Sometimes it's hard to tell a drug seeker from a patient in pain.

mystory, BSN, RN · Dec 14, 2011

I just document the patient's stated pain scale and give the drug. As harsh as it sounds, I don't care if s/he is drug seeking. It is that person's problem, not mine.

CAPPYBARA BREAKFAST · Dec 14, 2011

I'm an AEMT student. I've been taught to treat the pain if they have it. It's not really my problem if they are drug seekers. I just hope if they are, someone is able to get them the resources they need.

carolmaccas66, BSN, RN · Dec 14, 2011

It's very hard when u just know someone wants drugs.

You could refer them to the Acute Pain Service, but that's not practical in an ED situation.

The ED physicians I worked for not long ago will not give morphine/narcs on principal, unless someone is virtually dying. The strongest patients get is Tramadol or Panadeine Forte.

One top doctor I worked with told me under Aussie law that we cannot legally refuse someone pain relief - the law is quite specific on this - BUT that does NOT mean we have to give them morphine or narcs. He smiled after that and then said to me: 'That's how you get around the law Carol and keep the lawyers happy!!'

He was one smart cookie I tell you.

nerdtonurse?, BSN, RN · Dec 14, 2011

I used to try to educate, find non-pharmacological solutions when people were obviously not tolerating the demerol or dilaudid or whatever narc they were taking for whatever issue they said they had (30 year olds getting bowel obstructions, falls, I'm not talking about someone with a resp. rate of 4, I mean the folks who tumble out of their beds because they're just flat out stoned). I'm talking about folks like the woman who came in with "abdominal pain post miscarriage that happened the prior week" -- who forgot I'd been her nurse when she had a hysterectomy 6 months prior, and went into the DTs after the surgery.

Then I realized, people aren't going to change until they hit bottom and decide they need to stop what they are doing. I was banging my head into a wall, and only hurting my head, not teaching the wall anything. How did I learn this? I was trying all night to convince a woman she didn't need narcotics every 2 hours for a foot that was broken 3 weeks ago -- if you need narcs 3 weeks after a simple break, something's wrong that needs fixing, you don't need to lay in a hospital bed for a week getting all the demerol and soda you can ingest. No elevated BP, HR, RR, in all the time with ODs and ETOH, she was just getting a free narcotic ride. I was so busy trying to "save" her from her addiction, I almost missed a person who's rhythm started changing. New tele tech didn't notice, I walked in the room with the tele equipment and noticed that T waves were inverted, when they hadn't been at the start of the shift. Patient 2 was having an MI, and they were a horrible diabetic, very brittle -- so no telltale chest pain, was in with COPD, and we were having AC issues -- SOB, and sweaty wasn't unexpected. Their first troponin was over 10. They got shipped out for an emergency cath, and I almost missed it because I was trying to help someone who didn't want to be helped.

So, I learned. You want help to get clean, I will move heaven and earth to get you into treatment, will call everybody I know at public health to get the person a bed. You just wanna get stoned, here's your oblivion of choice, I've got people I can actually help. Now go away until your clock goes off in another 2 hours to wake you up so you don't miss your next PRN.

Sewbusy~RN · Dec 14, 2011

I feel for you. A while back I had a drug seeker who was angry I diluted and pushed slowly. I made an agreement with her that I would wake her for pain meds through the night. She was getting 2 mg dilaudid IV q 4h. I woke her twice and asked her if she wanted her pain meds, did the whole five rights and pushed it slowly. Both times, she called me 20 minutes after I gave it, asking if she could have her "pain shot". The first time I told her I had given it to her and she said "oh" and went back to sleep. The second time, she went all crazy and irate and started accusing me of not giving it at all, and then she started accusing me of taking it myself. I have never been so upset with a patient. I still don't know if she was making it all up or if she really didn't remember me giving it. Either way, her accusations made me wary of treating pain patients the same way. I see them now as a threat to my license. I'm scared they will stop breathing, I'm scared they will do what this creep did, and I'm scared that they will do worse things to get their fix. I'd rather have a confused patient trying to jump out of bed than a drug seeker.

Callisonanne · Dec 14, 2011

One of the ways I think about it is this. Pain is pain. As long as they have a prescription and their vitals and LOC are ok i'll give it. Withdrawal for an addict is also painful.

Kuniklo · Dec 14, 2011

Everyone deals with pain in their own way. Someone could report their pain as an 8/10 but be joking around b/c it distracts them from how much it hurts. I know someone who has an autoimmune disease and says her pain is a 7 or an 8 daily, but she never shows it and is always in a great mood.

Even if they are addicted, it's not our job to be the morality police. Every drug has side effects and medicine is about weighing risks against benefits. Yes, people with pain can become addicted as a result of pain control, but it's a risk that we take b/c it's better than an isolating, limited existence marked my crippling pain.

The brain is a powerful organ. The thing is that we don't know how addiction works. Sometimes the brain will trick you into feeling like you are in pain to get a fix. So even if someone looks like a drug seeker, there's a possibility that they think they really do have pain.

NO50FRANNY · Dec 14, 2011

I work in Emergency so my reply here mostly pertains to the emergency department (forgive me) and patients who are seeking IV narcotics in the absence of pathology to clinically warrant administration. I've spent the last few months scouring journals trying to find relevant and helpful articles about the best ways to care for a pt. who appears to be seeking opiods. I guess I was looking for something a little more constructive than not giving them anything (IV) and waiting for them to go away. I found ONE article that was helpful, just one. Part of our duty of care is that we do no harm and from what I have read, facilitating someones' addiction is not beneficial. Long term abuse of narcotics has extremely detrimental effects on the abuser, socially, psychologically and physically. To this end, we shouldn't be giving IV opiods to a patient who we suspect is feigning illness for drugs, we are helping them dig their own grave. We are also positively reinforcing unacceptable behaviour- manipulation, malingering and lying. I think the biggest frustration for me is that the sick people who so desperately need our attention and care are missing out because someone wanted a hit. This isn't about morals, it's about clinicians using their experience and knowledge to determine the most appropriate care to provide each patient. First do no harm.

We are obliged to give analgesia to all patients in pain, however we are not necessarily obliged to give IV narcotics. Drugs such as Panadeine forte, endone, ketorolac are very effective strong analgesics and we often will give these as a first line intervention and if the pt's pain is not reduced acceptably then we can move to stronger meds. For a lot of nurses, it can be difficult to differentiate the pt. in pain vs the pt. performing and there are no hard and fast rules, but I know for myself if I am in doubt I consult with the doc, and go from there. Liase with your doctors, observe the pts. behaviour, do they have physiological signs that suggest they are in such severe pain to necessitate morphine? Are they histrionic / narcissistic? Are they fixated on what medicine you are going to give them rather than actually worried about what is wrong with them? Almost all patients in pain will try ANYTHING you suggest, from suppositories to chewable aspirin. Narcotic seekers will often refuse PO meds, become verbally aggressive when offered them, or say they have already tried it or they are allergic, pretty much anything to ensure that the only thing we can give them is IV opiates. Not to mention doctor / hospital shopping, lost prescriptions, vague symptoms, from out of town, the list goes on.

I am amazed that some of the nurses who replied on this thread have actually had patients tell them how to "slam in" their dilaudid!!!! I can honestly say if that happened where I work, the drug would then be placed in a 100ml bag, alerts would be placed on our computer system and they would never receive narcotics from us again unless there was some major obvious trauma involved. I know that most EDs in my state don't even stock pethidine (demerol) anymore to address seeking issues. The general consensus in the very few articles I found suggest that offering detox programs and addressing the issue directly / confronting the pt. is the best thing we can do. I am really interested to hear other peoples opinions on this topic because there really is an astonishing lack of resources to educate ourselves about it. I have discussed this issue often with our doctors and they will often confront the pt. about their suspicions and offer help, surprisingly sometimes it is accepted. If anyone finds any useful literature please let me know.

Becky5 · Dec 14, 2011

I work in Emergency so my reply here mostly pertains to the emergency department (forgive me) and patients who are seeking IV narcotics in the absence of pathology to clinically warrant administration. I've spent the last few months scouring journals trying to find relevant and helpful articles about the best ways to care for a pt. who appears to be seeking opiods. I guess I was looking for something a little more constructive than not giving them anything (IV) and waiting for them to go away. I found ONE article that was helpful, just one. Part of our duty of care is that we do no harm and from what I have read, facilitating someones' addiction is not beneficial. Long term abuse of narcotics has extremely detrimental effects on the abuser, socially, psychologically and physically. To this end, we shouldn't be giving IV opiods to a patient who we suspect is feigning illness for drugs, we are helping them dig their own grave. We are also positively reinforcing unacceptable behaviour- manipulation, malingering and lying. I think the biggest frustration for me is that the sick people who so desperately need our attention and care are missing out because someone wanted a hit. This isn't about morals, it's about clinicians using their experience and knowledge to determine the most appropriate care to provide each patient. First do no harm.
We are obliged to give analgesia to all patients in pain, however we are not necessarily obliged to give IV narcotics. Drugs such as Panadeine forte, endone, ketorolac are very effective strong analgesics and we often will give these as a first line intervention and if the pt's pain is not reduced acceptably then we can move to stronger meds. For a lot of nurses, it can be difficult to differentiate the pt. in pain vs the pt. performing and there are no hard and fast rules, but I know for myself if I am in doubt I consult with the doc, and go from there. Liase with your doctors, observe the pts. behaviour, do they have physiological signs that suggest they are in such severe pain to necessitate morphine? Are they histrionic / narcissistic? Are they fixated on what medicine you are going to give them rather than actually worried about what is wrong with them? Almost all patients in pain will try ANYTHING you suggest, from suppositories to chewable aspirin. Narcotic seekers will often refuse PO meds, become verbally aggressive when offered them, or say they have already tried it or they are allergic, pretty much anything to ensure that the only thing we can give them is IV opiates. Not to mention doctor / hospital shopping, lost prescriptions, vague symptoms, from out of town, the list goes on.
I am amazed that some of the nurses who replied on this thread have actually had patients tell them how to "slam in" their dilaudid!!!! I can honestly say if that happened where I work, the drug would then be placed in a 100ml bag, alerts would be placed on our computer system and they would never receive narcotics from us again unless there was some major obvious trauma involved. I know that most EDs in my state don't even stock pethidine (demerol) anymore to address seeking issues. The general consensus in the very few articles I found suggest that offering detox programs and addressing the issue directly / confronting the pt. is the best thing we can do. I am really interested to hear other peoples opinions on this topic because there really is an astonishing lack of resources to educate ourselves about it. I have discussed this issue often with our doctors and they will often confront the pt. about their suspicions and offer help, surprisingly sometimes it is accepted. If anyone finds any useful literature please let me know.

Very well put! We are nurses. We treat the whole person, the whole problem. It is a part of our duty to assess a patient fully, identifying risk of opioid abuse and then taking the proper steps to help this patient. You are only doing harm by enabling them when they are manipulative to get there next fix. Document, document, document, and then seek help from the interdisciplinary team!!

applewhitern, BSN, RN · Dec 14, 2011

At my facility, management is never on the nurse's side with anything; the only thing that matters is that almightly customer satisfaction score. If their vitals are okay, and they are alert, I give them whatever the doctor ordered, and will call the doctor for more pain meds if the patient is not happy about what they get. I have been "written up" for not giving someone IV dilaudid in a timely fashion, or at least, quick enough to satisfy the patient who was in with a bogus complaint. I no longer try to police the world.

Good Morning, Gil · Dec 14, 2011

Pain is a highly controversial topic, and I remember learning in school that there are various theories on pain. The one I was taught was "pain is what a person says it is", subjective, and I truly believe that. However, like you said, there are drug seekers, but it is not our job to judge, but to give them the med they ask for if they say they are having chronic back pain, etc. (and, some truly do have back pain, they worked as a carpenter, etc), so it can be hard to tell at times, but there are the obvious drug seekers, too.

However, we give the pain med when they ask for it only if....obviously it's time for the next dose (or if they're clearly in severe pain post-op or something, I get them something ordered for breakthrough if they're ordered a measly dose; that's part of patient advocacy).

Also, and if it is safe to do so. I have had many a situation like you described...patient demands pain med, but then is asleep when you enter the room. What I do....I do not wake people up to give them pain medicine; if they are asleep, they clearly are very comfortable. I have no problem telling them that, too. I simply say," I came back to give you your pain medicine, you were asleep and resting comfortably. Now that you are awake, I will be happy to get you your pain medicine." (but obviously only if their VS are okay, etc). And, they'll usually say, "okay, that makes sense". Or "I wasn't asleep" lol.

pockunit, ADN, RN · Dec 15, 2011

Yes, people with pain can become addicted as a result of pain control, but it's a risk that we take b/c it's better than an isolating, limited existence marked my crippling pain.

Chronic pain pts don't generally become addicted. They develop a tolerance. Two totally different things.