Patient's addicted to narcotics

[rn undisclosed name]

I had a pt the other day that was addicted to dilaudid. I'll also assume he was addicted to xanax since he does take that 4x/day. He also takes several other psych meds. He requested a pain management specialist see him in the hospital so I had that arranged. They saw the pt and they checked the prescription reporting service (I don't recall the exact name) and they determined the pt is addicted to dilaudid and has multiple subscribers for his medications. I know I'm not supposed to judge his pain. Subjectively he states he has a lot of pain all the time. Objectively he looks comfortable. Those are facts and not my opinion.

I was wondering if a pharmacy is legally required to always fill prescriptions when it is known that they get prescriptions from various providers and there is a pattern of "doctor shopping" for lack of a better term. I asked another nurse I work with who said "well they have the prescription so the pharmacist has to fill it". I just think there should be some accountability and don't really know who it should fall on.

Needless to say the pain doctor would only authorize the pt to have dilaudid 1 mg ivp q3h prn. The pt takes dilaudid 8 mg po q4h atc at home. Of course the pt left AMA because he was not getting the pain meds he wanted.

[Horseshoe, BSN, RN]

Objectively he looks comfortable. Those are facts and not my opinion.

How someone "looks" is subjective, not objective. Secondly, people who are in chronic pain often do NOT display indicators of pain such as increased heart rate, blood pressure, etc. Over time their bodies no longer experience the fight or flight syndrome which is present during an acute episode of severe pain. They may become very adept at speaking and behaving normally because pain is such a constant in their lives. Doesn't mean they are not in pain.

I do agree that non narcotic interventions may be necessary to help a patient in chronic pain, however. Seems to me that your patient did ask for help by virtue of being open to the help of a pain specialist.

[Lovely_RN, MSN]

I agree. I've learned a lot about opiate tolerance during my time in the methadone clinic. I would be doing dose verifications for hospitalized patients and the nurse or MD on the other end would be in utter disbelief when the patient's usual dose was a number they didn't feel comfortable with. I’ve seen patients on up to 290mg (need state approval to go higher and I never saw anything higher than that). The phone call would usually go like: Yes, that's right TWO...NINE....ZERO ...two hundred and ninety mg uh..yes that's what I said 2...9...0...two-hundred-and ninety mg.

People would be surprised. They think only a huge man could be on a dose that high and it would be someone’s granny/grandpa...whose grandkids of course have no clue about what granny/grandpa was getting up to in their heydays of the 60s and 70s.

The best would be the MDs who would mumble that the dose was too high and the patient didn't need all of that or they were going to cut it down to ______. Next thing I see the patient back in the clinic the next day because they left AMA but before they did they probably gave the staff hell. We would of course assess them and then usually send them right back to the hospital via ambulance. Gotta love it...

How someone "looks" is subjective, not objective. Secondly, people who are in chronic pain often do NOT display indicators of pain such as increased heart rate, blood pressure, etc. Over time their bodies no longer experience the fight or flight syndrome which is present during an acute episode of severe pain. They may become very adept at speaking and behaving normally because pain is such a constant in their lives. Doesn't mean they are not in pain.

I do agree that non narcotic interventions may be necessary to help a patient in chronic pain, however. Seems to me that your patient did ask for help by virtue of being open to the help of a pain specialist.

[pattisarm]

First of all a patient who is addicted to pain medications has a very high tolerance to the same and will need much more medication to relieve his pain. Basic nursing. He is addicted, not a criminal, and deserves pain management without judgement or bias just as much as the little old lady who is addicted to ativan her MD gives her because she calls to often with complaints. I am sickened by nurses who think that they know it all. They are the reason that good nurses have to deal with the "problem patient", when it is really the "problem nurse". Wake up folks did they tell you in nursing school all you would have to do is text your friends and take breaks??? It is called work for a reason.

[Lovely_RN, MSN]

Are your really a nurse? Four posts so far and you've done nothing but attack people. Something smells fishy...anyway welcome to AN!

First of all a patient who is addicted to pain medications has a very high tolerance to the same and will need much more medication to relieve his pain. Basic nursing. He is addicted, not a criminal, and deserves pain management without judgement or bias just as much as the little old lady who is addicted to ativan her MD gives her because she calls to often with complaints. I am sickened by nurses who think that they know it all. They are the reason that good nurses have to deal with the "problem patient", when it is really the "problem nurse". Wake up folks did they tell you in nursing school all you would have to do is text your friends and take breaks??? It is called work for a reason.

[AngelfireRN, MSN, RN, APRN]

As a CRNP whose practice has emphasis on pain management, please let me say...there's addiction, and there's dependence. I find that a lot of my patients become tolerant of their meds after a period of time, and either require an increase in either dosage or frequency. My doc is great at it. We can both spot a seeker a mile away. We use the national database, we do random drug screens, and if we find that a patient is seeing other docs for the purpose of obtaining controls or that they are selling their meds, we dismiss.

If it becomes obvious that the patient is either going to require a massive dosage or that they're not going to be happy no matter what dosage of whatever it's deemed that they will receive, we refer to the pain clinic. We don't run a candy shop, nor do we knowingly let them suffer.

But I can tell you this, "Pain is what the patient says it is." Phooey. When you come to see me and you're whining and begging for more meds, I really have a hard time believing you're in such agony when I saw you 3 nights ago, riding the mechanical bull at the local cowboy club. Sorry, hon. BUSTED!

The look on her face was priceless.

[N.U.R.S.E.]

With pain management I think we need to start off on 1 tylenol and move up from there bcz for a person with chronic pain is to get them back to functioning a level of pain must be tolerated usually a 10 get them down to 5 and. That way you have a longer time before the become dependent andthey need the heavy stuff but I've never had chronic pain before had a toothache. With abscess and it hurt like the dickens 1 lortab was too much on the lowest dose because it made me high and so when it began to hurt again I took 0.5 tab or 1 tylenol and if thath didn't help it I could take another tylenol or the other 0.5 tab left which I rarely did low dose aspirin or tylenol I start with those first sometimes what's prescribed is over kill esp if you do not take recreational drugs that's how I have managed my pain in the past

[ybstressed, LVN]

i have worked at house call service for the past 6 months and i can't begin to explain the problem of addiction at our practice. i, the doctor, the patient specialists (if any), and any other members of the patients medical team attempts to help a patient who is truly in pain. now, with that said, i never judge a person's pain level. i truly believe pain is determined by the person. i also believe that pain can come from physical injuries or mental issues and the word "pain" can be abused by many to get (as my patients would say) hydrocortisones or the good stuff. the more you work with patients on such medication you will be able to determine:

1) who is truly in pain and need medication with other treatments

2) who is in pain but their pain has been managed poorly by script happy practitioners

4) who is good at what they do and do anything possible to get what they need (remember - these patients need treatment to for their addition)

the practice i work at uses multiple resources such the patient's pharmacy we have on file, the patient's insurance company, and personal investigation to see if the patient is obtaining multiple scripts from different providers. we also use these sources to make sure the patients pain is being managed appropriately. some insurance companies actually mail out a list with a detailed history of the patients scripts that have been filled and written and will give us the md's name and the pharmacies that they have been filled at. the providers also have the patient sign a controlled substance agreement that details when we will refill prescription, how we will refill the prescriptions, what will have happen if the script is ----- lost/destroyed/flushed/pills spilled/pharmacy did not give the right amount/my dog ate all the pill/the pills fell in the toilet/my aunt died and i need the pills to relax/my lady parts hurts i need fentanly/i spilled the pill box and ran over pills (only the pain pills)/i left them when i was on vacation but can you call them into the pharmacy (a local pharmacy)/i left them in another stat for the 5th time/i smoke weed and the pills help (we truly enjoy honesty)/i'm drunk and i need loratab/i have diarrhea and tylenol3 helps but i'm out (120 pills given) because i couldn't read the directions that have been the same for the past 2 years...etc.

so when i receive the chart of new patients or established patients that require some form of pain management i:

1) the physician and i do a very detailed review of the chart and determine what diagnostic test are needed before treatment can be prescribed, what pain medication will benefit the patient, what other disciplines will benefit the patient, the physiological needs of the patient , and other factors.

2) once a treatment plan is developed the we go back to the patients home and go over our findings, have a controlled substance agreement signed, and tell the patient it is their responsibility to complete all aspects of the treatment plan and to follow all the guidelines of the controlled substance agreement plan. if any of the guidelines or if the treatment plan is not followed we will review why the guidelines/treatment was not followed and go from there.

i am glad to say that most people that are truly in pain follow the plan very well. there is the issue of fixed income, poor insurance coverage, and other socioeconomic issues. many of our patients are on fixed incomes and find it hard to pay copay's for office visits, pt, ot, transportation, etc. this makes it extremely difficult to treat these patients especially when we are attempting to lower their dosages of medication will using alternative therapies. i am proud to say that i have worked extremely hard building relationships with many people in the medical community and i have been able to help numerous patients with this issue.

now the patients that have psychological issues that have caused addiction and patients that are using and selling the medication are discovered quickly and require a more in depth treatments. we usually refer for a psychological evaluation and if they deny we will not fill their medications. we then refer them to pain management. we try to avoid this since we are seeing patient that are home bound but if they are not willing to receive proper treatment then we can't help them. if we find out they are selling and abusing we refer the patient to rehab. if the patient denies our help we do not fill any prescription for them and cancel their services after we give then the names and number of multiple treatment centers. they are adults who need to take responsibly. plus, how dangerous is it for our employees to go into the home of someone who sells drugs. you never know what could happen. also, if they are able to go out and sell their pills then they are not truly home bound.

we only fill prescriptions while in the home and we write the fill date on the script. we provide enough pills until the next visit and if the amount of pills is not efficient and the patient request a new control such as fentanly we refer. we visit all of our patients monthly. we contact the pharmacy and tell the pharmacy that the patient will be dropping of a script and leave the fill date on the voicemail. the majority of our pharmacist will contact our office, hold the prescription, and verify the prescription if the patient has multiple writers or if they gut feeling something is wrong. we do not call the rx's into the pharmacy because we prefer to have a paper record. our records are meticulous! we do random drug test if we feel that something doesn't feel right and we do this without warning. if they deny their prescription is filled for 2 weeks and we refer.

so this probably doesn't help you at all and i'm sure i rambled on and on but i love the program we have because so many people benefit from it. we are able to manage our patient's pain efficiently and help patients that have true addictions.

[JSlovex2]

when someone is addicted to pain meds they may "look comfortable" because they aren't really in "pain" but they aren't really COMFORTABLE because their tolerance is so high. if they are taking more meds on the street than they're getting on the hospital, chances are they aren't in "pain" but they aren't really comfortable bc they are feeling less than "normal." that's the thing - people who are addicted to meds get to a point where the need a certain amount just to feel NORMAL. sometimes there are patients who have had so much medicine it would've killed the patient next door, yet they'll still rate their pain an 8 or 9 because they're smart enough to know (or so they think) that if they rate it a 1 or 2 they won't get any medicine - and the want that medicine to feel "normal" even if they aren't in true PAIN. on another note, you can't say patient A had the same exact procedure as patient B but patient A needs 10x the amount of medicine and he can't possibly be having that much more pain. well, he can be having that much more pain if he's an addict. i've known people on the street who would take between 4 and 10 lortab 10mg every day just for fun. so, if they were in the hospital and had surgery do you think 2 5mg lortabs would control their pain? not a chance. we might not agree with what people who have addictions do regarding medications, but we should understand that their tolerance is extremely high so they could be in pain if they're getting 1/4 of the meds to treat pain that they would take on the street when they were hanging out at home watching a movie.

[thehipcrip]

Don't most narcotic addictions stem from chronic pain?

No, they don't. This is a myth. The percentage of people with chronic pain who become addicted to narcotics is actually very, very low.

...there's addiction, and there's dependence.

THIS! And just for the record, THIS!

Please make sure you're using the correct terminology. Addiction is a psychological and behavioral disorder characterized by the presence of all three of the following traits:

• loss of control (i.e. compulsive use),
  
• continuation despite adverse consequences, and
  
• obsession or preoccupation with obtaining and using the substance.
  

What many of those responding to this thread have described is dependence, a physical condition. People who live in chronic pain and take narcotic pain medications may develop a physical dependence on those medications and will suffer the effects of withdrawal if the medication is stopped, but they are not addicts.

As someone who takes high doses of opioids to make the severe central pain and nociceptive pain I've lived with every day for decades more manageable, it's immensely frustrating that the majority of medical professionals don't know the difference between addiction and dependence, and fail to understand that the techniques and tools they use to assess acute pain (heart and respiration rate, outward affect, etc.) are meaningless when assessing someone living with chronic pain.

[seizetheday]

Please make sure you're using the correct terminology. Addiction is a psychological and behavioral disorder characterized by the presence of all three of the following traits:

• loss of control (i.e. compulsive use),
  
• continuation despite adverse consequences, and
  
• obsession or preoccupation with obtaining and using the substance.
  

What many of those responding to this thread have described is dependence, a physical condition. People who live in chronic pain and take narcotic pain medications may develop a physical dependence on those medications and will suffer the effects of withdrawal if the medication is stopped, but they are not addicts.

Where do you get your definitive definitions of correct terminology from? I have worked in addictions and never used the definition of addiction you have just given. DSM doesn't use that definition and I have found a great deal of overlap in definitions of dependence, abuse, addiction with these terms being used at times interchangeably and at times to mean very different behaviors.

So given you believe you have the correct and definitive answer, I am interested in knowing the source that provides that.

[Horseshoe, BSN, RN]

what many of those responding to this thread have described is dependence, a physical condition. people who live in chronic pain and take narcotic pain medications may develop a physical dependence on those medications and will suffer the effects of withdrawal if the medication is stopped, but they are not addicts.

as someone who takes high doses of opioids to make the severe central pain and nociceptive pain i've lived with every day for decades more manageable, it's immensely frustrating that the majority of medical professionals don't know the difference between addiction and dependence, and fail to understand that the techniques and tools they use to assess acute pain (heart and respiration rate, outward affect, etc.) are meaningless when assessing someone living with chronic pain.

this is true, and it's amazing how many times you will come across this misunderstanding just on this site alone. i usually try to counter that, but i think too many people don't care to understand the concept because they are way too busy being judgmental. i learned about the folly you described from a professor while in nursing school. she told us we would run across people who would try to deny a patient's pain because his vital signs were normal and they weren't writhing in agony, but that chronic pain sufferers no longer displayed those signs, symptoms and behaviors. and she was right on all counts.

[lollila]

I am a pre-nursing student, and also a person who lives with chronic pain. I had chronic pancreatitis, one of the most debilitating diseases and extremely painful. Mine was caused by gallstones blocking my duct, and backing up into my pancreas...however, it is common for us to be accused as alcoholics, and thus we become what everyone terms a drug seeker. I have seen many in my situation not get the help they so desperately need, because it is assumed that we just want drugs. We are in pain all the time, and eating makes it worse, activity makes it worse, and we need pain meds just to survive day to day activities. I don't know how many times I was told, "but you don't look sick", this is the most annoying phrase to me. If you are in chronic pain, you do just start to realize this is your new normal, and you aren't going to look like you are in pain all the time, or you wait until you are by yourself, at home, and let it all hang out. I hate the idea of nurses looking at patients as addicts because they need a high dosage of pain medication just to get comfortable. Most of the people I know with my disease go to the hospital as a last resort, and just want to be treated as a human being, and get the pain meds that they need.

I am one of the lucky ones, and have had awesome medical care. I had the total pancreactomy and auto islet transplant on 2/25/10, and am so much better. However, I still have residual pain, and do see a pain doctor. I only get my prescription once a month, and only take it when needed. I know that I will never be "normal" but this is my new normal, and I will take it.

My greatest wish is to be that nurse that gives compassion no matter what, and treats the pain as stated by the patient. Do I realize that there are truly drug seekers out there, yes. Do I realize that there are many who are truly in pain, that are labeled as drug seekers, yes. I just think as a nurse we need to make sure we are treating the patient as best as we can, and believe the patient, until you can prove that they are truly asking for drugs for the wrong reasons.

Sorry for getting on my soap box, it's just that I have been dealing with this for the last 4 years, and have many friends that I have met in my support groups that are treated horribly.

Thanks for the ear! :spbox: