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Prescribing Narcotics for Pt with Drug Abuse Hx

I work in a SNF where we recently admitted someone S/P ORIF of the femur for a short term rehab stay. This patient is in their mid 40s and among their very lengthy list of diagnoses there is a history of drug abuse. It's actually listed multiple times t/o their dx list "history of drug abuse. Has been clean for many years", "history of opiate abuse with misuse, overdose, and diversion", and "history of narcotic drug dependency with misuse, overdose, and diversion". They were admitted with orders for MsContin, Oxycodone PRN, and Xanax. Upon admission this patient was rating their pain a "12" on a scale from 1-10! They did not display any nonverbal sx of such pain... Within a few hours of their admission they were adamant that they were supposed to have orders for Lortab PRN along with the other narcotics. Since admission this patient has displayed drug seeking behaviors, demands the max amount of PRN Lortab every 6 hours to the minute (order is for 1-2 q6hr PRN), has attempted to manipulate the nurses into administering it earlier "that other nurse said I could have it every 4-6 hours...), has demanded that a MD is contacted to change the order to q4hr, wants the PRNs scheduled so they can self administer them (which we'd never allow), and yells at the nurses for not bringing their scheduled MsContin in within 10 min of the scheduled time (they got noon dose at 1150 and was upset that they didn't get it sooner)...

Am I wrong for questioning why an MD would order MsContin, Oxycodone, Lortab, and Xanax for a patient with a history of drug abuse/dependency?! Is it appropriate to have it listed on their Dx list that they've "been clean for many years"?

How do you think this person's pain should be treated? A current history of substance abuse wouldn't exclude the use of narcotic analgesia.

My question to you, as this individual "has been clean for many years" is it appropriate to list this multiple times on the diagnosis list?

People with a hx of abusing opioids have a much higher tolerance than the rest of us, and it takes much larger doses to manage their (legitimate) pain from things like major surgery (also, people with any kind of substance abuse/dependence hx tend to have a v. low tolerance for pain (or any other kind of stressor) and poor ability to self-soothe). What do you propose? That, because this individual has a past hx of abuse (which s/he apparently beat some time ago, according to what you quote from the records), s/he should just have to suffer? Give 'em a stick to bite on and wish 'em good luck? What makes you think this person hasn't "been clean for many years," other than what you are perceiving as drug-seeking behavior now? Is it possible that the individual is picking up on judgmental attitudes from the nursing staff and that is making the situation worse? What do you think your role is in this situation, other than to administer the medications rx'd by the provider and provide appropriate nursing care?

I'm not saying they should suffer in pain at all, but there are other non-narcotic options out there. When a physician orders Morphine, Oxycodone, and Lortab but not Tramadol, ES Tylenol or even a cryo-cuff I think the physician has done this person a great injustice by ordering multiple narcotics when they have a history of narcotic dependency. Ordering narcotics for a limited time is completely understandable but these orders have no stop date. If a patient is taking MsContin 15mg q12hr, Oxycodone 10mg q4hr, and two Lortab 10/325 q6hrs on day 9 post-op I think that may be a cause for some concern. We are now on post-op day 11. It would be concerning with any patient not just someone with a history of narcotic and opiode dependency. As far as this patient goes when they calmly rate their pain a "12" but their body language doesn't jive with having worse then the worst pain ever, is asking for PRNs at the exact time they can have it again around the clock, tries to get nurses to give it sooner then ordered, and yells at the nurses when she has to wait it is concerning. Even more so when the patient is refusing to participate in therapy but then leaves to "go out" with family. When a physician orders opiodes for a patient they are to take proper steps to help prevent that patient from developing a dependency or in this case a relapse, ar least in my state anyways, I cannot see where this was down for this patient...

I'm not saying they should suffer in pain at all, but there are other non-narcotic options out there. When a physician orders Morphine, Oxycodone, and Lortab but not Tramadol, ES Tylenol or even a cryo-cuff I think the physician has done this person a great injustice by ordering multiple narcotics when they have a history of narcotic dependency. Ordering narcotics for a limited time is completely understandable but these orders have no stop date. If a patient is taking MsContin 15mg q12hr, Oxycodone 10mg q4hr, and two Lortab 10/325 q6hrs on day 9 post-op I think that may be a cause for some concern. We are now on post-op day 11. It would be concerning with any patient not just someone with a history of narcotic and opiode dependency. As far as this patient goes when they calmly rate their pain a "12" but their body language doesn't jive with having worse then the worst pain ever, is asking for PRNs at the exact time they can have it again around the clock, tries to get nurses to give it sooner then ordered, and yells at the nurses when she has to wait it is concerning. Even more so when the patient is refusing to participate in therapy but then leaves to "go out" with family. When a physician orders opiodes for a patient they are to take proper steps to help prevent that patient from developing a dependency or in this case a relapse, ar least in my state anyways, I cannot see where this was down for this patient...

Have you shared your concerns with the physician(s) prescribing the meds? If I had concerns about a client care question, that's what I would be doing.

Concerns were brought up to the discharging facility as well as the PA who ordered the narcotics in the hospital and works with the MD who signed the discharge orders... The patient will be seen by the provider following them at our facility on Friday and I know he'll f/u, especially since it will be on him to sign the scripts for refills.

I feel that the intent of my original post was misconstrued... Nobody in our facility has "judged" them or treated them any differently then our other patients. I'm not looking down on them at all. Addictions are not a choice, they are an illness and should be treated as such. From day 1 in the hospital nobody took steps to help prevent a relapse, when treating one issue you can't just ignore other issues or illnesses that may be directly affected by that treatment. THAT'S where my concern lies. As to my question about whether they can considered "clean". Granted the patient remains clean from crack and heroin, they are on multiple narcotics and displaying drug seeking behaviors. When our admissions coordinator reviewed the patient's discharge summary that "has been clean for many years" was very misleading to her and unfortunately, we can't do anything about their dx list from that hospital. In reality they're not clean, the hospital loaded them up with multiple narcotics and sent them on their way with no plan of care in place to prevent relapse. I was raised by two recovering alcoholics, my husband's mom died of a heroin overdose when he was 10, and my sister-in-law is fighting an addiction to narcotics right now so for me to see so little care or thought put in to a patient's recovery by their medical team is heartbreaking and maddening at the same time.

Being treated for acute post-op pain is not a "relapse." And I still don't see why you have a problem with the notation in the chart that this person has been "clean for many years." Do you have any evidence that s/he has not been clean for many years? Other than being medicated for acute post-op pain following the recent surgery?

Your initial post indicates judgment against this patient and their prior addiction. You are assuming that there will be a relapse; treating post op pain, is not a relapse. I do suggest that you educate yourself on addiction and the pain threshold of someone who is an addict. There are quite a few online classes you can take, and it will be a mutually beneficial thing for yourself and your patients. You are assuming that at day 11, their pain should be under control and not using as much; that just isn't the case. This is an example where you are not understanding the complexities of working with patients who have hx of addiction.

Patient has now gone back and forth between doctors demanding more pain medication... The physician following them at our facility has now said he will not sign any further orders for more narcotics, his colleague saw patient at his request and this physician asked patient if they were ok with her contacting the "primary" MD that patient is also seeing at the other hospital so all providers could be on the same page and patient said "no." Patient was also seen for chemical dependency assessment today and will be seeing them on an ongoing basis as well.

THIS is what I was concerned about happening. Pretty sure I DO have an understanding of working with someone with an addiction, seeing two of our providers are sharing many of the same concerns that I had when patient was admitted 3 weeks ago.

THIS is what I was concerned about happening. Pretty sure I DO have an understanding of working with someone with an addiction, seeing two of our providers are sharing many of the same concerns that I had when patient was admitted 3 weeks ago.

And again -- what alternative path do you propose for this individual who had major surgery? "Too bad you need painful orthopedic surgery, no opioid analgesics for you because you have a hx of an opioid addiction. Here's some Tylenol"? Yes, these individuals present real challenges clinically, and working with them requires a lot of expertise and sensitivity. Was this individual being followed by a pain management specialist at any point in the process? Was there a plan for managing his pain post-operatively and tapering the meds, that included him in planning, or was he just treated like anyone else would be? Do the physicians who have been treating him have any experience with this kind of situation?

Psychcns specializes in Psychiatric Nursing.

OP-since you have an interest in addiction and pain management, have you considered any additional certification. There is CARN (certified addiction registered nurse). I think there is alsocertification in pain management nursing. As elk park says, working with these patients takes expertise and sensitivity. Why not learn more about it. I would think the pt would need to manage her pain without triggerring a relapse or at least be ready to deal with a relapse. I bet there is a role for nursing in all this. At very least to learn how to best support the patient. Best wishes.

Have you shared your concerns with the physician(s) prescribing the meds? If I had concerns about a client care question, that's what I would be doing.

It is attitudes such as this that has me deferring recommended surgical procedures. After one horrific surgery and being treated like I had zero rights for pain management, I am making a conscious choice, aware it could impact my lifespan. Today's medical community is ignorant on pain management for those with an addiction history. I had one such surgeon that opted for non-narcotic solutions, and a mega dose of novacaine. If it were not for my room nurse taking immediate action when she saw my neck was even with my chin, I very well might not be here today - major hemorrhaging from the non-narcotic options. And, I couldn't feel a thing with being numb from my eyeballs to my upper chest. I woke up in ICU for what was to be a 24 hour hold. (Another surgeon cleaned up his mess). It's attitudes such as these that scare me literally to death.

Anyone in the pain management and addiction field should read papers written by Howard A Heit, MD, FACE, FASAM, a local to the DC area. I was fortunate to call him my doctor. He is no longer practicing due to a family tragedy. He currently is recognized as a SME and lectures all over the US.

Dear DEA | Pain Medicine | Oxford Academic

Please learn more about pain management for those with dependence or an addiction history and do not let your preconcieved opinions interfere with patient treatment.

RNOTODAY specializes in NICU, ER, OR.

What would you like the doc to DO, give the PT a stick to bite on every day, and to be humane , a fresh one daily? I mean come on, a broken ( femur? ) you said?

I don't think the original post was judgmental. I think its a legitimate questions if the doctors have posted this note all over the patient's chart. I think I would also question why so many high dose strong narcotics have been ordered for the patient if they didn't try another route. Pain management is a tricky field. 

hppygr8ful specializes in Psych, Addictions, Elder Care, L&D.

My own history with both addiction and totally botched pain management has led me to several conclusion that I would like to share. You can Google my journey on this pain management forum but I would first ask you read through what I have to say. TO the OP when I read your original post I didn't immediately think you were being that judgmental. If you don't have training in pain  management one could easily be concerned unless you know what each of the meds is used for. Also I wasn't concerned about a lack of compassion on your part until you brought up your own family history. Then you projected your own experience and feeling onto the life story of someone else. 

I started drinking at about 13 years of age and progressed to drinking alcoholically with just a few years. I am a survivor of childhood abuse and the time I took an alcoholic drink was honestly the first time in my life I felt comfortable in my own skin. Fast forward through 30 some odd years of drinking a few years of sobriety I was facing a host of painful auto-immune diseases that left me debilitated and on Medicaid and Medicare retired to a wheel chair and unable to function. 

I had major surgery followed by a post surgical wound infection that took months to heal. My new primary care doctor at the time asked if I liked life in a wheelchair and would I allow her to try to help me. She had a back-ground in pain management and started me on low dose opioids, muscle relaxants and a sleeping pill. My life immediately improved. I got out of that wheel chair. Stared doing physical therapy and all things were looking up until that physician retired about a year ago. Enter the opioid pandemic police and it was all stripped a way. Putting me in in tractable pain . I had to fight to my right for treatment and ultimately one and was returned to the same protocol minus the sleeping pill. I was given a choice to give up the opioid or the sleeper and I choose pain relief.  This past year I did something I never thought I'd do again and rode a horse.

Oh there I go getting all wordy and emotional again.

_____________ anyway I'll continue the story If you want me too?

Hppy 

amoLucia specializes in LTC.

Hppy - Am admiring  your advocacy for addiction & substance abuse issues.

Edited by amoLucia

Trebug specializes in General Nursing.

On 6/22/2020 at 9:09 PM, hppygr8ful said:

My own history with both addiction and totally botched pain management has led me to several conclusion that I would like to share. You can Google my journey on this pain management forum but I would first ask you read through what I have to say. TO the OP when I read your original post I didn't immediately think you were being that judgmental. If you don't have training in pain  management one could easily be concerned unless you know what each of the meds is used for. Also I wasn't concerned about a lack of compassion on your part until you brought up your own family history. Then you projected your own experience and feeling onto the life story of someone else. 

I started drinking at about 13 years of age and progressed to drinking alcoholically with just a few years. I am a survivor of childhood abuse and the time I took an alcoholic drink was honestly the first time in my life I felt comfortable in my own skin. Fast forward through 30 some odd years of drinking a few years of sobriety I was facing a host of painful auto-immune diseases that left me debilitated and on Medicaid and Medicare retired to a wheel chair and unable to function. 

I had major surgery followed by a post surgical wound infection that took months to heal. My new primary care doctor at the time asked if I liked life in a wheelchair and would I allow her to try to help me. She had a back-ground in pain management and started me on low dose opioids, muscle relaxants and a sleeping pill. My life immediately improved. I got out of that wheel chair. Stared doing physical therapy and all things were looking up until that physician retired about a year ago. Enter the opioid pandemic police and it was all stripped a way. Putting me in in tractable pain . I had to fight to my right for treatment and ultimately one and was returned to the same protocol minus the sleeping pill. I was given a choice to give up the opioid or the sleeper and I choose pain relief.  This past year I did something I never thought I'd do again and rode a horse.

Oh there I go getting all wordy and emotional again.

_____________ anyway I'll continue the story If you want me too?

Hppy 

I would love for you to continue!

 

hppygr8ful specializes in Psych, Addictions, Elder Care, L&D.

6 hours ago, Trebug said:

I would love for you to continue!

 

OK so for the rest of my tale - I never did abuse the opioids and I have been sober from the alcohol for going on 20 years but I learned my lesson about even mentioning that I have a history of addiction to alcohol. The judgement I have received from my fellow nurses has at times been hurtful because I would expect a profession that prides itself on integrity, compassion and evidence based practice to have done a bit of research on the difference between addiction, dependence and tolerance if they were going to be working with patients who have pain.  I have often had to politely educate a nurse caring for me about the differences between these subject and how the body needs rest and relief from pain. In the past 5 years I have had two more surgeries and one more post operative infection that left a hip to hip 21 cm open wound on my lower abdomen. One nurse who came in to dress the wound asked me to tell her if I was having pain and if I wished to be pre-medicated prior to the procedure (Bless her heart) Even though this would have been an opportunity to get meds I told her "It actually doesn't hurt at all! .

Those of us with Chronic pain know that what we are seeking is relief from the pain and the fact that I can watch television or eat or talk on the phone (All things I do to distract me from the pain) does not mean that I am not in pain. 

So please put any pre conceived prejudices aside and listen to your patient. When I have worked with patient's in pain I take to time to listen to them , take a good history, explain the pain management options ordered and assure them that I will work with them to manage their pain.  Such conversations often lead to a better attitude from the patient which means an easier shift for me . I also make sure I check in with  the patient before procedures, rehab activity or around the time the next pain med might be due. Sometimes  A PCA works well because it lock's out to prevent overdose and give the patient a sense of control where their pain is concerned. 

So life today means that I am out of a wheelchair, working in a dynamic acute psychiatric environment and enjoying hobbies such as horseback riding, hiking, fishing and also knitting a quilting  

As far as projecting our own life experiences on others I have to say that as a recovering alcoholic, who comes from a long line of functional alcoholics I cringe a bit when I see young people going on a bender but it's not my business unless they ask for my opinion which they rarely do. 

peace out 

 

Hppy

amoLucia specializes in LTC.

Hppy - kudos to you for your perseverance in your struggles.

Also for your effort to educate those in need of educ thru their own misunderstanding or misjudgement.

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