prescription drug addiction

sallyrnrrt, ADN, RN · Dec 16, 2016

NSAIDs, Asa, and or toradol, for limited short time use works wonders.....and even they have risk, physical therapy, water therapy are effective in a lot of situations.....

Editorial Team / Admin · Dec 16, 2016

Oh, Esme, how horrible. It's too bad that healthcare is being dictated by those who have zero knowledge of providing healthcare and no training. A few bad apples among prescribers have led to punishment not only for all those associated with those bad apples (even if only by profession) but for those who truly need treatment for life-altering pain.

KatieMI, BSN, MSN, RN · Dec 16, 2016

Ecme12,

Hugs and tears...

RNrhythm, BSN, RN · Dec 16, 2016

I always feel conflicted when I have a new patient in LTAC who gets Dilaudid maybe once on my shift, then the next day maybe twice, then by day 3 they are setting their phones for the Q4 and they are around the clock from then on.

NotYourMamasRN · Dec 16, 2016

This is such a hard topic. I see everyone's points. Some days I hate narcotics and what I have to deal with because of them at work. But other days I hate narcotics because some of my patients desperately need them and the doc won't give them. It is such a catch 22. Most days I say to myself, "I will never take a freakin narc". Then I injure myself pretty bad at work and might need surgery and am like, "Well hell with it". I haven't needed them yet, but if I need surgery that will change. Most days I wish I could just smoke a joint and call it a day, it would help my mood and my injury.

allnurses Guide · Dec 16, 2016

I have no words, Esme. You've been through hell and back. I pray that you heal and find some relief. It's criminal what you went through.

allnurses Guide · Dec 16, 2016

I can absolutely see your point. I can see opioids for acute issues, for a short period of time. I don't work in a field where we are giving anesthesia so I have a different experience. I have the patients who have chronic issues or a lesser acute issue who aren't willing to try the lesser combination and want to shoot straight to IV dilaudid. And I have to explain to them, if you start at the top of the food chain, and it doesn't work, you are out of luck and there isn't anything we can add on. But if we start with the lesser meds and get the pain under control, or don't get it under control and you need other medications, then we can add on.
I also have the patients who are months out of surgery, and instead of being weaned off narcotics or given other pain control methods, the doses are increased and obviously increasing their tolerances. I understand as an ER nurse I am not going to fix anyone's addiction overnight, but I do face the front lines of overdoses and I do think it is a sad and widespread problem due to over-prescribing.

As a chronic pain patient who has had several surgeries who is also an RN I have been asked by Anesthesiologists "How do you want to manage your post op pain?" Personally I have pretty high tolerance but do utilize a combination muscle relaxant with an opioid for sleep. I can't take traditional sleep meds (Ambien, Lunesta etc) because they cause me to be suicidal depressed. I tell my provider I want a PCA for the first 48 hours if I'm inpatient - they set the medication and limits. I hate dilaudid because it has such a short half life less that 90 minutes for some people but is usually ordered q 4 hours. With the PCA I get up and walk with my IV pole - I don't have to bother the nurses for pain control and as pointed out by a pp I can turn, cough and deep breath. Then I switch over to PO. My last surgery I was in the hospital for 11 days and then recovering at home with a non-healing surgical wound for 13 weeks. I would not have survived without the wonderful care team which included aggressive pain management. I asked my Dr. during that ordeal what we would do if I became too dependent on the meds and she said "I'll set you up for detox when we are done here if you need it. "

Once the primary acute pain was resolved my need for serious medication went down. I still have fibromyalgia though and will not dare tell someone they don't appear to be in that much pain. I know what I go through with pain that is sometimes intractable.

Hppy

allnurses Guide · Dec 16, 2016

What is not being discussed here is that addicts regardless of their substance of choice are not created they are born. This is a controversial topic but since the mapping of the human genome was completed in 2003 there have been several genes identified as shared in common among people addiction issues. The University of Utah has been doing research on the genetics of addiction for some time: the following is a list of genes that appear to influence addiction:

The A1 allele of the dopamine receptor gene DRD2 is more common in people addicted to alcohol or cocaine.

Mice with increased expression of the Mpdz gene experience less severe withdrawal symptoms from sedative-hypnotic drugs such as barbiturates.

Mice without the cannabinoid receptor gene Cnr1 are less responsive to morphine.

Mice lacking the serotonin receptor gene Htr1b are more attracted to cocaine and alcohol.

Mice bred to lack the Î²2 subunit of nicotinic cholinergic receptors have a reduced reward response to cocaine.

Mice with low levels of neuropeptide Y drink more alcohol, whereas those with higher levels tend to abstain.

Fruit flies mutated to be unable to synthesize tyramine remain sedate even after repeated doses of cocaine.

Mice mutated with a defective Per2 gene drink three times more alcohol than normal.

Non-smokers are more likely than smokers to carry a protective allele of the CYP2A6 gene, which causes them to feel nausea and dizziness from smoking.

Alcoholism is rare in people with two copies of the ALDH*2 gene variation.

Mice lacking the Creb gene are less likely to develop morphine dependence.

Genes and Addiction

I attended a conference in 2007 where a lecture was given by an addictionologist and is was described very easily with the following story:

A guy who has never taken opioids goes on a ski trip and falls and breaks his leg - he is seen and stabilized and sent home to follow-up with an ortho within 5 days. He is given a ten day supply of opioids. When he sees his ortho the man who is not a potential addict still has lots of opioids in the bottle and tells the MD "I don't like the way this stuff makes me feel" The potential addict has an empty bottle and tells the md "I need a lot more of this!"

Peace out

Hppy

allnurses Guide · Dec 16, 2016

I agree with most all of your post but wonder if there is data to support that the problem started with poorly managed chronic pain patients.
The other thing that I will say again and again is there is absolutely no data I am aware of that indicates opiates are appropriate for long term pain treatment and can in fact make the chronic pain loop worse, opioid induced paradoxical hyperalgesia. This has nothing to do with appropriate, short term post op treatments with narcotics.

I think that poor management has led to a lot of chronic pain patients. Patients that should have never been on a large qty of opioids in the first place, but ended up on them and now after many years can't be taken off.

Inappropriate prescribing also led to more scripts on the street and that problem has bloomed: trade 7 days of oxycodone for 30 days of heroin. Dealers then use that oxycodone to get a new group hooked.

Caught up in the middle are the legit patients. They either can't get the mess they should because prescribers are wary and if they advocate for themselves they get labeled or dumped. Then they have to find a prescriber that will manage them and in the meantime they appear to be doctor shopping. That or they get blantantly undermanaged.

Its awful.

allnurses Guide · Dec 16, 2016

Ugh Esme. So sorry. And sorry your PCP felt the need to "handle" things that way.

shedevilprincss · Dec 16, 2016

No surprise it's been associated with higher levels of M&M.
I told a patient yesterday that "I'm sorry for your pain, but my goal as your provider is to make your pain tolerable so you can function not to make it non-existent" and she launched into a tirade about how "I don't know what it's like". You are right, I don't know what it's like to be in my 20s and on a narcotic, a stimulant, and a benzo for non-existent pathology. She looked even more shocked when I said that I would be happy to help her to the best of my ability but my plan involved none of those meds and perhaps she should keep searching for a provider.

I like that answer.

Libby1987 · Dec 16, 2016

The addiction pretty often starts as acute management when narcs and other drugs with high addiction potential are given for no good enough reason.
The thing is, pain relief 30-40% (i.e. to 4/10 from 7/10, 10/10 being extremity amputation "as it is") is what considered by experts to be "adequate" in majority of cases. The people, though, expect and want 0/10, 10 being whatever hurts them now. That is simply not possible without narcs. So, a 17 y/o given given 30 pills of Norco5 to begin with for sprained ankle. Norco is hydrocodone. She feels 1) wonderful feeling of being OK in all capiral letter, and 2) no pain at all, so instead of RICE she goes back to her busy life and uses not yet healed joint, which thus never heals.
The PT/OT plus some Motrin would be more than adequate, but the nearest PT clinic is in 30 miles and works 9 to 5. The patient has a job, the employer won't let her get off early, won't find light duty, will just throw her out. School is of no help. And, yeah, her mom's insurance doesn't cover PT for dependants.
To cope with all that at once, she is given 30 of "nerve pills" (Xanax). And then things just go underhill from there.

I didn't realize things like a sprain in a young adult would receive a narcotic rx.

(Counting my blessing my kids didn't become addicted to Norco when they all 3 have had some type of surgical procedure)