When Your Patient is an Addict...How to Deal

[BlackMagicGypsy]

I really enjoyed this article!

It is so sad when patients are surprised to be treated like people by medical staff....

[nutella, MSN, RN]

I think that self-awareness, self-reflection and mindfulness are generally good ideas when coping with feeling manipulated, supporting an addiction, and questioning motivation, needs, ad truth.

I think it is also true that it is helpful to clearly see ones limits - my power as a nurse is limited - I will not change the patient through trying to "parent him into insight" or that he will suddenly have an epiphany.

Other strategies are to

utilize policies that require to administer dilaudid via infusion over 15 minutes and could be ordered by the MD as it will not produce the "high" as much

ask for a pain consult if patient has reasons to be in pain as it can be very difficult to control pain when the person is also using or has been using and a pain service may be able to recommend something that is better for pain control or combinations

Use "care plans" for high utilizing patients with pain "problems" including clear guidelines of what medication may be ordered and so on. We utilize care plans so that everybody is doing the same thing to avoid further manipulation and message congruence.

[macawake, MSN]

I'm feeling repulsed. Did I say repulsed? Yes. I'll be honest here. You may stop reading now, you may be shocked, you may unfollow me. But I know that if I feel this way…I can't be the only one.

More on How I Feel

Dirty. Tarnished, as if I'm complicit in Jake's addiction. I'm pushing IV drugs on an IV drug user? Really? That's not what nurses do!

I'm angry.

• Angry because I feel manipulated and used
  
• Angry because Jake's not playing by My Rules
  
• Angry because I'm a tight-lipped, mean nurse with Jake. Not the compassionate angel of mercy I prefer to think of myself as! I hate when that happens, JAKE!!
  
• Angry because I'm angry
  I'm a tight-lipped, mean nurse with Jake, the drug addict
  

These patients are tough.What's your experience? What helps you get through your shift?

I can honestly say that I've never once felt tarnished, used or complicit in a patient's addiction. I have however sometimes felt that patients try to manipulate me. Not every patient who tries to manipulate me is addicted to opioids, people from different backgrounds and of different personality types do this. In my opinion it's just par for the course when dealing with a cross section of humankind.

I definitely don't regard myself as a compassionate angel of mercy. I associate such an self-image with someone teetering precariously atop a pedestal with an inevitable brutal crash landing looming on the not too distant horizon. I think that it places unnecessary stress on a person to have that self-image and try to live up to that unrealistic standard. We're all just human. I'm rather pragmatic about my profession. I do try my best to do right by my patients by keeping current with evidence-based medicine/practice and treating folks like I'd like a loved one or myself be treated if we were sick/in pain /scared/ hospitalized, but at the end of the day to me, nursing is a profession, not my identity.

Now I'm not sure if you OP personally experience all the thoughts/feelings described or if it's an illustrative amalgam of various thoughts expressed by many different posters in previous threads on the subject? When reading how Jake makes you feel my first reaction is that you're giving Jake way too much power. We can all decide how we choose to react to someone else's behavior. I make an active choice to not allow someone else's behavior sour my mood. Sure, I need to remind myself about this occasionally but it really does work.

OP, I like the rewind, try again new tactic you describe at the end of your post :) It's win-win. A nurse who chooses that approach will benefit from it, so will the patient. The nurse doesn't have to have her/his shift ruined by experiencing negative, non-productive feelings and the patient doesn't risk having their pain undertreated due to a nurses' personal bias/judgment.

On this admission, Jake had an appendectomy. He also has a substance abuse disorder.

My advice, focus on the fact that Jake has had a surgical procedure. That is after all what's relevant here. While I personally can't fathom why anyone would ever want to play Candy Crush, poor taste in games shouldn't mean that we don't treat post-surgical pain appropriately All patients deserve that.

Pain Intensity on the First Day after Surgery:A Prospective Cohort Study Comparing 179 Surgical Procedures | Anesthesiology | ASA Publications

Results:: The 40 procedures with the highest pain scores (median numeric rating scale, 6–7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many minor” surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of major” abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia.

[russianbear]

Drug seekers are a problem and sadly nobody wants to address it. "Pain is what the patient says it is" makes as much sense as "the customer is always right." No, the customer is not always right. The only problem with your scenario is you indicate Jake has recently had a surgical procedure. That causes pain. Change the scenario to "Jake presented to the ED having bumped his arm on his kitchen table, has no bruises, no fracture, nondislocation and was admitted because he screamed at the ED doc, called th nursing supervisor and heartened to sue if they didn't make him comfortable." Oddly enough, the hospitals which utilize carenplans don't get this as often.

[Irish_Mist, BSN, RN]

The problem I have with all of the Jakes I treat is that many of them expect me to drop everything I'm doing all at once to give them their IV dilaudid and phenergan even if I am providing care to another patient. If it takes me more than two minutes (not an exaggeration), they pitch a fit. If I don't "push it fast" or if I dilute it, my practice and technique is questioned. If I refuse it due to them being hypotensive or difficult to arouse, I am nurse ratchet who doesn't care about their pain.

They are so nauseous and in so much pain yet they can chow down on potato chips and starbucks despite being NPO. They claim that PO Dialudid doesn't "treat" their pain yet will ask for it one hour after getting their IVP of Dilaudid. That's interesting. I thought it didn't "work". And then, down the hall you'll have a patient ready to be discharged home with hospice already in the active stages of dying who fervently denies pain whenever I try to encourage him/her to let me medicate him/her.

Don't get me wrong. I am professional and courteous to every Jake I encounter. If I know someone with undeniable pain is going to be discharged soon, I try to encourage them to move over to PO pain meds because we all know Dilaudid or Morphine IVP is not available at home. I cannot make someone change their ways and I cannot cure a drug addiction. If a pain med is ordered, I will give it if it is safe to do so. However, it is incredibly difficult not to resent these type of patients when they use manipulation to get their way and monopolize my time. I have other patients whose needs are just as important as Jake's.

[Lev, MSN, RN, NP]

I have dealt with many "Jakes" and I will dilute their pain medicine and push it over the recommended minutes.

[Alex_RN, BSN]

Excellent article.

[ohiobobcat]

I have dealt with many "Jakes" and I will dilute their pain medicine and push it over the recommended minutes.

And I don't "flush it fast". When asked why, I tell them, like I would any other patient, that if I push the med too fast it could slow down their breathing enough that I might have to help them breathe, and I would rather not do that today if I don't have to. I used humor when appropriate and firm boundaries with people like Jake. Sometimes it worked, sometimes it didn't.

This is a good article because I struggled with some of those feelings about addicts when I was a newer nurse.

[russianbear]

And I don't "flush it fast". When asked why, I tell them, like I would any other patient, that if I push the med too fast it could slow down their breathing enough that I might have to help them breathe, and I would rather not do that today if I don't have to.

Or, you can also add that we are not enablers and will not help them get a fix. This "I'm gonna take the high road" stuff is getting old. Drug seekers are a drain. They drain resources. They drain the energy from staff. You know, there are facilities that do things differently. They don't give seekers Dilaudid Q3H for vague pains. Guess what they have fewer of? Why can we not be honest about this problem? Not to mention how we've created a disgusting opiate epidemic.

[oldpsychnurse]

Psych is full of drug addicts. I always tried to be very nonchalant when dealing with them. If you try to reason with them, it turns into a power struggle. Some of them will talk with the nurse about their addiction (while we're pulling the opiate of the hour out of the pyxis) but most of them deny having any problems. If you can make the interaction as pleasant as possible (while explaining to them on day 1 that you will always get their meds as soon as possible but sometimes you can't be there that very second) it's easier for them and you. I also tried to always work with the doc to get their prn's and scheduled meds as in synch as possible. That cuts down on their constant requests and also seems to make them more satisfied with their meds. And my posts are in the past tense because I finally got out of nursing. I had enough of the patient and family centered waitressing, and kow-towing to addicts was a big part of it.

[cwentworth]

This was a fabulous read. I also have experience working with patients with addiction in the ER. To say it's "frustrating" work is a gross understatement. In any other context, their behavior towards us would be considered abusive. Like many of you, I've been called vulgar names, had my life threatened, had objects (usually food items) thrown at me. If I went to Staples, demanded a turkey sandwich and a giner ale and then proceeded to melt down in the store when I was told, "it might be a little bit", I would be arrested. However, I remind myself that these people are sick. They are emotionally, physically and spiritually bankrupt. Their drugs have robbed them of any positive qualities and ability to care about their life or the lives of others. Fortunately, I am in the position where I bare witness to their recovery. I witness the benefit of your hardwork, nurturance and compassion. Knowing that recovery is possible maintains my equinimity.