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

[Nurse Beth]

Jake is very sociable, and has a lot of ...colorful friends who visit him in the hospital. He's quite likable, because he's intelligent, funny and clever. He's not bad-looking, but at 35, his lifestyle is starting to take a toll on his looks.

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

Time: 1940. Right now, Jake is leaning against the doorjamb in the doorway of his room, looking up and down the hallway for me. He's holding his cell phone in hand and repeatedly checking the time. Just to irritate me, I'm sure. He always calls for his pain meds before they're due.

Funny, I've yet to ever see him exhibit any outward signs of pain. On the contrary, Jake always appears relaxed, but his reported pain level is always a "ten."

Jake Lies

Time: 1945. Only because I have to, I ask: "What's your pain on a scale of one to ten?" He automatically answers "ten" without blinking an eye or looking up from Candy Crush. I might as well have asked, "Yo, Jake, what's six plus four?"

Jake Gets His Dilaudid

Some patients always know exactly what time it is

Time: 2005. Ok, Ok! It's time. Reluctantly, I enter the room. My eyes roll as Jake scoots eagerly to the side of the bed nearest me and proffers his inner arm, exposing his antecubital saline lock. With his opposite hand, he pushes the sleeve of his patient gown up high and out of the way. His eyes are bright and his gaze is steadfastly fixed on the syringe in my hand.

He watches intently as I swab his saline lock port with an alcohol wipe. He's craving his fix. He swallows. He supervises as I pierce the rubber hub and finally inject the Dilaudid into his bloodstream. Then he asks me to "flush it fast." I don't respond or make eye contact. I flush the port and leave the room as quickly as I can.

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

What about the Rules? I'm playing by the: "What the Patient Reports as Pain is the Gold Standard" Rule Book. And Jake's Rules? No rules. He's just playing me for a fool. Or so it feels.

Take a Deep Breath and Repeat

I don't like how I feel. So, for a minute, let's just step back from Jake and the floor and review some pain management terms.

Tolerance

Tolerance is a normal physiological response to exposure to a substance over time. Think coffee. You require more caffeine to realize the effects you enjoyed when you first started using, I mean, drinking, coffee. There's:

• Tolerance to side effects can include sedation or nausea, (opiates) and
• Tolerance to analgesic effects, which requires higher doses to achieve pain relief

I need my coffee strong, please!

Jake has tolerance to both. "Normal" doses of pain medication will not relieve Jake's post-op pain. Dilaudid one mg IV for Jake is like a lukewarm, watery, half cup of coffee is to me. Due to tolerance, Jake needs more pain medication, not less.

Dependence

Physical dependence develops with repeated exposure to opioids.

"Tolerance, withdrawal, and physiologic dependence are expected responses to opioids ...and are not by themselves indicative of addiction."

American Society of Pain Management Nurses (

ASPMN)

Position Statement on Pain Management in Patients with Substance Abuse Disorders, 2012

Many respectable, functioning members of society live with chronic pain that's managed by some form of opiate. Given enough time and drug, they become physically dependent. Dependence in and of itself does not constitute addiction.

Addiction

According to the American Society of Addiction Medication (ASAM), addiction is "A chronic, primary disease of (the) brain...characterized by inability to abstain." People with active addictions can't control their cravings or impulses.

Here's the thing- patients with active addiction have pain, too. Perhaps even more pain than other people undergoing the same procedure. There's a phenomenon known as opioid-induced hyperalgesia, in which patients dependent on opioids have increased pain despite increasing doses of meds.

What Else ASPMN Tells Us

The (ASPMN) Position statement further says:

"Patients with substance abuse disorders and pain have the right to be treated with dignity, respect, and the same quality of pain assessment as all other patients.

So when Jake, the post-op substance abuser, asks for his pain meds, it's complicated.

It's easier to dismiss Jake as a drug user than to sort this all out

Added to the problem is that few providers are schooled in managing pain in patients addicted to opiates. Dr. McSurgeon will most likely order his one size fits all post-op pain management order set.

Here are some things I've learned to reduce my frustration:

Six Resolutions that Help Me Cope with Patients with Substance Abuse Disorder

1. I will check my judgmental attitude. I remind myself that I don't know how Jake got to this place. I don't know his story, all the factors and forces that led to his addiction. Was he a cute little boy?

Did someone hurt him? Did his father leave him? I'm not saying that any of these are an excuse to use drugs. I myself didn't have a stellar childhood, and I don't use drugs. But reminding myself that I haven't walked in Jake's shoes instantly changes my perspective and helps me be less judgmental.

2. I will be realistic. Why am I surprised when a person with a substance abuse disorder displays behaviors... consistent with those of a substance abuse disorder? Folks with DKA have high blood sugars. Folks with an active addiction lie, cheat, steal and manipulate to get their drugs. When Jake lies, flatters, or wheedles, I won't take any of it personally.

3. I will understand my job. I can't cure Jake's addiction. I'm not that powerful. Even if I could, which I can't, and even if he wanted me to, which he doesn't, that's not why he's here. Jake's here because he had surgery. My job is to provide the best post-op nursing care I can.

4. I will take control. Of myself. My anger is my problem, not Jake's. I own it. I can only be manipulated if I allow it.

5. I will not engage in a power struggle with Jake. We both lose. I've worked with nurses who use passive aggressive behaviors, "forget" to medicate their patient, wait until change of shift, etc. Failure to treat pain is profoundly wrong, unethical, and unprofessional. Nurses who position themselves as "She (or He) Who is the Gatekeeper of Pain Medication" need to re think how they're using their authority.

6. I will be professional. I won't use stigmatizing terms such as "drug-seeking" and "clock-watcher." In handoff report, I will simply inform the next RN when Jake's pain med is due. Jake deserves the same access to pain medication as Edna, my 78-year-old female post-op hip surgery patient, and the same dignity and vigilance. (Actually, I have a hunch Edna was a little tipsy when she fell and broke her hip). I will respect Jake as a fellow human being who, for all I know, is doing the best that he can with what he has. As are we all.

Rewind and try Again

New tactic.

Time: 1945. I go into Jake's room, smile, make eye contact, and ask him if needs his pain med. He is completely taken by surprise, and his face and eyes show it. Someone is treating him like a human being?

As for me? My anger is gone! I'm in control and I feel much kinder towards Jake. I can do this. It just takes practice..to improve my nursing practice!

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

[Guest957596]

Guess what !? AGAIN-- that's NOT your job though , now is it?

No,it is his job.

[nutella, MSN, RN]

I talk a lot to patients who have a high tolerance to narcotics for a variety of reasons. Some have been on narcotics for medical reasons for a long time and develop tolerance, some were IV drug users in the past and now have a medical problem that is painful with hard to relieve pain, some are active users who happen to have a medical problem.

The other day, a patient who was an active user and who also had endstage liver disease with ongoing abdominal discomfort and pain decided after months in and out of the hospital and trips to the ICU for low blood pressure, bleeding and so on on comfort measures / care and comfort. She was middle age and homeless - tried to get sober but was not able to maintain and would sign out AMA and use. Partly because she had unrelieved symptoms from her liver failure but also because she could not cope. She was well known to the nurses who were very compassionate and just accepted her the way she is. Of course she did not get good pain relief but she also wanted to be a "full code" and was thinking that she would get sober, stop drug use and alcohol to get on the liver transplant list. So she was struggle for months between pain, craving, use, re-admission, homelessness and so on. She could not commit to anything including some program to help with addiction.

In the end, when she was ready to chose care and comfort, she was already in the dying process when she called for palliative care to come by - she did have a relationship with our team, we had seen her throughout. She had just come out of the ICU where she had struggled with low blood pressure, bleeding, pain, shortness of breath and so on. In that conversation she initiated the conversation and said "I understand now that I am dying no matter what I do or not do - my liver is so damaged and sick that I am dying. I am not able to get out of bed anymore, I am in constant pain and cannot breath and I will never get a transplant. I just want to receive hospice care and be comfortable for the last days - I already changed my code status to show that I am serious about it."

Her family was also there and everybody cried - this was the most honest conversation she had in a long time.

We had a long discussion about care and comfort, what it means, what it would mean for her.

She had only two wishes left at the end of her life:

- to be finally comfortable and to receive enough medication that she would cherish the last hours and days free of pain and shortness of breath

- to reconcile and "make good" with her family who had withdrawn from her years ago - including her kids. She said "I know I can not make good what I did to them and for the pain I have caused but I would love to see them a last time and tell them that I love them."

- to not die alone

I told her that the first one we can do if everybody - she and her healthcare proxy are on the same page - the second one I was not sure. I told her that we can call family and let them know - my recommendation to the family member who was present was to come today or tomorrow - because that is probably all the time left. But I was honest and told her that I was not sure they would come in and that sometimes it does not happen that families can reconcile and get closure.

But if they are unable to come in, we will make sure that she is not alone and since she was well known to the nurses and other teams we would make sure to check in with her a lot and spend time with her.

Luckily, her family came through. Once they heard that she was dying and they had to come today/tomorrow if they wanted to spend time with her , they showed up in large amounts. The patient was now comfortable with medication but still awake and able to talk on the first day - there was a lot of crying, laughing, joking, and reconciling - she was able to get closure and the family as well.

On day two she was mostly sleeping but still waking up between and smiling - she needed more pain medication - she moaning with abdominal pain and her shortness of breath was severe and needed aggressive symptom management. One of her children who had not seen her in more than 10 years came that day - she smiled - later on she passed peacefully.

It is never easy for patients and staff when there is a medical illness and the patient is also an active user or was a user or tolerant because of chronic opiate use.

[wonderwhy]

I don't understand flushing it fast. A needle in my vein makes me nauseous, that would be horrible. You unprofessionals make it look like judgement. God help the lot.

[CanadianRN2017]

Thanks for the post... I have felt some of the same things early in my career. What I like about my current place of employment is that POD2 the if dilaudid is changed to subs Q4-6 hrs for the next 24-48 hrs, and then to PO. For our frequent flyers... they automatically get a sub butterfly for their pain Meds..... it is a great way to wean them to PO and then get them well enough to go home....

it works well... the patients with addictions, generally get "better" quicker when we use the subq method. They get to the PO quicker.... and out of the hosp with a referral to an addiction clinic. Do not know if many actually do go.....

[Bizyfe0415]

Very good article. I have had a few 'Janes' (I work Women's Services) who fit this description to a "T". My problem is with the Pharmacy. The doc knows his patient and adjusts his/her order plan to allow for a little more and/or on a more frequent basis. Then I get a phone call from Pharmacy informing me a choice has to be made since 3 IV meds are ordered and 2 po meds are ordered. AND I am informed if I give any one med as ordered I could be giving too much, not to mention giving all of them as ordered (as if I am too stupid to know what's been given and OD'ing her). After arguing and fuming and stewing, I have learned: When I initiate the plan, as soon as possible I send a Pharmacist Communication that the patient takes X on a daily basis and has built up a tolerance for similar meds that the doc has made accommodations for. No phone calls. Yet.

[babychickens]

@cwentworth...oh my gosh, do we work together... or are turkey sandwiches and ginger ale the food and drink of choice for throwing?! :)

[Munch]

As far as I am concerned we need to take some advice from the legal profession..."It's better to let ten guilty people go free than have one innocent suffer." I think it should be the same with health care..I would rather medicate ten supposed addicts than let one genuinely sick person suffer. I am not the police, judge, jury or executioner. If the medication is ordered and VS are WNL then give it. I can't stand when some of my co-workers(not all) get all self-righteous when they have "figured it out" that the patient is malingering just to get drugs. They act like that dose of dilaudid is coming out of their paychecks and take it so personally when they figured out a patient is a seeker. Its not personal...these addicts need their next fix like a fish needs water. Of course seekers can be demanding and draining but so can many other patients! My sister is a social worker in a city hospital and finds dialysis and diabetic patients who aren't complaint draining. It comes with the territory.

Someone mentioned that detox meds should be provided and addiction services referred..its not going to do any good unless the addict actively WANTS to get clean. Its not always the drug seeker that's the problem either. When I was very briefly working in a small community hospital I saw twice something happen that was absolutely maddening. This was my friends patient that had come into the ED from a local detox/rehab facility because he had an abscess and the facility wouldn't admit him until a doctor medically cleared him. Our hospital wanted to admit him for a few days on IV antibiotics. Okay great but this patient was going to the facility for detox before rehab so obviously the patient was concerned with withdrawal and wanted to know if the hospital would give him methadone until he could go back to the detox facility. The doctor said they would give him some clonidine, phenergan and vistaril. The patient who on his own checked into a detox and rehab facility then left the ED and didn't get the help he needed(couldn't go to rehab without having that abcess treated). Clonidine is garbage as a sole opiate detox med..we all know any detoxing patient isn't going to feel better without some kind of replacement medication. What's tragic is 2 months after that my friend said that patient came in DOA of an overdose. The second was a patient of mine..same situation pretty much. Came to the ED from a detox facility to get treatment for an abcess. This patient made it up to the floor with a central line in his neck(couldn't get regular IV line in obviously). He was suffering from heroin and benzo addiction. All the doctor ordered to help him with his symptoms was a baby dose of Xanax. That's it. I do have a feeling though that his girlfriend was bringing him some heroin because he darted to the bathroom immediately after she arrived every single time. But I didn't witness any handoffs or find any paraphernalia so that was that. I honestly can't really blame him either IF that's what he was doing. He genuinely wanted to go get help and checked himself in to a detox facility on his own. Sadly 2 days later he wound up leaving AMA with the line still in his neck. Not too long after(maybe 8-9 months) he was in the papers for armed robbery charges just to name a few. You can bet his crimes were committed to support his habit. That is no excuse in the least bit to commit violent felonies..but he must have felt like he had been shoved in a corner. He actually asked for help and was denied anything useful to help his detox symptoms. I always think of those two patients. What if the doctors actually had some compassion and prescribed some methadone until they could go back to the rehab facility? I'm not saying the doctors are responsible for these patients death and crime spree but things certainly COULD have been different for both of them if they actually completed rehab like they voluntarily committed to...A couple of situations where the health care professionals are part of the problem, not the solution.

In my sisters hospital she says the doctor gives out doses of morphine if a patient comes in with active withdrawal ALL the time..he titrates it up too until the patient actually feels better..he uses zofran and small doses of valium to help with anxiety. He said if the patient didn't get it from that emergency room he was going to get it from somewhere..he would rather give it to him than have the patient rob a pharmacy or shoplift or whatever it is junkies do to get their own fix. At least that patient came in with a tangible problem that he can help fix. He said he will only do it if the patient is in acute withdrawal. He won't do it if the patient just wants to get high. Obviously you can tell by looking at the patient if they are in active withdrawal. He also will refer the patients to local suboxone doctors in the community if they are interested.

[babychickens]

Munch BSN, you make some interesting points. There are so many factors, as I'm sure you can imagine, which decide whether or not a doctor can treat with methadone. Is it in the hospital formulary? Are the MDs fearful of an OD on their watch? If word got out that withdrawing addicts could come to the ED what would the waiting rooms look like? Lord knows. Harm reduction is a fine idea and one that I support depending on the circumstances but my ED has enough on our hands with "regular" patients. I wish there were more services for people, and especially specialized ones for 5150, etc but that's not the way it is right now. By the way, I'm right there with your sister...non-compliant DM pts frustrate me as much as drug seekers, if not more, any day.