I originally posted this under psych, since thats where I work, but haven't gotten any answers. Thought I would try the main nursing forum.
I'm just wondering the experience others have with their doctors, and the treatment of patients with a history of drug abuse? I work as a float in an acute locked unit. We have 4 units in our department, with 6 doctors total, although one is the director and rarely has patients. Obviously we get a lot of patients who have dual diagnoses. It seems frequently they will wean these patients off all benzos and narcs over a 4 day period, and then offer them next to nothing. They frequently act out, and then it's just said Oh they are drug seeking.
I was taught in nursing school that even if a person has an addiction, it does not mean their pain is not real. Does the same not go for psych patients? Doesn't mean their anxiety/agitation is not real and deserves to be treated. I feel like they are frequently blown off when they report the Vistaril ordered is not working. A few of our doctors also frequently will D/C the pain meds they have been on for years, because they have a hx of polysub.
I am sure some of them are drug seeking, and it is obvious at times that the behaviors are intended to get them meds. But then others seem they truly need something.
I have worked in drug and alcohol rehab as well. The drug seekers were not indulged. The ones who came back from the dentist with root canals, the fractures, etc were medicated. Addicts can still have physical pain- that's my only point. They shouldn't receive lousy pain control for objectively substantiated problems......and of course, emotional pain should not be medicated ( a few would get antidepressants, Depakote, etc- non-scheduled meds).
ED jockeys shouldn't be indulged w/o objective medical diagnosis of injury/disease (pancreatitis is painful and legit; fractures from falls, etc- I believe they should get very monitored adequate pain meds- Our patients used to get a few days of hydrocodone for actual medical procedures initiated by the rehab facility. The ones who were jonesing were escorted to a CADAC or LCDC to talk. :)
This is what worked where I was a nurse.
:)
Then we are on the same page here.
I would love to see addiction specialist NP's, PA's and Doctors used in Emergency and other treatment situations to work with current and former addicts who are experiencing acute pain. That would be ideal- expensive and probably not necessary from the hospitals point of view, but definitely worth it to help the addicted.
I would love to see addiction specialist NP's, PA's and Doctors used in Emergency and other treatment situations to work with current and former addicts who are experiencing acute pain. That would be ideal- expensive and probably not necessary from the hospitals point of view, but definitely worth it to help the addicted.
Yes- that would be wonderful. I'm not working now, but the 5 years between two facilities (one was adolescent psych/CD combined) the patients were mostly there and wanted to get clean/sober. But, of course, there were the usual attempts to sneak stuff in (pills sown into shirt collars was inventive !), and con the docs. One was the president of the addiction doc association (whatever the name is- it's been a while ). I worked at the place Dr.Phil sends people now (wasn't going on when I was there- glad I missed that- though the place was good about not doing the VIP stuff- a drunk/junkie is still a drunk/junkie whether he/she comes by private plane, or straps everything he/she owns on a bike and rolls in :). A lot of the patients were a lot of fun after detox (usual misery during that- but the protocols were good- they've probably changed a lot since then :)).
I really liked working alcohol/drug rehab. I learned a lot.
I agree with Sweettart. No one is saying do not treat their pain. We are saying treat it without drugs that have a high potential to send them back down the spiral of addiction/using.
I don't know where everyone in the world got the idea that life is pain free anyway. A torn ACL is going to hurt, period. Take some ibuprofen, use RICE therapy and get thee to PT and suck it up cupcake. It'll get better. Vicodin/percocet, etc in such a scenario, addict or not, is ridiculous. We do the patients no favors by Rx these drugs indiscriminately.
MVA with multiple fractures, or post-op, is clearly a totally different story.
FWIW, I have opted not to have for schedule II drug authority and won't be prescribing them at all. Not even going to go there. Chronic pain patients will simply be referred to pain specialists!
I agree with Sweettart. No one is saying do not treat their pain. We are saying treat it without drugs that have a high potential to send them back down the spiral of addiction/using.
I don't know where everyone in the world got the idea that life is pain free anyway. A torn ACL is going to hurt, period. Take some ibuprofen, use RICE therapy and get thee to PT and suck it up cupcake. It'll get better. Vicodin/percocet, etc in such a scenario, addict or not, is ridiculous. We do the patients no favors by Rx these drugs indiscriminately.
MVA with multiple fractures, or post-op, is clearly a totally different story.
FWIW, I have opted not to have for schedule II drug authority and won't be prescribing them at all. Not even going to go there. Chronic pain patients will simply be referred to pain specialists!
It also causes loss of functioning. The pain is worse than post-op pain. "Sucking it up" doesn't work well if you're pre syncopal from pain.....:)
A good pain specialist is wonderful.... and some are DR. Feelgoods, and pad their wallets by creating dependence.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
This might be a great question to ask one of the psychiatrists on your unit. There can be a number of different reasons, and I'm sure it's not the same for each patient.
For example, a patient admitted with depression/suicidal ideation who is also taking narcotics for long standing pain. The patient needs to be evaluated and treated for the depression. Narcotic pain relivers, as CNS depressants, might make it more difficult to assess the patient's actual affect and psychiatric status.
Are the patients being weaned off prescription benzos? Or illicit use? If the patient is in a locked unit, their current medications obviously aren't being take regularly or aren't working for the patient. Therefore it might be necessary to wean them off to get a better idea of their actual mental status and prevent any drug interactions in future therapy.
Unfortunately, even if the patient is anxious or in pain, it's difficult to tell whether they are seeking, withdrawing, or have a legitimate reason. Depending on why they are weaned in the first place, it might not be a good option to reintroduce the medication.
If you encounter this situation, though, I would consult the doctor or phsychiatrist in charge of the patient. Actually, first do a physical exam and see if you can find any physical cause for the pain. Try non-pharmacological methods such as distraction, relaxation, music, ice/heat, etc. If that's unsuccessful, then notify the doc of the complaint and ask if it's possible to give the patient something. If the patient is complaining of pain, there are non-narcotic options that should be offered first. Someone who is legitimately in pain should be willing to try to non-narcotic methods. For anxiety, try to help the patient identify the root of the anxiety and work with them to resolve it.
Thats a very good point. The problem I sometimes come across for myself personally, is that some people who have chronic pain, or have dealt with anxiety and agitation for so long related to their condition.... they may not always reflect it in their vital signs or physical symptoms right away. Some people will feel themselves getting anxious and want to do something about it before it escalates. So I'm still learning how to handle that aspect in a psych patient. Being that I'm newer to psych, I'm still learning. Well always learning, but you KWIM. Medical I had much more experience so I was more comfortable and confident in my decisions. Although I have come a long way since I started.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
SimplyComplicated, I missed the part about the docs being psychiatrists. So, with that in mind...
1. Someone graduates at the bottom of the doctor/psychiatrist class
2. Some psychiatrists get pretty hardened from dealing with pain and anxiety day in and day out, and lose their empathy
3. Some psychiatrists, just like some people, in general, just don't understand and don't care to understand
4. Some psychiatrists don't understand addictions (to benzos, narcs, or any other addictive substance)
This brings me back to the weaning in 4 days...people can die from that or at least feel like they're dying...
If someone has been using prescribed medications, even at a high rate, and comes into the hospital (psychiatric or otherwise), the few days there (most psych hospitalizations are short-term) aren't the time to wean off the drugs. It will be cruel, and won't work. What in the world is the point? To show them a thing or two?
Can you tell I have feelings about this?
I think we have very similiar views with this. I get frusturated with the patients who are frequent flyers and the docs do this every time they come in. They know the patients who act out. Instead they make us wait until it's a problem that disrupts the floor and then it's a necessity. These same patients are in and out. We are not going to "cure" their addiction, and as you said we don't really have enough time to treat it.
I get they need to watch their license, and they don't want to always give in to the patients manipulation. I just wish sometimes we could find a happy medium. Order the meds q8h or something, rather than the q4. But give us SOMETHING.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
When I worked drug/alcohol rehab, the docs were great- and addiction certified MDs.... they would treat the symptoms of the acute issue with a dosage that took into consideration the length and extent of their addiction- and during that time, do 'talk' therapy to help them with whatever was causing most of the anxiety (usually a fear of being taken off stuff cold-turkey, like they had in other places- we didn't' do that)... of if pain (like getting teeth pulled while in tx since they hadn't seen a dentist in 10 years d/t spending $ on drugs), treat them with narcs for 2-3 days, then NSAIDs..... there was NEVER a situation where the acute situation was not dealt with in whatever way necessary. But, they were also temporary w/additional meds.
When patients had to be transferred to the acute care hospital (and where I later worked and saw this), they were essentially ignored. It was horrendous.
One LTAC I worked at had a paraplegic (still had pain sensation- no mobility), and hip disarticulation, w/a dinner plate sized decub in his sacrum - to the spine. He HURT. And he was on methadone maintenance- and not a very high dose. The admitting doc refused to give him pain meds for the decub. I'd go into the room (him not expecting me- so no time to work up a tear stained face) and be sobbing. I'd call the on-call docs (worked weekends) and tell them about the hx of addiction and decub pain, and get IV morphine for the weekend. Finally I had to refuse to take him when the doc got mad about it. I would not participate in torturing the guy. He may have been an addict (and dealing with it by methadone maintenance- which I don't like- BUT it is an effort to not use the street/contaminated/illegal stuff) but the guy was also a human being, and deserved humane care...
That is really sad. Actually downright ignorant on the doctors part:crying2:
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
this statement couldn't be truer.
when i was hospitalizd (1 night) for a diagnostic procedure, it necessitated me needing a chest tube.
and boy, that hurt.
i got iv fentanyl, dilaudid, and morphine.
those did little to nothing for my pain...they only changed my perception of it, i.e., making me loopy/high.
nurse gave me iv toradol...my pain went from an 8 to 0.
i'm telling you, no pain whatsoever.
that's the only med i wanted after that.
so yes, if someone is legitimately in physical pain, they'll take whatever works....and they're not always narcs.
leslie
Good point. Same goes for someone with anxiety. You can usually get a pretty good idea of the drug seekers when they flat out refuse to try ANYTHING besides that narc or benzo or whatever. I just went through this with a guy with the vistaril order. He didn't want it because "it doesn't work" Well he kept saying he was so anxious, so agitated that he "needed" something right then. But had no orders due to polysub abuse. But he hadn't even tried the vistaril in over 24 hours, even though it was ordered q4 prn. He refused anything I suggested. Must not have been to bad then.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
I strongly disagree with much of what I see.
I have found that most drug addicts and alcoholics are struggling from severe EMOTIONAL pain, and use drugs and alcohol to self medicate this pain. It helps numb them and not deal with the emotional needs that they have so that they can "function." As much as they want to try, they can not treat emotional pain with drugs; it's not going to help the underlying problem. And any doctor who realizes this, and encourages therapy and treatment rather than giving pain and anxiety meds has my vote. I understand that we are to treat pain as subjective, but I simply can not do that in those who have a history of drug abuse.
(We do not allow any narcotics, benzos and others of any kind, and we strongly discourage the use of muscle relaxers and other drugs. Some will abuse their Seroquel and Wellbutrin, but we usually get them out of the program for doing that sooner rather than later. )
Out of curiosity what kind of program do you work? I'm in an acute lock down unit, so the patients we get are in crises. We don't do long term therapy. We do have counselors, and they go to groups and all that. But our average stay is 4-7 days. We are also dealing with the Bipolars, paranoid schiz, Schizoffectives, and all that. So without these medications all hell breaks loose.
Specializes in Med/Surg, Neuro, ICU, travel RN, Psych.
It also causes loss of functioning. The pain is worse than post-op pain. "Sucking it up" doesn't work well if you're pre syncopal from pain.....:)
A good pain specialist is wonderful.... and some are DR. Feelgoods, and pad their wallets by creating dependence.
We have a pain management doctor who is like that. He creates his own monster with it. A good majority of the patients we get that are under his service are so demanding and entitled about their medications. He pretty much gives them whatever they want. To the point that when they come in and have a pain management consult through the hospital, our pain doctor has to wean things down. He's not comfortable giving them what they "want" and have outside.
Out of curiosity what kind of program do you work? I'm in an acute lock down unit, so the patients we get are in crises. We don't do long term therapy. We do have counselors, and they go to groups and all that. But our average stay is 4-7 days. We are also dealing with the Bipolars, paranoid schiz, Schizoffectives, and all that. So without these medications all hell breaks loose.
Long term rehabilitation. They are all allowed to be on psych meds, but no benzos or narcs while in our program. They drop dirty and they are out of there.
). I worked at the place Dr.Phil sends people now (wasn't going on when I was there- glad I missed that- though the place was good about not doing the VIP stuff- a drunk/junkie is still a drunk/junkie whether he/she comes by private plane, or straps everything he/she owns on a bike and rolls in :). A lot of the patients were a lot of fun after detox (usual misery during that- but the protocols were good- they've probably changed a lot since then :)). 
SweettartRN
661 Posts
:)
Then we are on the same page here.
I would love to see addiction specialist NP's, PA's and Doctors used in Emergency and other treatment situations to work with current and former addicts who are experiencing acute pain. That would be ideal- expensive and probably not necessary from the hospitals point of view, but definitely worth it to help the addicted.