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?

[russianbear]

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).

Id love to work in the hospitals you people work in where you never get people in the ED with vague pains, not confirmed by any diagnostics, demanding IV dilaudid. Same people who test positive for opiates in them (often other drugs), are difficult to get an iV in due to track marks, and repeat this behavior with frequency. Must be nice.

[EaglesWings21, ASN, RN]

I would never treat my patient with disrespect for the simple fact that they are an addict. I know many addicts. My own father is an alcoholic and had a short opioid addiction after shoulder surgery. I do think that the way we treat pain is broken. The magic word for pain treatment is not always dilaudid and narcotics aren't always appropriate. It is disheartening when we try to use our knowledge to care for our patients the best way we know how only to be yelled at by the patients and frowned on my management because our HCAHPs weren't up to par.

[heron, ASN, RN]

Id love to work in the hospitals you people work in where you never get people in the ED with vague pains, not confirmed by any diagnostics, demanding IV dilaudid. Same people who test positive for opiates in them (often other drugs), are difficult to get an iV in due to track marks, and repeat this behavior with frequency. Must be nice.

Oh, please ... can the drama for a minute and try to understand that no one has claimed that addicts don't try to get over, especially in the ED. What we are tryng to explain is that righteous indignation, while lots of fun, is no excuse for sloppy, inappropriate care.

[russianbear]

Oh, please ... can the drama for a minute and try to understand that no one has claimed that addicts don't try to get over, especially in the ED. What we are tryng to explain is that righteous indignation, while lots of fun, is no excuse for sloppy, inappropriate care.

Please show me where I've advocated inappropriate care. I, however, do not agree that enabling addicts is appropriate care. If a person's sole purpose for here ER visit is to get high, and this really does happen, that is not a reason for admission, nor should he providers be prescribing narcotics for them. If they have medical problems, including pain, we treat that. I happen to come from an inner city ER where we do just that. Known seekers have care plans. It reduces a lot of BS.

[heron, ASN, RN]

Please show me where I've advocated inappropriate care. I, however, do not agree that enabling addicts is appropriate care. If a person's sole purpose for here ER visit is to get high, and this really does happen, that is not a reason for admission, nor should he providers be prescribing narcotics for them. If they have medical problems, including pain, we treat that. I happen to come from an inner city ER where we do just that. Known seekers have care plans. It reduces a lot of BS.

When you characterize any effort to place the issue of addiction into some kind of larger context of intertwined care issues as "enabling", then you are, indeed advocating for inappropriate care. Prioritizing the suppression of addiction behaviors over all other medical needs is sloppy and self-indulgent.

Showing the junkies who's boss is only the first step in dealing with the needs of addicted patients. We still have to treat their pregnancies, diabetes, heart disease, COPD, liver failure, DTs, HIV, broken bones, strokes, sickle cell, cancer and, yes, their pain. The ED, while it assuredly bears the brunt of system-gaming and outright seeking, is only one piece of the problem ... and not the largest piece by any means.

BTW, Boston City Hospital in the 70's and AIDS nursing in the 90's also provided plenty of experience with out of control addicts. That experience taught me that there is nothing simple about working with addicted people, whether active or in recovery.

[russianbear]

When you characterize any effort to place the issue of addiction into some kind of larger context of intertwined care issues as "enabling", then you are, indeed advocating for inappropriate care. Prioritizing the suppression of addiction behaviors over all other medical needs is sloppy and self-indulgent.

Showing the junkies who's boss is only the first step in dealing with the needs of addicted patients. We still have to treat their pregnancies, diabetes, heart disease, COPD, liver failure, DTs, HIV, broken bones, strokes, sickle cell, cancer and, yes, their pain. The ED, while it assuredly bears the brunt of system-gaming and outright seeking, is only one piece of the problem ... and not the largest piece by any means.

BTW, Boston City Hospital in the 70's and AIDS nursing in the 90's also provided plenty of experience with out of control addicts. That experience taught me that there is nothing simple about working with addicted people, whether active or in recovery.

So if a person comes in with the sole purpose of satisfying a craving for opium, and we give them that, if it's not enabling, what is it? I think if you examine the concept of enabling, and codependency, you'll see that it is. If a cocaine addict comes in sans medical problem, should we give them a dose of pure Colombian?

[BostonFNP, APRN]

So if a person comes in with the sole purpose of satisfying a craving for opium, and we give them that, if it's not enabling, what is it? I think if you examine the concept of enabling, and codependency, you'll see that it is. If a cocaine addict comes in sans medical problem, should we give them a dose of pure Colombian?

Self-reflective practice is a vital component to providing good care, at any level. Posts like this indicate a need for some serious self-reflection for all of us. Struggling to create a barely fathomable scenario to try and justify a reason for why it is "ok" to have a prejudiced approach should itself indicate there is a problem.

If nothing else, hopefully this thread has engaged everyone reflecting on how we individually approach patients that have been labelled "seekers". As said before, I don't think anyone likes feeling manipulated, and drug addicts by the nature of the disease attempt to manipulate members of the health care team.

[Nurse Beth, MSN]

Self-reflective practice is a vital component to providing good care, at any level.

If nothing else, hopefully this thread has engaged everyone reflecting on how we individually approach patients that have been labelled "seekers".

That was my goal in writing this.

[russianbear]

Self-reflective practice is a vital component to providing good care, at any level. Posts like this indicate a need for some serious self-reflection for all of us. Struggling to create a barely fathomable scenario to try and justify a reason for why it is "ok" to have a prejudiced approach should itself indicate there is a problem.

If nothing else, hopefully this thread has engaged everyone reflecting on how we individually approach patients that have been labelled "seekers". As said before, I don't think anyone likes feeling manipulated, and drug addicts by the nature of the disease attempt to manipulate members of the health care team.

I love the air of superiority in your posts. Like I said before, I'd love to work in your hospital where "seekers" do not exist.

[BostonFNP, APRN]

I love the air of superiority in your posts. Like I said before, I'd love to work in your hospital where "seekers" do not exist.

Save your ad hominems and discuss the topic, if you can't defend your position without personal attacks perhaps you are on the wrong side of the issue.

Seekers exist. They get appropriate care (as thy are humans after all, sick humans) regardless of their addiction, at least when I am the one admitting them. Or I do my best at least/hope.

[russianbear]

Save your ad hominems and discuss the topic, if you can't defend your position without personal attacks perhaps you are on the wrong side of the issue.

Seekers exist. They get appropriate care (as thy are humans after all, sick humans) regardless of their addiction, at least when I am the one admitting them. Or I do my best at least/hope.

I have defended my position admirably. I'm shocked one of you finally acknowledged the existence of drug seekers. Now, will you be courageous enough to say that physicians should not order them narcotics for the sole reason of feeding their addiction?

[MunoRN, RN]

I have defended my position admirably. I'm shocked one of you finally acknowledged the existence of drug seekers. Now, will you be courageous enough to say that physicians should not order them narcotics for the sole reason of feeding their addiction?

It doesn't appear that anyone ever argued that drug seekers don't exist or that it's fine for physicians to order opiates for the sole reason of 'feeding their addition'. Maybe you could specify where you feel that statement was made?