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?

[KatieMI, BSN, MSN, RN]

Post-operative analgesia is standard of care; don't the vast majority of major post-op patients chase pain with narcotics?

Precisely so. 1 mg of dilaudid IVP Q2H PRN for "pain" (no other parameters) is an order which practically chases the pain. It can be ok for "naive" patient who has no other pain issues but not for someone who was taking Norco 10 Q3-4 (prescribed for Q6 originally but "I found an online site and another doc") for years before.

I didn't write about "holding meds". I wrote that I would question such order, even if it is "legitimate" because AFTER I give patient that 1 mg of Dilaudid I will speak with him and explain that if we can arrange for scheduled meds in pill form, he will feel better, but I need to know what he was taking when he was at home. Then I will call the doctor and ask not for 2 mg of Dilaudid but either for pain consult or for some prolonged action narc to be given on schedule. Methadone often works spectacular.

[BostonFNP, APRN]

Precisely so. 1 mg of dilaudid IVP Q2H PRN for "pain" (no other parameters) is an order which practically chases the pain. It can be ok for "naive" patient who has no other pain issues but not for someone who was taking Norco 10 Q3-4 (prescribed for Q6 originally but "I found an online site and another doc") for years before.

I didn't write about "holding meds". I wrote that I would question such order, even if it is "legitimate" because AFTER I give patient that 1 mg of Dilaudid I will speak with him and explain that if we can arrange for scheduled meds in pill form, he will feel better, but I need to know what he was taking when he was at home. Then I will call the doctor and ask not for 2 mg of Dilaudid but either for pain consult or for some prolonged action narc to be given on schedule. Methadone often works spectacular.

I agree that acute pain can be difficult to manage in a patient with a history of narcotic abuse, for a number of factors, including using sufficient and safe dosing schedules. I also agree that sort-acting opioids have a limited role in treating chronic pain and are often more dangerous for creating psychologic dependence.

I don't know if I agree with using long-acting narcotics for acute post-operative pain when there is no plan for the patient to go home with the medication, as is the case for street-drug users. Methadone is a underutilized chronic pain medication, however, I would not use it to manage acute pain as by the time a steady state was reached the patient would be out of the hospital (4-5+ days to reach steady state). I would be very hesitant to have any plan to send a patient home with narcotics if they are actively abusing street drugs.

[madricka, BSN, RN]

The saddest thing I have seen is surgical patients who are too afraid of judgement to reveal their addictions and thus receive FAR LESS pain medication they need and I walk in to see them pale, sweating, shaking and in absolute agony. I assure them that what they do at home is none of my business (which it is not) and my job is to take care of their pain and help them recover from surgery. They will not recover smoothly if their pain is not controlled. They will not eat, do physio, get out of bed or communicate well. Having a pain team on call is a blessing. But encouraging those with addictions to feel safe to reveal their true use is crucial.

As for my opinion, I should not have one. I am NOT qualified, educated or trained as an addictions specialist, a social worker, or interventionist. The patient has not invited me to help them heal their addiction issues. If anything, their time in hospital is the absolute worst time to try and take away their (likely) sole coping mechanism since they are experiencing an enormous amount of stress. It's not the time or the place. Am I contributing to their addiction? Please. It's not as simple or as straightforward as that. And misunderstandings like this are why I have to do extensive education with so many other (non-addicted) post-op patients about how they will not become addicted to opioids if they take pain medication that they desperately need (or have had it in recovery).

There are some nurses who insist patients couldn't possibly sleep if they had severe pain. As someone with chronic severe migraines, I assure you, it is possible. Other times I lie so still I appear to be sleeping, because if I move, the pain intensifies, the room spins and I will vomit. I could be in agony but trying to use deep breathing and meditation to cope so by outward appearances it seems that I am calm and relaxed but inside I feel like my skull is being ripped apart. It's heartbreaking when someone doesn't believe you. My worst fear is being in horrible pain and no one will help me. Sadly, it happens far too often.

Thank you for this article!

[K9lover, ASN, RN]

I assure you, addicts know we are judged harshly, we are not stupid although perception seems to be given healthcare providers make certain their disdain is obvious. I have been clean and sober since 1989, no opiates and, except for one time, I never went to a hospital for anything just for this reason.

Ended up in an ER once; the doctor hated addicts as did nurse; they really wanted me to know this; I never would have gone to a hospital for help of any sort for this reason. Congratulations, your message gets across.

[Nurse SMS, MSN, RN]

First, it is a classical example of not ADDICTION, but ABUSE (i.e. using substance with a purpose other than assumed therapeutic action). Second, you have no idea what this elderly lady occupies herself once out of acute care. Plenty of them sit forewer in their PCP offices or shop around in search of more scripts.

It was a story. I know what she told me and I believed her. I did not call her an addict OR an abuser. Her printout from the pharmacy listed no narcs. Texas has a centralized system to check if people are prescription shopping. Is it perfect? No. However, I had no reason to doubt this woman.

It will not take you looking far into my posting history to see that I am a big proponent of caring for the marginalized and protecting the right of addicts to get good pain control, as all of us should be. It was a story. End of story.

[russianbear]

Why would you need to question a legitimate order? I am assuming it would be because you are trying to imprint your own feelings/agenda on to it. Personal bias and judgment are not reasons to question an order.

How many people do you know personally who have died because of an epidemic that we play a role in? How high are your deductibles and premiums because of waste? If it affects me, I'll speak up, thank you.

[russianbear]

Under what parameters are you questioning the order? Is the patient somnolent, delirious, bradypneic? Or do you just not think the patient has enough pain to warrant getting an ordered dose?

I'll give you an example. I can think of several patients who, the moment the attending sees their name puts in various orders for controlled substances before even knowing why the patient is there. That's how littl of a f*ck some people give about the problem we've caused. So I ask you, just because it's John Doe, we automatically order Dilaudid and Percocet. What is the medical justification for that? Is that prudent?

Every now and then we get seekers in who don't know we have access to records of other hospitals in our system. The providers rarely check that prior to ordering Dilaudid. Not so they ever check OARS reports. However, when we let the provider know that the patient was in a different hospital the day before exhibiting seeking behaviors, the providers do cancel narc orders.

[russianbear]

It was a story. I know what she told me and I believed her. I did not call her an addict OR an abuser. Her printout from the pharmacy listed no narcs. Texas has a centralized system to check if people are prescription shopping. Is it perfect? No. However, I had no reason to doubt this woman.

It will not take you looking far into my posting history to see that I am a big proponent of caring for the marginalized and protecting the right of addicts to get good pain control, as all of us should be. It was a story. End of story.

The problem this debate always brings up is hat the people on the side of never question narc orders and requests by patients fail to distinguish between cases where pain is legitimate vs seekers. I've never heard anyone advocate for holding meds nor questioning administering pin meds to post op patients, patients with cancer, trauma, etc. The animosity comes from the people who come to he ER with vague complaints, not verified by diagnostics, and yell and scream and threaten until they get what they want and do this frequently because they know eventually the docs will give in as opposed to telling them they will not prescribe them controlled substances th do not have a need for.

[BostonFNP, APRN]

I'll give you an example. I can think of several patients who, the moment the attending sees their name puts in various orders for controlled substances before even knowing why the patient is there. So I ask you, just because it's John Doe, we automatically order Dilaudid and Percocet. What is the medical justification for that? Is that prudent?

That's a really complex issue, why is John Doe being admitted and/or what is John Doe's history? To be honest, I don't know many providers that just order inappropriate narcotics, especially for those that are labeled as frequent flyers or seekers. I have a few patients that have addiction issues that I admit on a monthly basis or so and those are the ones I am the most stringent with, as I know their history. I would be very surprised if narcs were being ordered without some sort of medical justification. That is malpractice and unethical.

That's how littl of a f*ck some people give about the problem we've caused.

I see the ravages of the opioid-abuse crisis every day in clinic: it is one of the most difficult parts of my job. That being said, I still believe that all patients deserve to have access to a standard of care following major surgery. I also believe that the acute care setting is not the place to "cure" addiction.

[russianbear]

That's a really complex issue, why is John Doe being admitted and/or what is John Doe's history? To be honest, I don't know many providers that just order inappropriate narcotics, especially for those that are labeled as frequent flyers or seekers. I have a few patients that have addiction issues that I admit on a monthly basis or so and those are the ones I am the most stringent with, as I know their history. I would be very surprised if narcs were being ordered without some sort of medical justification. That is malpractice and unethical.

I see the ravages of the opioid-abuse crisis every day in clinic: it is one of the most difficult parts of my job. That being said, I still believe that all patients deserve to have access to a standard of care following major surgery. I also believe that the acute care setting is not the place to "cure" addiction.

Again, I am trying to distinguish between people with medical issues versus those who do not.

[heron, ASN, RN]

Again, I am trying to distinguish between people with medical issues versus those who do not.

So, how do you deal with people who have both medical and addiction issues? This is the point that PPs are trying to make, I think. It's not a strict either/or algorithm. Which issue gets prioritized?

[BostonFNP, APRN]

Again, I am trying to distinguish between people with medical issues versus those who do not.

If you have the education, experience, facility privileges, and scope to determine that it's a different argument than not giving a post-op patient pain medication as the attending nurse because you personally feel the patient should get it (for whatever reason).