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?

[cmryan12]

Not giving pain medication that's ordered after a painful procedure is cruel and not why we are there. Not working to control her pain isn't going to magically fix a history of drug use. What it will do is impair her recovery and make her less likely to seek needed care in the future. Unless she comes in for detox and recovery of her own free will, you will not do anything to help any drug problem she may have. Those are decisions for her to make, and she has to do the work to recover. By all means, educate and offer resources while working to manage her pain. But please keep working to manage her pain, drug history or not.

[dragn2623]

Bottem line ... you are there to treat their postsurgical pain, not their addition or history of addiction. That's what rehab is for and not for your colleague to withhold medication that was rightfully ordered. Shame on them!

[2ndCareer2]

There's somewhat of a fine line here- it's absolutely appropriate to offer pain relief to anyone and everyone, regardless of drug abuse hx.

As nurses, we also keep in mind the future impact of what we do...by this I mean is giving certain types of pain meds going to cause a relapse (and in this case, a patient needing heart surgery at such a young age could very easily be from her prior- or current- drug use). So, is giving these pain meds going to, in the end, create further health issues for this patient because it causes a relapse? Who can say? We really don't know for sure. And is it ok to hold pain medication on a 'what if' scenario? But detox and getting clean can be EXTREMELY difficult, do we want to have a hand in destroying all the work, the heartache, the patient went through?

Honestly, I think it comes down to the patient and the doctors. The doctor has to have an open, forthright discussion with the patient before the surgery- you're going to be in pain and you have a drug abuse history, here are your choices for pain control, what do you prefer? That way the doctor can order appropriate pain meds and tge patient is prepared and aware.

My final thought is, did anyone offer or attempt other alternatives to opoids? We know about the Tylenol (which is laughable for post-op pain), but maybe Toradol could've offered some relief without the risk of relapse.

The patient is really the one to dictate what she wants- was she able to understand the risks of getting vicoden and morphine? If so and she chose to get them, then that's her choice.

I think you made the right decision. It's one of the millions of ethical dilemmas we deal with as nurses!! It's a fine line, but pain control is very high on our list of needs and rights as patients. (And, honestly, if you're still questioning it, talk to the doctor- even if the patient is already gone, just run the scenario by the doctor and see what they say...which will probably be to offer pain relief)

[CrazierThanYou]

I've been in a very similar situation. My response was "You make the nursing decisions your shift and I'll make them on mine."

Also, it isn't your job to rehab the patient.

[Nursejm1]

As a nurse who has to take pain medication on a regular basis (no I am not in patient care so all of you can just rest) when I had surgery guess what I needed, pain medication! Wow, what a bunch of holier than thou nurses can be. So she was a drug addict? So that means she doesn't feel pain after heart surgery? Even if we err on the side that she was drug seeking, did that one dose of Morphine do anything more than ease her suffering? I have worked with post-op nurses who don't think their patients shouldn't have pain medication. I hope all of you who think because society has dubbed this person as terrible and bad and not worthy to be treated as a human, be denied when you are truly in pain. Get a clue, you cannot feel someone else's pain so who are you to deny your patient. You are supposed to be an advocate. Good for you for helping your patient and giving her something a physician ordered. You're no hero by denying your patient for the good of your moral high ground.

[BostonFNP, APRN]

2ndCareer2 said:

There's somewhat of a fine line here- it's absolutely appropriate to offer pain relief to anyone and everyone, regardless of drug abuse hx.

As nurses, we also keep in mind the future impact of what we do...by this I mean is giving certain types of pain meds going to cause a relapse (and in this case, a patient needing heart surgery at such a young age could very easily be from her prior- or current- drug use). So, is giving these pain meds going to, in the end, create further health issues for this patient because it causes a relapse? Who can say? We really don't know for sure. And is it OK to hold pain medication on a 'what if' scenario? But detox and getting clean can be EXTREMELY difficult, do we want to have a hand in destroying all the work, the heartache, the patient went through?

Honestly, I think it comes down to the patient and the doctors. The doctor has to have an open, forthright discussion with the patient before the surgery- you're going to be in pain and you have a drug abuse history, here are your choices for pain control, what do you prefer? That way the doctor can order appropriate pain meds and tge patient is prepared and aware.

My final thought is, did anyone offer or attempt other alternatives to opoids? We know about the Tylenol (which is laughable for post-op pain), but maybe Toradol could've offered some relief without the risk of relapse.

The patient is really the one to dictate what she wants- was she able to understand the risks of getting vicoden and morphine? If so and she chose to get them, then that's her choice.

I think you made the right decision. It's one of the millions of ethical dilemmas we deal with as nurses!! It's a fine line, but pain control is very high on our list of needs and rights as patients. (And, honestly, if you're still questioning it, talk to the doctor- even if the patient is already gone, just run the scenario by the doctor and see what they say...which will probably be to offer pain relief)

From a provider perspective, it's not the RNs job or role to withhold prescribed medication because of a "what if" concern about what might happen in the future. If there is not an immediate physiologic contraindication that requires a call to the prescriber, then give the med if it is indicated.

[BabyFood26]

To put it all simply, sounds like a human being was made to suffer because someone had their panties in a twist while being incapable of climbing off their high horse ... The orders were there to be utilized for the sake of the patient's well being. Did she ever think that withholding effective pain relief could result in a less than speedy recovery or add to the slew of already present complications?

[Tenebrae, BSN, RN]

Did you give any medication that wasnt charted, or wasnt due?

Otherwise you did exactly right and exactly what I would have done in a similar situation.

[JinnSchlajfertig]

So many great responses that hearten me!

A friend of a friend is a long-term, stable opiate addict. He lives in a small town about 90 minutes away from me. I live in a large metro area with magnate hospitals. This gentleman, let's call him Fred, was in a very bad car accident (not his fault, clean UA, not impaired, etc., in case that matters for some). He had multiple broken bones, life-threatening organ injuries, etc. He was flown to the major trauma hospital in my city and ended up there for a few months in recovery.

At the request of our mutual friends (who are mostly indigent and unable to make multiple trips to visit Fred), I checked in on him. I was doing clinical training for Occ Health MN in the same hospital, so NBD.

I had never met him, but he was very thankful for my visit. I point-blank told him that our mutual friends were worried that he was getting adequate pain control due to his long-term opiate abuse history. I further explained that I was not there to judge, that I had worked with opiate addicts for a long time, was (at the time) a detox RN, etc.

His eyes lit up. He was thankful that I asked. He said that the providers and nurses were amazing. They not only were totally blunt and accepting with him about his history, but adjusted his pain control, and worked intensly with him to taper. The just rolled that right into his treatment plan.

He was EXCITED to taper all the way off and detox right there in the hospital.

The social worker had a treatment bed all lined up for him.

His boss had his job waiting when he ready.

If he had judgment and cruel withholding of pain relief, NONE of that would've happened.

Are there manipulative people and addicts who will lie out of desperation? You betcha. But it is part of our job not to get all freaked out by that and treat them like human beings. If we need more training and support, it is on US to ask for help.

We are health care providers. PERIOD. We are there to help ensure our patients are better off for our interventions. PERIOD. We are there to provide care that our patients find acceptable. PERIOD.

That often involves setting reasonable and consistent limits with people. It never involves allowing our personal biases getting in the way of quality patient care.

P.S. why would the one nurse get all upset about the OP following orders? I'm not the most experienced nurse, but I can't imagine tolerating that level of disrespect. Like others said-it's the OP's shift, the OP's assessment, the OP's responsibility. What gives?

[Medic/Nurse, BSN, RN]

I think the one of the most important roles in nursing practice is advocacy.

OP did what was best for their patient. That is excellent nursing.

The biggest question I have — Why is Tylenol nurse even in your lane? I wouldn't discuss the matter with them further as their simply a safety risk (all their patients with pain are likely not being treated appropriately (cause "judginess" likely extends to other less deserving populations too). Put simply — untreated/undertreated pain = increased MVO2 and all its badness. Very bad in post cardiac surgery patients.

Now that you know what you know, well, you know what to do. But, no more unit discussion. Depending on unit politics, your educator and if anything could actually make it better for patients. I might even just look into a BON complaint. I consider this a serious matter.

Cause it takes allows a nurse to just ignore MD orders because the nurse knows better/more than the surgeon for the sole reason of social bias. A nurse should know a few post-op doses of pain meds won't change addiction, so maybe it's something else motivating this nurse to NOT treat a patients pain.

Maybe something like, this patient doesn't deserve pain control cause they brought this valve replacement on themselves by all the narcotics they used to get here, so now they can just suffer. That is scary, scary stuff.

[BeenThere2012, ASN, RN]

No, no, no and no again...you did NOT do anything wrong. Drug addicts and those with a history of.drug abuse deserve.pain control the same as anyone else. What's more, even years after the last dose of an opioid drug, the person.may still have a tolerance above the average person and requires larger doses.

The only time I would say it would be wrong to give, would be when the patient requests not to be given opioid meds in their affort to continue abstinence.

Having said the above, it would be important for the patient to have a plan with their MD to wean off again and/or an agreement for limitations on how long to give the meds and how to address issues of relapse or threat of relapse should that come up....if it comes up and that is to be addressed at a later time?

[lbenbenek]

If the pain medicine is ordered and it's due give it. Regardless of her issues with addiction. Why would the other nurse just give her Tylenol? I wouldn't want her as my nurse.