findings possibly no pain meds. It's a rough situation for everyone.

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Christy1019, ASN, RN · Feb 16, 2014

Unfortunately, whether these pts get narcotics or not is not up to us, its up to the MD. However, you can definately document objective data regarding the pts behavior. You may have a pt rating 10/10 pain but has already received 2mg dilaudid and can barely keep their eyes open long enough to rate the pain, document it as such. Asking the pt to open their mouth is more appropriate for confused/dementia pts, or sometimes even suicidal pts (if you suspect they might cheek the meds until they have a big enough dose to try and overdose). Just keep in mind that unfortunately you aren't going to fix their addiction in the acute setting, but you don't have to over-medicate them either. Sorry I don't have anymore interventions for you.

zmansc, ASN, RN · Feb 16, 2014

As mentioned previously, it's not really a big concern if they are going to take the medication, they are trying to get a dose (or more) of the meds, they generally jump to take it.

As for the documentation, also mentioned earlier, document both subjective and objective data about their pain. Everyone has tons of stories where the patient complains of 10/10 pain, yet their actions indicate the pain is really much less. In these cases, I simply document both the subjective 10/10 and the objective information based on their actions.

I think sometimes, and I know I've been guilty of it, we forget that these people are sick. Even if the objective data tells us they do not have pain, or the pain is much less than the subjective rating they gave us, they have an illness that is causing them to come to the ER to get treatment. Their illness may be pain, which is what they are complaining about, or it may be addiction to narcotics, or both, or something else entirely.

Because it's easier on everyone, they are frequently treated by giving them a quick dose of narcotics and sending them out the door. Yes, that is the quickest way to turn the room, and it is easier to not have to deal with educating the patient, and diagnosing what it is they really need. But, in the end, it doesn't solve the issue, it doesn't really help the patient other than to get them out of your ER and hopefully not have them come back on your shift again.

I would actually like to see a way to put patients on an outpatient pain management program that is still within the hospital system. I.e. when these patients show up to be triaged, as long as there is no outstanding medical need for ED tx other than the pain, divert them to a different treatment path, much like a sexual assault pt is treated. In smaller EDs, the patient might continue to take up some ED resources, but it would help all involved including the staff to realize that the normal flow of ED in/out as fast as possible does not fit with this patient's true needs.

Pangea Reunited, ASN, RN · Feb 16, 2014

Nobody wants "pills".

LiamBear · Feb 16, 2014

Thanks for the replies! I think documentation is the big intervention here. I've heard some hospitals have a red flag system for the "frequent flyers". Hmm, not much interventions you can do because I agree, it's always more safe to treat the pain and that's up to the doc.

SionainnRN · Feb 16, 2014

yep, you document that pt states 10/10 pain, currently eating, watching tv in NAD, VSS. Or that they are requesting more pain meds even though they are having a hard time keeping their eyes open or slurring their speech. But people with chronic pain can 10/10 and not show it, because they've dealt with it for so long. I try not to judge (hard in an urban ER) but it's no skin off my back if we medicate them. Now I know it's different in patient with trying to track down docs for orders and stuff, but luckily in the ER the docs are right there with us.

manusko · Feb 16, 2014

Why would you make the pt show you their mouth? What is that going to do other than antagonize the pt? I work in a large urban hospital and we have a majority of pts who are drug seekers. You treat the pain. Pain is what they say it is. Generally the more upfront the pt is about what they want the easier it is on everyone. If the come in saying they have chronic pain and are out of meds, we'll hook them up with a small script. They come in whaling and moaning that they have the worst headache if their life, or worse belly pain ever, they get a million dollar work up and based on the findings possibly no pain meds. It's a rough situation for everyone. Sent from my iPhone using allnurses.com[/quote']
Absolutely what I was taught and what I believe in. It's your job to help the pt. We are not the watchdogs of the pain pill abusers in the world. Be their nurse, treat their pain and don't judge them.

uRNmyway, ASN, RN · Feb 17, 2014

Absolutely what I was taught and what I believe in. It's your job to help the pt. We are not the watchdogs of the pain pill abusers in the world. Be their nurse, treat their pain and don't judge them.

I'll agree to a certain extent. Not my place to judge, but if you claim to have 20/10 pain, your BP is tanking, or sats, or you are trying to grab those non-existent bugs in front of your face, I'm definitely not going to give you that 3mg IV Dilaudid. And I don't give a hoot what 'that other nurse' did. I'm not pushing it fast, I'm going to dilute it to 10ml, and I'm going to give it distal. Hearing that whole 'other nurse' line is almost as much of a red flag to me as the other nonsense.

And seriously, if you are really in 20/10 pain, and I CAN'T give you that IV narc without immediately calling RRT, but I offer you tramadol, which you pretty much throw at my head...well, let me tell you, I'm not likely to go hunting down the MD to get authorisation to kill you with opioids. Because believe me, they don't want to do all that extra paperwork either.

And you can threaten all you want my friend, I am a pretty awesome, detailed documenter(is that a word? Lol). It has saved my butt and other butts before, it will do so again with you.

friendlylark · Feb 19, 2014

I found an excellent article regarding drug-seeking behaviors and super users in the emergency department written by Studer Group coaches. Run a google search on "Managing drug-seeking behaviors and super users in the emergency department" for the pdf article. It may come in handy in your research.

Editorial Team / Moderator · Feb 19, 2014

I found an excellent article regarding drug-seeking behaviors and super users in the emergency department written by Studer Group coaches. Run a google search on "Managing drug-seeking behaviors and super users in the emergency department" for the pdf article. It may come in handy in your research.

I found the same one last year -- I loved the term "super users," I thought it was perfect! Great article. If I recall correctly, it had a lot of info for physicians to use as well.

JenniferG rN · Feb 20, 2014

I had a patient today in w pneumonia and chronic pain. She had on 75mcg patch of fentanyl- she had prn orders for 2mg dilaudid, 25 pgenergan and 50 Benedryl PO. She refused all her am meds d/t being nauseous and ordered me to get the dr to change all her prn meds to iv. The noc RN gave her all 3 prn's as a cocktail before I came on shift. This patient had a G tube also that she refused to let us use because it made her feel "bloated" talking w the dr- he refused to change her meds to iv because she was a seeker and he felt it wouldn't b appropriate. I told the patient her 2 choices were by mouth or the g tube and asked which she would prefer- she asked for time to think about it stated she'd call me in after she went to the bathroom. About 15 minutes later her call light went off- I entered the room to find her g tube sitting on her bedside table!! She said she was so violently vomiting that it "fell out" Of course she flushed her emesis, she says.Dr. Again called no further action needed at that time- cont w same orders- advised not to give her PO dilaudid if she is c/o nausea. When she asked about the dilaudid iv I told her it wasn't an option- she signed out AMA. Wth? I seriously am at a loss of words for what some people will do for meds.