over-medicated patients

Thunderwolf, MSN, RN · Jul 25, 2008

not knowing more about this patient....i would bet a polysubstance addict stemming from a primary opiate addiction and his possibly looking for any goodies he can obtain from "your store." the smooth manipulation is sort of diagnostic here. opiate users can initially be very charming or selectively charming...a tool of their trade. polysubstance is not uncommon. you hit it on the head here too in describing him, what i call the "uneducated" opiate addict:

detox symptoms were nebulous based almost solely on anxiety and body pains

...and if not successful, then they may often "up the symptomatic ante" by copying others' mental health symptoms around them on the unit or from folks they have come to know. and yes, addicts do share with each other their secrets to obtain more meds....not very bright though...but neither is their addiction. in my past detox experience as a nurse with a great detox doc, neurontin 1800-3600mg/day in divided doses typically chilled these somatic complaints quite nicely with opiate addicts....and it's totally nonaddicting. the max is 4800 mg/day. no contraindication unless there was impaired kidney function (see labs). and also, the key is to get them off the dope...not put them on it (ie narcs and benzos). relapse for opiate addicts is extremely high...typical aa stuff is usually not enough...and many of them laugh at it (aa). it is hard core addiction much worse than etoh...which often requires hard core after care (post detox) in order to achieve continued success. quite often, ongoing confrontation and support is required till they really kick it...not hugs....hugs are typically not enough and are easily manipulated in order to "fake out" the supportive people in his/her life. sponsors who provide "ongoing, in your face, tough love" are usually the best sponsors for these folks.

however, you do have my hugs...sorry you had to go through it. if anything, chalk it up as experience.

Thunderwolf, MSN, RN · Jul 25, 2008

If not gathered already, I am not one of those who propose that "all addictions are the same and can/should be treated the same way"...because of rationale such as "addiction is addiction."

Why?

Different drugs, different physiological responses and withdrawal, different patient mindsets and behaviors, and different medical treatment (depending upon the substance) while in detox...begs different after care. I would never propose one treatment option, like AA, for all folks with addiction....it is denial at its best in the form of treatment. When they are treated the same, I truly believe the high recidivism rates for opiate addicts lays it out rather boldly...in stark black and white.

DUI's come with ETOH.

Felonies come with opiates.

Alcoholics most often come in for detox for various reasons (impairments from the intoxication...work, family, relationships, self).

Opiate addicts often come in for treatment in order to acquire drugs because his/her source has been "busted" or dried up OR because he/she may be facing the law (see felonies). Although impairments occur not unlike the alcoholic (loss)...it tends NOT to be the driving force towards treatment for the opiate addict.

In detox, you may often have to go out into the unit and medicate the alcoholic, even convincing him/her that the medication is necessary as evidenced by his/her objective signs. Alcoholics typically have some remorse which makes AA a viable option.

And in detox, the opposite is often true for the opiate addict....one often feels the need to beat him/her away from the nursing desk with a broom...for feigned or vague symptomatic complaints...way before any objective withdrawal signs are even present...IF ever present. Opiate addicts typically lack the remorse for quite some time, especially during the early course of their sobriety.... which can often make AA-like groups not the initial best choice.

Diagnostic pearl as a detox nurse: opiate user vs alcoholic?...one typically "stalks you" as his/her nurse, the other one typically doesn't.

ETOH and Opiate addiction is NOT the same...nor is the detox...nor should be the follow up.

Truly, it is like apples and oranges...both fruit (addiction), but totally different in many, many ways.

If I have offended any CD counselors, my apologies. Look at the studies, and then GO WORK IN a detox unit side by side the doc and nurses during active, genuine, patient withdrawal. Solely running treatment groups or 1:1's in your office (both at the periphery) doesn't really count...you become stale and sheltered from the truth and can be easily manipulated by those who sit in front of you. The best education is in the detox trenches...seeing it up close and personal. No doubt, it will assist you in being a more effective clinician.

Thunderwolf, MSN, RN · Jul 25, 2008

i am ashamed about feeding patient addictions and sending them back home more ill than when they came in. the nurses are starting to get together to complain to our unit manager about this patient; i hope something is changed. "do no harm" is being violated.

don't feel ashamed. your colleagues feel the same who have been there even longer. denial runs thick in detox....that is why these patients are there. and if your patient is not being detox'd and confronted, he is taking you all for a merry little ride...at staff expense. the dictums "the customer is always right" and "customer service" does not and should not apply in any addicts obtaining "the store candy." many addicts truly do not intend to come into the hospital as their place of healing...many do, however, truly do see themselves as genuine customers (not shoppers...don't call them that...they rarely pay for it) and come in fully expecting their goods to be delivered (entitlement). righteous anger is not uncommon when it doesn't go their way and they are sent packing...as it should be, if no interest in detox and treatment. however, some management do tend to give in to them and allow them to misuse their system in order to fill the bed and to boost their own satisfaction scores....but, this is very ill placed and very dangerous at best. believe me, the word on the street gets around and gets around fast. this is not good for another reason...for it only chips away the hospital's reputation in the community....a reputation which many hospitals honestly try to protect.

you have a good conscious...cherish it....and please don't lose it.

Thunderwolf, MSN, RN · Jul 25, 2008

do your facilities have problems with discharging seriously overmedicated patients?
and
my opinion is that he truly does have depression, anxiety, ptsd issues and is absolutely desperate to remain numb (sounds like some of addiction psychology doesn't it?).
the psychiatrist has been practicing for decades. is he easily manipulated with a bleeding heart? the nurses who have worked with him for years describes him as placating patients so they will not be issues on the unit.

nope....i have been blessed to work with some top notch psychiatrists/detox specialist psychiatrists in the past. alcohol and opiate detox lasting typically no more than 3-5 days inpatient. in true detox, they are slammed (with treatment meds) and slammed hard upon admit with the onset of objective criteria...if none, out the door. mental health inpatient typically was 3-7 days (at the most). of course, there are rare exceptions. 20 days inpatient psych (even for any detox) is totally unheard of in this day and age. case management is very important...moving these folks along and getting these folks connected to where they need to be post inpatient stay. if you have poor case management, your unit will suffer...and suffer badly.

now to address the mental health issues.

i am not unsympathetic to this or to the patient if his mental health picture is legit. one in every five adults, or about 44 million americans, experiences some type of mental disorder every year. i too, many years ago, suffered from ptsd and depression...and needed knocked down by meds during an inpatient stay. i was in good company though....my room mate was a practicing physician, depressed and almost committed suicide. we as health care providers had much to talk about, our stress, and inability to cope at the time. that is why we were bunked together as room mates. by the way, i am very ok now.

typically, with ptsd and depression....antidepressants are commonly used. with flashbacks, anxiety, and insomnia, antipsychotics/antidepressants, less/non addictive anxiolytics, and trazodone are very helpful. and even if benzos are used, they are used for the short term...long acting ones are best for several reasons. with anxious depression, sedating antidepressants are very appropriate. with significant mood swings and irritablility, mood stabilizers. counseling is imperative...for "continued numbness" is not the answer or the goal of treatment...learning about one's symptoms, risk factors, and how to reduce/manage/live with them (separate from medication) is part of treatment, however. 20 days inpatient seems like an aweful long time...regardless if ptsd and/or depression. either the patient has most excellent insurance or your hospital is eating the bill. social work/case management really needs to be on the ball with this case.

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my bet is still (from the picture you paint)....addiction as primary. his desire for "the injectable" is also somewhat diagnostic of a possible continued addiction...especially if ever he requests for iv, he may want to feel his "rush" then. if he did get iv, his next request would be for the nurse to "push it in fast." ativan iv is a favorite. i have known addicts to throw themselves down to the ground to fake a seizure just to get it...even for the im (watch your tv monitors on these folks if your facility has them). addicts also like phenergan iv for supposed nausea for the same reason. dilaudid iv for supposed pain tends to be a hospital acquired drug of choice for addicts as well. if addiction is suspected/confirmed, all meds really need converted to the po form asap and all iv's removed (even saline locks), if present. otherwise, you are simply playing the addict's game.

and secondary diagnostic impression....ptsd/depression (if legit) with maybe an axis ii personality disorder (as a rule out). 80% of antisocial personality disorders abuse substances.

however, for billing purposes, the mental health diagnosis would be flipped as primary...many inpatient psych hospitals do this to get reimbursed.

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lastly, you can have the great fortune in having a great doc on board as well as having the bad luck in having a poor one (who may be simply burned out). i knew one inpatient doc as a side colleague who diagnosed everybody who walked in the door as dissociative disorder (he still referred to them as "multiples")....not good....he had issues himself. the worst detox patient i had was a hospital administrator at the phd level who used to self inject himself in the neck (at his collar/necktie line)...talk about narcissistic manipulation. opiate users tend to have this grand self entitlement that no one else seems to share about them. hmmm...wonder why? so, i feel your pain. hang in there. you are learning.

inthesky · Jul 27, 2008

thank you so much for this wonderful informative comment. I'm exhausted from work right now, but when I have a bit more time, i would love to continue this discussion :rcgtku:

inthesky · Jul 28, 2008

Thunderwolf, I read your response carefully sentence by sentence and definitely made connections to situations I have already seen. I'm a new nurse and really have had very little training in detox. I started knowing AA steps and some basic addiction psychology and physiology. I am completely just confounded at the opiate detoxers asking for opiates.. and being SUCCESSFUL :banghead: . Alcohol detoxers can't ask for alcohol . Alcohol detoxers tend to want to sleep and come to the desk when feeling sick. I have known some detoxers to lay in bed shaking and not come up (which is why I do monitor them frequently and sometimes convince them to take the ativan). I have had a couple of alcohol detoxers fake symptoms to get more ativan; they tend to sleep all day when given the ativan they ask for =P.

I actually do tend to give opiate detoxers more ativan than ETOH detoxers. Many opiate detoxers will wait every 2 hours on the dot. Is ativan even effective for opiate withdrawal? I've been told that clonidine + flexeril + bentyl are the meds that will best take care of the symptoms. I'm finding people so desperate for a 'fix' or something to solve the turmoil that it doesn't matter what you give them as long as you give them 'something'. Benadryl is quite a useful drug to be that 'something'. Opiate detox really is an uncomfortable detox, so what really is unreasonable (except of course more opiates =P)? That patient pacing the floor, looking really stressed, complaining of a 'creepy crawly feeling', and asking when she can receive clonidine again.. that sounds pretty legit.. why not offer some ativan in between clonidine times (if BP allows)?

also..some hard situations (what do you do?):

*the patient is threatening to kill themselves because the chronic pain is so severe (The patient has actual herniated spinal discs, hx back surgery, old lodged bullet, fibromyalgia, bone cancer, etc and you name it).

*The patient is 'freaking out' and makes clear allusions that they are going to hurt someone else (or themselves) if they are not given either more ativan or opiates. The two specific patients I'm thinking of do appear antisocial and have histories of violence towards others.

(ps. we had 4 patients like the above * and all of the staff were ready to explode in frustration). The patient group as a whole were so explosive that we had to send all the nursing students home right after they walked in the door. (it was pathetic/funny to watch the doctor literally hide from them).

My opinion is that our unit is not a pain clinic and the patient will have to see a pain doc. Unfortunately, i think that the patient who threatens DTS/DTO will succeed in attaining wanted (although compromised) ativan.

what happened to the overmedicated patient mentioned in first post: The unit manager put pressure on the doc who caved with a great deal of embarrassment. He cut this guy's meds in half the next day. The patient 'agreed' with us that he was too tired and that cutting out the morning thorazine and the daytime valium was a good idea. He was very upset about the cut in oxycodone and as I type is trying to get more. I wonder if he will threaten to kill himself right before discharge (finally monday -he was admitted 7/6) or whether he is resigned that he overplayed his cards. At least, he is not an 'act-outer'.

ps. I'm so glad that you have worked through your depression/PTSD issues. Your strength is admirable. I know (as having recovered from an eating disorder and managing bipolar disorder) that it can be an uphill battle and requires a lifetime effort to stay well and help others :)

ruralnurs · Jul 28, 2008

Couple of things to remember as a nurse about withdrawal:

ETOH withdrawal needs treatment, they can die.

Benzo withdrawal needs treatment, they can die and the horrific seizures they often have can cause long term damage. For those unfamiliar these are the "Ams" ie. lorazepam, diazepam, clonazepam, temazepam, alprazolam, etc.

Narcotic withdrawal makes you feel like you will die, you want to die, but does not kill you.

Another thing that really chaps me is the docs that put people on these chronic pain meds like oxy and so on and never tell them that when (not if) they have an acute pain condition, it is almost impossible to kill their pain. They have become so habituated that there is a fine line between killing their pain and killing them and they suffer, big time. I have cared for people in the ER after MVC or even kidney stones and I hate to hear that they are on lortab 10/500 every 4 hours, because I know they are in for some real suffering.

And if you are on ETOH, lots of pot or benzos you can have the same reaction as they are on similar receptors in the brain, that's why ativan works for ETOH withdrawal and some alcoholics have a hard time getting pain relief from even high dose narcs, and people that use lots of pot can have the same prob.

Good drugs for narcotic withdrawal are beta blockers, and buspar is a wonderful anxiolytic, even PRN though most providers do not know that it can be helpful PRN.

Thunderwolf, MSN, RN · Jul 28, 2008

Thanks for reply.

The 20 day stint in the hospital is sort of diagnostic of the treatment approach (if any)...and begs the questions: What are you treating? What is the objective criteria warranting treatment? What is the plan of treatment? What discharge criteria is being made to move this patient along out from inpatient? And what referrals are being set up for the patient to follow up with? Again, I greatly sense this patient is taking you all for a ride. Interesting, and sort of telling too, that this patient was agreeable to have all meds cut in half EXCEPT for the narc. Hmmm...very telling.

Now to get down to opiate detox and symptoms.

The key is to medicate with meds that are NOT addictive or potentially addictive. I mentioned Neurontin...I have seen this used very, very effectively. Seeing the results, I am a firm believer of its use in opiate detox with the complaints of anxiety, restlessness, agitation, muscle and joint pain...but it has to be used in the amounts that I first mentioned (up to its max)...tailored to the patient and symptoms. Bentyl for stomach cramps. Zofran or Tigan for nausea. If an opiate patient states they are vomiting, the vomit must be witnessed as evidenced via the toilet. Ativan really should not be used with opiate users....and if it is, very sparingly. Remember, these folks also tend to be polysubstance users as well. I need to ask though, what is your primary drug used for opiate detox?....clonidine? For some, it is effective...for some not as effective. I worked in a detox where Ultram was used with a taper for Opiate detox....detox done in 4 days...done...and symptom free.

Chronic pain?....you are not there for chronic pain management...that is a referral elsewhere. Not inpatient psych or detox business. That should not be part of the inpatient treatment plan or a basis of when to discharge (ie less pain or pain free)...it should however be part of the discharge plan with referral outside from you...but not your current focus of care...and that needs explained to the patient. You are not there to address chronic pain issues...period. It is inappropriate use of your services.

Again, 20 days is mind boggling as to why he is still around. He needs moved out...either discharged with referrals or shipped off to a higher level care psych facility (who would either treat him more appropriately or could clamp down better on his behavioral manipulation). The more you paint the picture, Axis II is strongly inferred as well. You can't treat that inpatient...and should not be a basis of your treatment.

Hope this helped some.

Let me know.

Thunderwolf, MSN, RN · Jul 28, 2008

ETOH withdrawal needs treatment, they can die.
Benzo withdrawal needs treatment, they can die and the horrific seizures they often have can cause long term damage. For those unfamiliar these are the "Ams" ie. lorazepam, diazepam, clonazepam, temazepam, alprazolam, etc.
Narcotic withdrawal makes you feel like you will die, you want to die, but does not kill you.
Good drugs for narcotic withdrawal are beta blockers, and buspar is a wonderful anxiolytic, even PRN though most providers do not know that it can be helpful PRN.

Totally agree. Thank you.

The worst DT's I had ever witness was from Xanax...the person nearly died. Totally agree with you regarding Benzos and detox....and risk of lethality.

Ativan really has no place for the Opiate addict.

For the alcoholic in detox, Ativan or Valium (depending upon the liver zymes) are the key in detoxing them off the ETOH.

Thunderwolf, MSN, RN · Jul 28, 2008

The patient 'agreed' with us that he was too tired and that cutting out the morning thorazine and the daytime valium was a good idea. He was very upset about the cut in oxycodone and as I type is trying to get more. I wonder if he will threaten to kill himself right before discharge (finally monday -he was admitted 7/6) or whether he is resigned that he overplayed his cards. At least, he is not an 'act-outer'.

At this stage of the game, I would totally be focusing with him discharge and referrals....and emphasizing, treatment here is essentially done and over. I would also emphasize that treatment is an ongoing process, pointing him to these other referrals.

Thunderwolf, MSN, RN · Jul 28, 2008

also..some hard situations (what do you do?):
*the patient is threatening to kill themselves because the chronic pain is so severe (The patient has actual herniated spinal discs, hx back surgery, old lodged bullet, fibromyalgia, bone cancer, etc and you name it).
*The patient is 'freaking out' and makes clear allusions that they are going to hurt someone else (or themselves) if they are not given either more ativan or opiates. The two specific patients I'm thinking of do appear antisocial and have histories of violence towards others.
(ps. we had 4 patients like the above * and all of the staff were ready to explode in frustration). The patient group as a whole were so explosive that we had to send all the nursing students home right after they walked in the door. (it was pathetic/funny to watch the doctor literally hide from them).

Again, pain management is not your focus....this needs clearly explained for chronic pain suffers RIGHT AT ADMISSION. You do not treat chronic pain. You can help him/her with acute depression and to help ride out the impulse to suicide and keep him/her safe. But chronic pain is and should be addressed elsewhere. And fibromyalgia...many in the psychiatric community still don't buy this diagnosis and view it as a quasi diagnosis at best...sort of like "stomach virus causing pain" in the ED. Some buy it as a distinct and genuine diagnosis, some do not. Much of this diagnosis can overlap with or actually be part of Depression or Dysthymia.

Threatening homicide or acting out on another in order to acquire addictive drugs is intervened upon from a safety standpoint. It should be clearly explained that acting out like this would either be reason for immediate discharge or call for restrain/seclusion...without any promise in meds or drugs. And if it does call for meds, it most probably would not be the meds he/she is seeking for. This should be laid out very black and white. Call the bluff with the facts. If "X" happens, "Y" will or may be the result of "X". The protocol and doctor dictates treatment..."not the patient" in these type of acute situations. So, as a nurse, know your protocol. Acting out behavior...It is met like for any other patient. What are your guidelines for this? What is your protocol, policy, and procedures? Become familiar with them. Acting out or threatening behavior should NOT be the ticket to "goodies." If your unit has done this for him or any other patient, you as a unit have reinforced the acting out. Your unit milieu and rules are to dictate behavior on the unit for patients and staff, NOT that patient. The question I ask regarding this is: who is in charge here....the patient or the unit? The unit is only as safe as your milieu. Compromise milieu, you compromise safety and the therapeutic environment.