Pain medicine to drug addict?

[MrBlueSky]

Hey guys I have a scenario I want to run by. So I work on a cardiovascular surgical floor. One of the things we do is heart valves. Every so often we get the endocarditis from drug use. Sometimes we get repeat offenders which is sad.

So anyways, thats the background. So I get my patient, 20 something year old female drug addict who had recent heart surgery. I got report in the morning and of course pain was a major issue. The night nurse was like I gave her vicodin and that seemed to help. So I come on and shes crying and visibly in pain. The vicodin is due, so I give that. Hour later she is still crying so I look on the mar and she has a small dose of morphine. So I give that. '

Next day nurse confronts me and says why would you give an IV drug user morphine? She goes on to say she was only giving the patient Tylenol. I tell her that the night shift nurse told me she was taking vicodin. She says he should not have even given her that.

Did I do wrong? The patient was clearly in pain and the medication was ordered by the surgeon. If the patient is in pain shouldn't we treat it?

[Been there,done that, ASN, RN]

The patient is not a "drug addict", the patient has a history of drug abuse. Medicating the patient for an acute condition is the same as medicating any other patient.

GET THEIR PAIN UNDER CONTROL. Give any ordered pain rx, if it is not effective get another order. The nurse that gave Tylenol needs to be educated and written up.

[Cowboyardee]

Been there,done that said:

The patient is not a "drug addict", the patient has a history of drug abuse. Medicating the patient for an acute condition is the same as medicating any other patient.

GET THEIR PAIN UNDER CONTROL. Give any ordered pain RX, if it is not effective get another order. The nurse that gave Tylenol needs to be educated and written up.

You're right. +1 this.

And just to be clear - even if the patient were a current drug addict, that is no justification for denying them pain medication in a situation where you would expect them to have significant pain (e.g. post-operatively). We don't torture patients in this country, drug addict or not. In fact, in such a situation, a patient with a history of opioid abuse will typically need a higher dose of pain medication than most patients to achieve the same degree of pain control due to their higher tolerance.

[iluvivt, BSN, RN]

I was so happy to see the two appropriate responses above.Her nervous system and her body's response to surgery does not change because of her drug addiction.I would like the nurse who under-treated her pain due to ignorance have to suffer postoperatively so she could muster up a little empathy.I would also have a talk with your educator and manager as this nurse needs some education.It is not a punitive thing but a need for understanding and a chance to grow professionally. You need to stand by your assessment and nursing actions based on that.She was not there on your shift so she needs to keep out of it unless there was some glaring error she had to point out.You must report this so other patients do not suffer needlessly as ypu now know she lacks the appropriate knowledge to assess pain and treat it based on the orders.Her personal beliefs could also be clouding her decision making.

[Davey Do]

MrBlueSky said:

Did I do wrong?

As ELO sang, "Mr. Blue, you did it right..."

[KatieMI, BSN, MSN, RN]

iluvivt said:

I was so happy to see the two appropriate responses above.Her nervous system and her body's response to surgery does not change because of her drug addiction.I would like the nurse who under-treated her pain due to ignorance have to suffer postoperatively so she could muster up a little empathy.I would also have a talk with your educator and manager as this nurse needs some education.It is not a punitive thing but a need for understanding and a chance to grow professionally. You need to stand by your assessment and nursing actions based on that.She was not there on your shift so she needs to keep out of it unless there was some glaring error she had to point out.You must report this so other patients do not suffer needlessly as ypu now know she lacks the appropriate knowledge to assess pain and treat it based on the orders.Her personal beliefs could also be clouding her decision making.

Actually, they do. They change toward INCREASED requirements for opioids for adequate pain control, that is. She has lower baseline level of endorphins, orexins and such other substances in her brain, and so might need more opioids to bring her pain level perception to the level where it is not interferes with immune response and other functions that involved in recovery and healing. About 10% + to start with.

And I see no reason for not giving such patient all that plus those 10%. And even more, if necessary. Leaving alone ethics, denying this patient opioids would make no more sense in terms of pharmacology than denying insulin for decompensated type II diabetic. Does it really NOT occur for some people who apparently spent that many years in school??

[elkpark]

KatieMI said:

Actually, they do. They change toward INCREASED requirements for opioids for adequate pain control, that is. She has lower baseline level of endorphins, orexins and such other substances in her brain, and so might need more opioids to bring her pain level perception to the level where it is not interferes with immune response and other functions that involved in recovery and healing. About 10% + to start with.

And I see no reason for not giving such patient all that plus those 10%. And even more, if necessary. Leaving alone ethics, denying this patient opioids would make no more sense in terms of pharmacology than denying insulin for decompensated type II diabetic. Does it really NOT occur for some people who apparently spent that many years in school??

I agree -- not only do individuals with a hx of opioid dependence, whether in the past or current and active, have the same right to have their pain treated as anyone else, they typically require much higher doses than opioid-naïve people in order to get relief because of the tolerance they have developed over time.

[ED_Murse]

Treat her pain. Doesn't matter if she's an ex drug user or a current drug user she is still going to experience pain the same as anyone else - she's just had major surgery.

If she tells you she doesn't want opiate based analgesia then that's a different story.

You should feel good about the care you provided for that patient, it's the other nurse I'd be concerned about.

[nutella, MSN, RN]

It is unethical and inappropriate to withhold pain medication based on a personal opinion or bias when the patient has pain after surgery and is ordered for pain medication and obviously it was not like the patient was too sedated or such. Not to mention that it is highly questionable as a human being to let somebody suffer after a procedure with the argument of "addiction" or "possible addiction" and my favorite is "they brought it upon themselves and this will teach them consequences"....

This is how I go about those things:

I do a pain assessment that includes the patient's subjective number but also observational items. In addition I will ask the patient about their current drug use or previous pain medication use, and also if they are in recovery or not.

Based on all of that I usually find out if the patient needs a specialty consult to pain services (highly recommend if available at your location - some have acute pain on call for people after surgery or similar) or if no pain services available palliative care physician for recommendation re pain as they are well versed.

The dialogue with patients is most important. Some patients who are in recovery do not wish to take narcotic pain medication because of the risk of addiction but if they have severe pain will agree to take it short term. Important here is to make a plan that sets them up for success and include counseling and after care appointments.

Some people are active users and those may need higher doses to relieve the acute pain as they have a tolerance. The key here is to ensure early coordination of services based on patient needs - perhaps they want to get into a methadone program or they just want to continue to use (in that case they usually get discharged with pain medication script for only very few days for narcotics (if at all) and follow up appointment with their PCP / pain clinic whatever applies.

I would ask the nurse that made the comment to how she views herself ethically in this scenario. It is not our job as nurses to "police" the patient or force our own agenda onto them. Our practice should be guided by the nurses code of ethics and policies and procedures - plus the often missing common sense ...

Perhaps it would be a good opportunity to ask the unit educator if they can do an education on pain intervention for patients in recovery, active users, chronic pain medication users and so on ...

[Here.I.Stand, BSN, RN]

Giving Tylenol postop is just cruel and ignoant. This poor woman had her sternum cut and held apart by retractors, and had her heart operated on. Heck last year I had post-dental procedure pain -- I was in a bite block for 1.5 hrs while the dentist made me a crown, then he accidentally dropped it in the back of my throat and unable to retrieve it (I swallowed it, feeling like my choices were swallow or aspirate it) and then make me another. He gave me Vicodin for that. After all that I ended up needing 2 root canal procedures, and I got an infection way down to the bone. My endodontist gave me an Rx each time I visited which was weekly for a month.

It was horrendous and I definitely needed those strong pain meds, and I alternated with 800 mg ibuprofen. (On my work days, I just did the ibuprofen and 1000mg Tylenol.) I'm also sure that heart surgery is miles more painful than what I had experienced. Giving plain Tylenol is basically NOT treating the pain.

In addition to the cruelty of making her suffer, I would be concerned the safety of withholding pain control. How the heck is she supposed to cough and use her IS, or participate in PT if her pain is not treated?

Honestly I would be encouraging the patient to report these refusals to treat. This RN needs to be re-educated, or else she needs to stay the heck away from post-op patients as she has proven her incompetence.

[spacemonkey15]

You did the right thing OP, often people with a history of drug misuse require a lot more analgesia to get their pain under control, o even the addition of more novel analgesics such as ketamine.

As for the nurse who only gave tylenol (I'm UK, from what I've seen it's paracetamol/acetaminophen isn't it?), their attitude goes against how we should be working as nurses, pre-judging an individual and not giving prescribed treatment. This could even be interpreted as a fitness to practise issue.

[MrChicagoRN, RN]

OP, Good advice has been given. She didn't come in to detox, she came in for surgery. She deserved at least the same level of analgesic medications (but likely more) that anyone else would receive for that type of surgery.

I'm MrChicagoRN, and I approve of all the above messages. (A little election levity)