Pushing Dilaudid?

TDCHIM · Jun 10, 2010

So, from a naive doctor...
I get a mixed tone from the responses here. Some seem to have no problem giving Dilaudid to a patient with no organic cause for their pain and some seem to dislike doing it but realize that is their job and others will do anything to avoid giving the drug-seeker their buzz while still giving them the drug.
Like all hospitals, we have obvious drug seekers who fake pain and come in every few weeks for their free food, nice TV, and "hospital heroin." The ED docs give in to get them out of the ED, the doc on call does not want to confront the patient and the nurses just do what is ordered. Every 3 hours the call light goes on, they want it pushed fast, they want the Zofran/Phenergan/Benadryl to follow and when the weekend rolls around their pain disappears and they ask to go home. We are getting denials from insurers and Medicare for these patients for lack of medical necessity for the admission and when the hospital gets denials and has to eat the costs eventually they have to start firing staff to cut expenses, and that includes nurses.
Is this a satisfying part of your job? Do you worry about contributing to a drug habit? Is it as rewarding as treating a patient with cancer or someone with true pain after a surgery? Or do you just "do your job" every day and do what you are told, whether it is the right thing to do or not? Would you not be happier not dealing with these patients?
Why the resistance to do the IV drip or PCA? Pharmacologically there is no reason the drug has to be given over 2-3 minutes- it has a half-life of several hours so giving it over 3 minutes or 15 minutes will produce the same analgesic effect.
I'd love some comments.

Every hospital has drug addicts who try to scam narcotics. However, your post is a little disturbing to me, because you appear to assume that doctors and nurses are always capable of determining who is or is not in "true pain." As another poster noted earlier in this thread, some patients who are in "true pain" may appear to be drug seekers simply because their pain is not being adequately assuaged. For instance, requesting pain medication as often as it can be administered is a reasonable response to uncontrolled pain, not an automatic indicator of a drug addict.

Perhaps the tone you intended to use isn't being conveyed correctly through an online post. However, some of the questions you've posed - whether posters worry about "contributing to a drug habit" and if treating patients you view as drug seekers is "satisfying" for nurses - are coming across as a bit harsh and condescending. You might obtain more informative answers if you clarified or rephrased your queries.

LouisVRN, RN · Jun 10, 2010

So, from a naive doctor...
I get a mixed tone from the responses here. Some seem to have no problem giving Dilaudid to a patient with no organic cause for their pain and some seem to dislike doing it but realize that is their job and others will do anything to avoid giving the drug-seeker their buzz while still giving them the drug.
Like all hospitals, we have obvious drug seekers who fake pain and come in every few weeks for their free food, nice TV, and "hospital heroin." The ED docs give in to get them out of the ED, the doc on call does not want to confront the patient and the nurses just do what is ordered. Every 3 hours the call light goes on, they want it pushed fast, they want the Zofran/Phenergan/Benadryl to follow and when the weekend rolls around their pain disappears and they ask to go home. We are getting denials from insurers and Medicare for these patients for lack of medical necessity for the admission and when the hospital gets denials and has to eat the costs eventually they have to start firing staff to cut expenses, and that includes nurses.
Is this a satisfying part of your job? Do you worry about contributing to a drug habit? Is it as rewarding as treating a patient with cancer or someone with true pain after a surgery? Or do you just "do your job" every day and do what you are told, whether it is the right thing to do or not? Would you not be happier not dealing with these patients?
Why the resistance to do the IV drip or PCA? Pharmacologically there is no reason the drug has to be given over 2-3 minutes- it has a half-life of several hours so giving it over 3 minutes or 15 minutes will produce the same analgesic effect.
I'd love some comments.

I do not like taking care of anyone that claims to be in pain, whether they actually are, think they are, or just want to get high. Frankly, giving medication every two hours, documenting an initial assessment, and then a reassessment, checking frequent vitals, only to be told it brought the pain from 10/10 to 9/10 is frustrating as all hell and makes me paranoid that something is wrong. Which makes me spend more time assessing and reassessing the patient, calling the doctor for additional orders/interventions. I would rather an IV drip or PCA to be honest, at least the PCA does most of its own monitoring and will alert me to a potential problem should I be in another patients room. The aversion to hanging narcotics in an IVPB bag...well lets face it, I worked hard for my title, got up everyday and went to school pregnant and went back 2 days after having my son while he was still in the NICU to graduate. Lose that for letting some addict decide he wants to drink/keep the narcotic because I am too busy or my pt down the hall is coding and I can't stand there for 15 minutes and watch it infuse - I don't think so. If we had lock boxes for IV drips, okay sure, PIA, but I can see this might work. In talking to the addictionologist at our hospital he once said something I still repeat in my head on occasion, "Even if we know they are addicts, you're not going to cure them while they are here". Drug addiction treatment requires months if not years of hard work and desire on the part of the patient, if they are in the hospital claiming to be in pain, they are obviously not at that point. Does that mean we should give in and give in to their demands...no. But that doesn't mean I have the right or ability to judge who is and is not in pain. I have a high pain tolerance, but I do not judge those that think having an IV inserted should be rated 10/10. I will happily medicate them accordingly.

I don't know your taste in music Doc, but I would suggest you listen to the lyrics of Type O Negatives "Life is Killing Me" before thinking you have the ability to determine when someone deserves pain medication.

signaturedoc · Jun 10, 2010

Thanks for all the quick replies.

How do I know they are seekers and not in real pain? My state, and many others, has an online database to look up all narcotic prescriptions and I can see they got 90 Vicoden on May 17th from a doctor in Town A, filled at Walgreens then on May20th filled 60 Norco from a doctor in Town B at Walmart. True pain? I don't think so.

My intent is to decide if this is worth the effort to develop a "pain management" program for patients with recurrent admissions for pain who display behavior suggestive of drug seeking behavior- treating their pain but not feeding their high, using methods such as requiring PCA pumps for all pain meds rather than IV by the RN.

txspadequeenRN, BSN, RN · Jun 10, 2010

i have given dilaudid po, ,via pump but mostly ivp....i had a patient the other day c/o severe pain to his doctor (unrelieved by dilaudid 4mg every 3 hours) in his bil extremities .....(drumroll) so the new order was for dilaudid 8 mg every 3 hours.....i am no stranger to high doses of pain meds cause i am a hospice nurse and this didn't effect him at all he was down in the parking lot smoking in 30 minutes.....

signaturedoc · Jun 10, 2010

i have given dilaudid po, ,via pump but mostly ivp....i had a patient the other day c/o severe pain to his doctor (unrelieved by dilaudid 4mg every 3 hours) in his bil extremities .....(drumroll) so the new order was for dilaudid 8 mg every 3 hours.....i am no stranger to high doses of pain meds cause i am a hospice nurse and this didn't effect him at all he was down in the parking lot smoking in 30 minutes.....

and you had no qualms in giving it? or letting him leave the room to smoke?

LouisVRN, RN · Jun 10, 2010

i have given dilaudid po, ,via pump but mostly ivp....i had a patient the other day c/o severe pain to his doctor (unrelieved by dilaudid 4mg every 3 hours) in his bil extremities .....(drumroll) so the new order was for dilaudid 8 mg every 3 hours.....i am no stranger to high doses of pain meds cause i am a hospice nurse and this didn't effect him at all he was down in the parking lot smoking in 30 minutes.....

if this is a po dose then although extremely high, i wouldn't be too adverse to it, although i would have suggested that the doctor try a different medication. some people just don't respond well to certain narcotics. i had one lady post-gyn surgery claim to be in excruciating pain after we gave her a vicodin, i had the person i was orienting call and get her percocet instead and low and behold it worked wonderfully. i definitely would not be letting a patient of mine out of their room that soon after having received it, especially as it was the first dose. imo if they are in that much pain, to receive iv meds particularly they do not need to be leaving the floor.

LouisVRN, RN · Jun 10, 2010

Thanks for all the quick replies.
How do I know they are seekers and not in real pain? My state, and many others, has an online database to look up all narcotic prescriptions and I can see they got 90 Vicoden on May 17th from a doctor in Town A, filled at Walgreens then on May20th filled 60 Norco from a doctor in Town B at Walmart. True pain? I don't think so.
My intent is to decide if this is worth the effort to develop a "pain management" program for patients with recurrent admissions for pain who display behavior suggestive of drug seeking behavior- treating their pain but not feeding their high, using methods such as requiring PCA pumps for all pain meds rather than IV by the RN.

IMHO I absolutely feel that this is something worthwhile in ever hospital. As nurses we struggle so much to help our patients in pain and there is nothing more frustrating than calling the doctor and having him say "Well what do you want me to do?" There is only so much that heating pads, back rubs and cold compresses/ice packs will help. Even if patients are having multiple narcotic prescriptions filled in different cities it doesnt mean they are not in pain, maybe they are seeing different doctors to try to resolve the pain. IE went to general practitioner on May 17th got a RX for vicodin, on May 20th went to specialist got a Rx for Norco.

My miracle combination IVP toradol and IVP dilaudid. I know toradol is contraindicated in some patients

(renal insufficiency) but for young healthy male patients with intractable pain it truly seems to work miracles. Not saying it doesn't work well for female patients too, I've just found it to be MOST effective on the aforementioned.

POTR · Jun 10, 2010

I initially woke up in ICU following a Laparoscopic cholecystectomy with a 0.5mg demand PCA of Morphine with an unknown base rate and lockout.

Probably would have been ok if there weren't 12 holes in me instead of the usual 4, and if I weren't already tolerant due to long term prescription use of dilaudid.

No fun waking up feeling 'gut shot' and having the 'seasoned, old' RN looking at me like a junkie when I asked where my pain meds were (woke up screaming) and telling me "you're on them" pointing to the pole with the pump, cord hanging over the top of it, button out of reach.

I may not have helped her impression of me when I yanked the pole over by my lines to actually reach said button and push it, evidenced by her eye roll, shrug and abrupt about-face out of the room.

I probably further damaged her image of me when I found the call button (conveniently located on the 'not so' bed side table) a full 5 minutes later, and used it to call her to inform that the 'pain meds' weren't working, demanding to know what I was on.

I was informed that I can't be in pain because I was on morphine. Really? How much, and did anyone bother to read my history showing monthly Rx hydromorphone? GASP! Apologies.. can't do anything... must call MD... apologies.. 15 minutes later two syringes bedside.. one for the PCA and one for me, pushed so fast it would make your head spin... more apologies while reloading and resetting the PCA...

What a lot of fun we had that day.

nursemike, ASN, RN · Jun 10, 2010

Thanks for all the quick replies.
How do I know they are seekers and not in real pain? My state, and many others, has an online database to look up all narcotic prescriptions and I can see they got 90 Vicoden on May 17th from a doctor in Town A, filled at Walgreens then on May20th filled 60 Norco from a doctor in Town B at Walmart. True pain? I don't think so.
My intent is to decide if this is worth the effort to develop a "pain management" program for patients with recurrent admissions for pain who display behavior suggestive of drug seeking behavior- treating their pain but not feeding their high, using methods such as requiring PCA pumps for all pain meds rather than IV by the RN.

In answer to the OP, I push dilaudid slowly, but our typical dose is 0.2 mg. When able, I often try to combine the IV dose with a PO med, usually acetaminophen or one of the combos, like Lortab or Percocet. If I give dilaudid and 2 percs at midnight, pt is usually comfortable until 0600 or so. My shift starts at 1900, so I usually have a pretty good idea by midnight how they are responding to pain meds.

That plan has worked well with normal pts in normal post-op pain. Useless with drug-seekers. Lately, we've been have a lot of back surgeries on people who've been eating Lortabs for a year and have become resistant, so we get lot's of call outs for meds that aren't yet available. Many residents on night call aren't willing to address the issue, some attendings don't want to "overprescribe," so the patient's right to pain mgt goes unsatisfied. In some instances, I'm pretty sure the patient just wants narcs (I dunno, but if I was in severe pain and someone offered me a percocet, I think I'd take it and then demand something stronger, rather than turning it down because "it doesn't work."). But others are pretty obviously in pain and get treated as drug-seekers. (And some are just wimps, having 10/10 pain over piddly crap, and not satisfied if we can get it down to 2/10).

So I'd be thrilled if my facility got more serious about pain management. Particularly for patients who probably are in real pain. But even some rational plan for "drug seekers." I've been guilty, at times, of shielding docs from obnoxious patients--I told one, once, that our clerk calls me every fifth time the pt rang out, and I paged them every fifth time I got called. I don't think it's my job to nag the doc for more meds if I know they aren't going to order them. If I call you at 20:00 and you don't order anything new, I'm not going to call again at 21:00. But I'm starting to think that if a patient is unrelieved and the doc doesn't do anything about it, I'm going to seriously consider an ehtics consult. I don't think it's an appropriate strategy, or use of my time, to just leave me as a go-between for greedy patients and stingy docs.

oldiebutgoodie, RN · Jun 10, 2010

Pass the popcorn.

Oldiebutgoodie

TDCHIM · Jun 11, 2010

Thanks for all the quick replies.
How do I know they are seekers and not in real pain? My state, and many others, has an online database to look up all narcotic prescriptions and I can see they got 90 Vicoden on May 17th from a doctor in Town A, filled at Walgreens then on May20th filled 60 Norco from a doctor in Town B at Walmart. True pain? I don't think so.
My intent is to decide if this is worth the effort to develop a "pain management" program for patients with recurrent admissions for pain who display behavior suggestive of drug seeking behavior- treating their pain but not feeding their high, using methods such as requiring PCA pumps for all pain meds rather than IV by the RN.

I agree that narcotic databases are a good screening tool, particularly for those displaying some drug-seeking characteristics. However, the database doesn't tell the whole story. What if the individual gets a prescription of 5/500 Lortab on May 17 from his family practitioner and on May 24 fills a prescription for Percocet written by another physician? Would you automatically assume the patient is a drug seeker if the patient ended up in the hospital a few days later?

In that hypothetical situation, the second physician is a pain management specialist. The patient ends up in the hospital for a severe, incapacitating flareup of a recently diagnosed major chronic pain condition. It took the patient two months to get in to see the pain management physician, and in the interim, he was forced to see the family practitioner, who was reluctant to prescribe strong pain medication. The pain management specialist prescribed Percocet as a stronger alternative (along with a muscle relaxant and Lyrica), but is considering switching the patient to a more powerful narcotic in the near future. The patient has ended up in the hospital after his wife made him go because the pain was still uncontrolled. Relying on a drug database to determine whether the patient is in pain or drug seeking in this instance would probably incline you to an inaccurate conclusion.

When thinking about whether it's worth the effort to devise a pain management plan for patients who show up at the hospital for frequent treatment for pain, it might help to stop and think about other possibilities in addition to drug-seeking. Perhaps the patient is uninsured and cannot afford regular visits to a physician (let alone a pain management specialist), leaving the hospital as the only avenue through which she may obtain some pain relief. Perhaps the patient fears becoming addicted to strong pain medications (news organizations love to do easy stories along those lines, so people have a distorted idea of the likelihood of addiction in cases of substantial long-term pain) and sees an occasional trip to the hospital as preferable or "safer" than taking medication more frequently. Perhaps the patient is a prescription drug addict who wants to break the cycle but can't get past the withdrawal symptoms. Or perhaps the patient is an out-and-out drug seeker intent on scamming you for narcotics.

Creating a pain management plan for patients who show possible drug-seeking behaviors is a humane and effective move, in my opinion. One potentially beneficial option would be for that plan to include the physician spending a substantial amount of time talking to each patient about their pain, medical history, overall background, etc. Just asking why they're in the hospital so often, without seeming to judge or condemn, could lead to some illuminating answers and aid in developing better long-term treatment options. It's pretty basic, I know, but time is at such a premium that such discussions with patients are often brief at best.

lkwashington · Jun 11, 2010

One of our doctors literally created an addict where I work, by just changing med orders because the patient 'requested' her 75mg Demerol push q4prn... we all wrote nurses notes on her behavior of NOT having pain, just seeking her fix and he still won't change a thing. She's 'weaned' off her med some to 50mg q 6 scheduled. I've never in my life heard of anyone receiving that amount of Demerol and all of the nurses are having a very difficult time with this. I feel like my license is on the line at times.

I have administered 100 mg of Demerol IV every 6 hours. In our accudose we had to get 2 50 mg vials. I agree it is a lot of pain medication.