"I'm NOT going to support his habit...." LONG

[tencat]

I've had two patients who are well-known drug addicts (UA's done and they tested positive for every drug on the panel) who had large abscesses drained from their arms. Abscesses were due to IV drug use. Both patients required QID wet to dry dressing changes. I've done QID changes on 'non-addicts' and always in the orders I've had PRN morphine to give prior to the change. But not with the addicts. Both addicts only had 1 PRN 7.5 mg Lortab ordered q 3-4 hours for pain. Now, I'm really new to nursing (I've only been one since September), so maybe I am not fully understanding what's happening. But I do know those wet to dry changes are PAINFUL, even with the morphine. It seems to me that it's downright cruel to expect a heroin addict to deal with these dressing changes with only one lortab q 3-4 hours. Am I wrong? I suppose the rationale could be that it's impossible to give them enough morphine to ease the pain without killing them with an overdose. But when I talked to my nurse manager about the latest patient, she said that she would not, under any circumstances, support his drug habit by ordering morphine for dressing changes. The physician feels the same way. I guess I need some validation that I'm not wrong, or at least some advice on how to emotionally deal with these dressing changes. I'm really distressed by the pleas I get from them for something to help with the pain, and me being powerless to do anything other than pre-medicate with one lortab. Any words of wisdom? Thanks!

[partyof5]

ya know, I have a problem with this too. Just because someone is an addict does not mean they are not in pain. They have every right to pain relief just like the next person, if it is necassary. And of course they will need more than the average because they are an addict. They deserve the same treatment the next person would get in the same situation. Sometimes people forget that addiction is a disease. A nurse would not withhold treatment from a diabetic that could be under control if they lost weight would they? no they would not. Also, a nurse should not let thier personal beliefs stop them from treating just because thier beliefs do not match the beliefs of the patient. just my thought on it.

[tencat]

Thanks for the response! My coworkers are fabulous and supportive, but this is a 'taboo' subject for us all, so it's hard to discuss at work.

Are there other medications like Torridol (sp?) that could be used instead of morphine? Maybe if I had some other medication ideas to put on the table the physician and manager would be more willing to think about the idea.....

[Jolie, BSN]

You have a legal obligation to question and refuse to carry out inappropriate medical orders. To do a painful dressing change without sufficient pain medication is indeed an inappropriate order. Let your charge nurse know that you will NOT participate in carrying out this order. She can address it to the physician and/or do it herself.

[UKRNinUSA, RN]

I know where your coming from. Its tough. But these addicts are dealing with the adverse consequences of their addiction - the abcesses, poor pain control. If you remove these adverse consequences, they have no incentive to stop using therefore they are enabled to keep using and so the cycle of addiction continues.

However, having said that, as an RN with substantial wound care expertise/education, I can tell you that QID wet-to-dry dressings are NOT appropriate and may even be considered by some to be positively pre-historic - they actually delay wound healing. Significant advances have been made in wound care in the last few decades. Contact a wound care specialist or ET nurse for a more appropriate dressing and then spend some time pondering the law of Karma. Good luck and remember that these patients are expert manipulators -keep it in mind whenever you have to deal with them.

[tencat]

Any ideas on alternatives to opioid meds?

You have a legal obligation to question and refuse to carry out inappropriate medical orders. To do a painful dressing change without sufficient pain medication is indeed an inappropriate order. Let your charge nurse know that you will NOT participate in carrying out this order. She can address it to the physician and/or do it herself.

Easier said than done. I really like my workplace, and to go against the surgeon would mean a loss of my job and an 80 mile commute one way to work at another hospital. Most of the charge nurses also agree with him....

Yes, I know that they've brought it on themselves, and yes I know they manipulate. It's just that I know I haven't done everything that is possible to at least reduce the pain, and I don't see it as my 'duty' or 'calling' or whatever to meet out 'justice' to these guys by not doing everything possible to at least attempt to address it. It's real pain. There's no faking when someone is poking around in your gaping open wound with peroxide. What kind of Karma do I bring on myself by inflicting unnecessary excessive pain on another?

I did think that wet-to-dry changes 4 times daily was not best practice. It is usually a temporary measure for us until a wound vac is secured, but it still lasts a few days. The wound vac changes are also painful.

[TazziRN, RN]

Even addicts deserve pain relief. Not sure about how you should handle this, though, if refusing to carry out the dressing changes as ordered would jeopardize your job.

However........you say you really like it there. Do you think you'll feel the same way 6 months from now if this is how all addicts with pain are treated? Would you be able to look at yourself in the mirror?

[Antikigirl, ASN, RN]

I have come up with problems like this before, some dealing with addicts...some dealing with folks with mental probelms/brain injury/ or odd reactions and can't take narcotic pain medications.

What I have done is talk to the MD about other alternatives to this. You sugested Toridol...that is going in the right direction to me, or at least worth sugesting. How about ice or heat before dressing changes (per MD)? A PCA but set very structured and limited? A local? Just anything!

You can't refused to give good pain management to patients (not you, but your MD) anymore. It is considered unethical and is just plain out wrong! Pain is now considered a vital sign and must be addressed and treated. If a plan, like the one lortab, doesn't work...other methods must be tried till pain management is achieved.

[MultipurposeRN]

Well, you could say most patients w/ obesity, diabetes, heart disease, etc who have lived an unhealthy lifestyle and diet have brought their problems on themselves, but they are still entitled to the best care that is available out there. No less should a drug abuser get the appropriate care for their injury. Not to mention that it's possible the physician, staff, and hospital could be found liable if one of these patients were to sue and it was proved that they were deliberately undermedicated. There have been lawsuits over patients having inadequate pain control.

[topkat, ADN, RN]

I went to a seminar on acute pain mgmt. It had some good ideas for guidelines on treating chemically dependent patients. Here is an excerpt:

" Pain Mgmt Guidelines

Periods of acute illness often represent opportunities for meaningful intervention in addictive disease

Aggressively encourage entry into addictions treatment

But, addiction treatment is not the priority during the period in which the patient is experiencing acute pain"

As nurses, we have a responsibility to assure our patients receive adequate pain relief. Treating acute pain doesn't equate to feeding in to their addictive habits.

remember the pledge:

With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care.

best wishes to all those that care for these patients...they can be very manipulative and demanding...remember they often develop drug/alcohol addicitions because they have poor coping mechanisms to begin with...disease only exacerbates the issues....

topkat

[Pompom]

Perhaps a pain clinic consult would be in order. Other than than premedicate with the medication ordered, chart that you notified the physician and nurse manager that patients states c/o inadequate pain management.

[augigi, CNS]

I agree and was going to suggest a consult with pain management department. That takes it out of your hands. It's great that you're questioning this.