I've started working prn at a new hospital in a different county from my previous job. At my full time job (a med surg floor) we see our share of drug seekers. We may have one drug seeker as a patient every few shifts. They almost always have another underlying medical problem. But at my new job the amount of drug seekers is absolutely ridiculous. I will have 1-2 drug seeking patients every shift. And yes they usually have underlying medical problems. But seriously 8mg of morphine and 25mg of phenergan IV every 3 hours for a patient with DM? Where is your pain? Your abdomen? Well you're eating soup and drinking coffee so it must not be too bad. I guess because this hospital is the only hospital in that particular area we see more drug seekers than my other job. At my full time job the hospital is 1 of 2 major hospitals in that particular county.
I have never given narcotics like I am having to give at my new job. I have patients who are getting Morphine 4mg IV every 2 hours for SBO and this has been going on for over a week!! And you wonder why your bowels haven't started moving????? I had a patient 2 nights ago call for her morphine and phenergan and when I got down to her room she was snoring!! Then when she woke up 2 hours later she was furious that I didn't give her the medicine while she was sleeping?
These people aren't fooling me? How do they fool their doctors so easily? Or do their doctors just not care? The same people come into the hospital over and over every few weeks with the same issues and spend their entire admission higher than a kite. I know addiction is a disease but when doctors are enabling the disease they surely won't get better!!!
And the truely scary part is this hospital is full of new grads... These new grads don't even blink an eye about giving large amounts of narcs over and over every 2 hours.... This is a serious accident waiting to happen......
I hope so, but I did get off on a bit of a tangent, sorry! The problem remains how do we as nurses provide quality care under these circumstances. I do believe the pt. I was talking about in my previous post has pain, but I think it could be better managed by other means...I think we are creating a situation where he has become dependent on the medications. 20mg of hydrocodone in 5 hours is a hefty dose, and I see the guy swinging his legs that are "off the charts" in pain around, meanwhile he falls asleep when I tell him I can't give him anything but an ice pack or the aquaK until 4am, and then he falls back asleep and gets mad when I didn't wake him up.
This is an issue I struggle with, I have chronic pain r/t tendonopathy in my right foot. I take upwards of 400mg of tramadol a day, depending on where I'm working and how much I'm working.
here we go
Edit: we are talking about drug addicts/seekers here... not talking about people who are really in pain?
when i was in active addiction, i would take 300 mg morphine SQ 3-4 times a day. with my tolerance, i dread the day i have to have some sort of pain meds. you guys will think i'm the biggest drug seeker in the world when i tell you that 8 mg morphine wouldnt work on me.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
it is easier than treating the underlying mental condition
Not that that makes it right, but it is easier
Unfortunate, but right. We have chronic painers come for surgery all the time. Once, I had someone on a double digit dose of Morphine. Per hour. We're talking a lot of Morphine PER HOUR. , not 10 plus, not 15, plus, not just 20, but MORE....and this is not someone in palliative/nor hospice care.....this is HOW THEY LIVE...
Do you really think I (recovery room) can fix their issues that quick? I don't try. That's for a different speciality at a different time.
Specializes in Emergency Dept. Trauma. Pediatrics.
It's funny, I am in school just my first semester, in Fundamentals we are taught that pain is the 5th Vital Sign (I know it's a huge debate on this board) and pain is whatever the patient says it is and so on.
So we have this Multi Cultural group project to do and my group pics Incarceration, the nurses and the prisoners. So we meet with the lady in charge of the medical staff and stuff at the Jail for an interview and then I shadow a med nurse on the high risk inmate ward for a night.
One of the firs things this administrator told is "So in school you are taught that pain is whatever the patient said it is right?" We all said yes. She goes on; "Well in here pain is whatever they can prove. You are throwing up, prove it, you have diarrhea, don't flush so I can see, female is complaining of bleeding through a bad every hour, you better be saving the pads"
It is such a completely different style of nursing. Where hospitals everything is subjective but in the prison it's all objective.
Obviously though a lot of times pain is hard to prove, although I do have to wonder sometimes. I know someone that is always talking about having a bad migraine while on their computer. yet I know when I get a really bad migraine I need to be in a dark room with no sound just to try and help ease the pain, I can't be on the computer with a severe migraine. Usually when someone is in severe pain they aren't doing normal activities without a problem.
None the less though pain is not always easy to prove so we can't just take on the Jailhouse mentality. You would think though that their would be a balance somewhere to stop the cycle of over medicating that this era has come accustomed to.
But seriously 8mg of morphine and 25mg of phenergan IV every 3 hours for a patient with DM? Where is your pain? Your abdomen? Well you're eating soup and drinking coffee so it must not be too bad.
As many as 75% of patients visiting diabetes clinics will report significant GI symptoms. The entire GI tract can be affected by diabetes from the oral cavity and esophagus to the large bowel and anorectal region. Thus, the symptom complex that may be experienced can vary widely. Common complaints may include dysphagia, early satiety, reflux, constipation, abdominal pain, nausea, vomiting, and diarrhea. Many patients go undiagnosed and under-treated because the GI tract has not been traditionally associated with diabetes and its complications.
I have patients who are getting Morphine 4mg IV every 2 hours for SBO and this has been going on for over a week!!
How does one fake a SBO? (Since the implication is that the drug seekers are somehow faking to get narcs).
I am neither the narcotic or pain police, and I don't even try to be. It is a useless fight.
My only complaint with the docs is DO NOT write Q1hr PRN pain meds. That is a waste of my time. I don't have the time to assess for pain and draw up the meds Q1hr. If someone needs Q1hr pain meds, they NEED a PCA.
I could better use my time helping other patient's who really need help. Helping my fellow nurses who really need my help.
I don't really need to be courting a drug seeker in order to get a good Press-Gainey score. Get him a PCA and I will monitor his vitals as I would in any case.
I think that as nurses we have an obligation to perform a pain assessment that takes the patient's medical history, current condition, the patient's report of the quality, location, and intensity of their pain, as well as their response to any interventions into account. To blindly accept the patient's report of pain without such an assessment and just give whatever is ordered because "pain is what the person experiencing it says it is and exists when they say it exists" is just as irresponsible as labeling a patient a "drug seeker" simply because we don't believe their report of pain.
The fact is, drug seekers do exist. There are people who work the system and manipulate health care providers in order to abuse prescription narcotics. Many of these people *do* have chronic medical conditions that cause pain, but they exploit this in order to receive more pain medication than they really need in order to control their pain, or inappropriate medications for their particular type of pain, and it is doing them no service to just hand out whatever they ask for because you don't want to rock the boat. This is completely different from pseudoaddiction, which is a result of poorly managed pain, and causes the person to behave in ways that are easy to interpret as "drug seeking". I find the trend of turning a blind eye to the drug seeking phenomenon and denying its existence just as offensive as labeling pain sufferers as drug seekers unjustly.
I don't think physicians are as easily manipulated as it would seem. If the person is diagnosed with a medical condition that is reasonable to expect would cause moderate to severe pain, then it is appropriate to prescribe narcotic analgesics. If the person has a history of chronic pain treated with narcotic analgesics, then it's reasonable to assume that they may have a tolerance to these medications, and larger doses will be needed. A patient may indeed be an addict, but that does not mean they don't have pain.
I think making pain control the topic of conversation between the nurse and the patient should be a priority. Talk to them about the most effective pain control strategy, let them know when you will able to assess their pain and intervene next, communicate clearly what you are able to do for them and what you are not able to do, and for Pete's sake, follow through. One of the most important aspects of my pain control conversations, especially with those suffering from acute pain (because folks with chronic pain already know this) is the fact that it may not be possible to get their pain level down to a 0/10 without killing them. So, to set a reasonable pain goal, like cutting their current pain level in half (if they're at a 7, shoot for a 3-4, for example). Try to get them on board and recruit them as active participants in this process. Make sure to let them know that it is not possible for you to be there at exactly the time their next dose is due, because of the nature of the work flow in the hospital, but that you will be by to assess their pain in a reasonable time frame.
The reason doctors write PRNs or sliding scale doses is to allow nurses to use our judgment. We certainly are not obligated to give any patient the maximum amount of drugs they can have if our pain assessments do not indicate it. We are where the rubber hits the road, and it is within our area of responsibility to be judicious in the choices we make regarding the administration of PRNs.
Some patients do not want to be conscious at all. If they are able to speak, they will request pain meds, even if their RR is 6 and they're nodding off and snoring.
Over all, it's critical to document your observations and interventions meticulously. For example, "C/O lower back pain "20/10", states pain "cramping". Resting quietly with eyes closed, RR 10, SaO2 99% on RA, snoring and appears to be dozing. APAP, warm and cold compresses, repositioning offered and refused. Left resting quietly with bed alarm set and call bell within reach."
My goal is never to leave someone in pain unnecessarily, and obviously if the patient's pain is not well controlled with whatever the doctor has ordered, then the doctor needs to be contacted and notified. But we are under no obligation to just dole out whatever the patient asks for without using our brains and thinking through whether it is indicated or not.
Oh, and I can't stand when you ask the person to rate their pain on the 0-10 scale and they say "15" or "20". That's not how it works! 10 is the maximum amount of pain you can have, it is life threatening pain that completely debilitates you.
hey guys, i didnt mean to sound like i was saying anything negative with my post about myself earilier in the thread. i actually meant to say it in a light hearted, amusing tone. while reading the thread i just got tickled at myself thinking "omg im doomed if i ever have to have real pain meds, they will think im nuts" type thoughts. anyhoo...it came out wrong.
but i would like to talk about the subject. i realize this is a vent thread and im NOT trying to come here and preach cuz God knows i hate that when someone does it on my vent thread.
i would just like to tell you about my first husband. he had porphyria. he also had long hair and tattoos. he lived with chronic pain from the nerve damage. the only time he could escape was when he was asleep. so many times i saw him call out for prn meds then fall asleep. many times i saw nurses come in the room, see him sleeping, and refuse to give him the meds. he lived with the chronic pain so much that by looking at him, you wouldnt know he was in horrible pain unless you really knew him. he also didnt want the nurses to see him "whine" so he would put on a face for them. (it's not manly was his thinking). when at home, he was on constant IVs and IV pain meds. we had a fridge stocked of morphine for him (and thus where i got my drugs). when he had been diagnosed only a couple years, his doc tried him on methadone for the pain. it worked really well with him. (this was a long time before he was on IV meds constantly). he was on a large dose. his doc was trying everything with him to see what worked and all the while trying to keep him on the least amount of meds possible because dependence/addiction was inevitable with his diagnosis. once she started him on the methadone, he was immediately labeled a drug seeker by the nurses. for 10 years he went to that hospital, and for 10 years...despite many trips to ICU on a vent from the porphyria, despite seeing how his condition declined over the years, despite his doc trying to educate the nursing staff AND the other docs about porphyria...he was ALWAYS labeled a drug seeker by them all.
again, im NOT preaching. i just wanted to share what i learned while sitting at his bedside. (i was not a nurse then).
i saw the shame he felt because he knew what they thought of him. it made every hospitalization horrible for him.
i guess what i wanted to say was because of this experience, i try to try to put myself in my patient's shoes when i feel they are drug seeking because of watching how he lived with chronic pain all those years. people with chronic pain still have to live. so they do things that most of us couldnt imagine. even when in a lot of pain, they can still eat, sleep, do normal things we take for granted.
had the nurses trusted his doctor that she knew what she was doing with him because she was the only doc in our town that understood his disease, had they just researched his disease or educated themselves on chronic pain, had they cut her and my husband some slack instead of fighting them both on all fronts, it would have cause him so much less mental anguish and shame.
i try to remember all this when ive got a drug seeking patient. if the doc orders it, i just give it. ive learned its not my job to police their morality, it's my job to make sure they arent in pain if i can.
ok..im done. just ignore me, lol. im sorry i posted all this on a vent thread. yall know how i am tho, if i dont say it when i think it...i'll forget what i wanted to say later, lol.
How does one fake a SBO? (Since the implication is that the drug seekers are somehow faking to get narcs).
Oh come on... I never said he was faking a SBO? I said the morphine wasn't going to help his GI motility.....
Some of y'all are really ridiculous. This is my VENT thread and if you don't like it please leave.
And I am not this horrible nurse most of you are probably picturing. I medicate my patients as ordered and I show them compassion. I just started this thread to show my frustration at how some patients are so easily able to manipulate their physician into ordering absurd doses of meds while they are in the hospital. If you work on the floor then you all know what I mean.
I'm not directing this towards you Southernbee... I thought that was an excellent post.
And for those that might imply it isn't the nurse place or the doctors place to question if someone is truly in pain or not....I know the teaching pain is what the pt says it is....but doctors have been sued for "getting" people hooked on narcs. And like if or not we are in a very drug manipulated world.
when i was in active addiction, i would take 300 mg morphine SQ 3-4 times a day. with my tolerance, i dread the day i have to have some sort of pain meds. you guys will think i'm the biggest drug seeker in the world when i tell you that 8 mg morphine wouldnt work on me.
Thank you for adding your insight. I did not think that a tolerance is somethig that lasts once the person is clean for a period of time though. How do you know that 8mg of morphine won't work on you? I'd also discuss it with your team and see if there isn't a better choice for someone with your history.
With regard to the OP, you do have to be careful if they are withdrawing from something like ETOH than can be life threatening. Of course they know this and will milk it. I normally just give them what want to shut them up and keep my milieu safe. Sorry if that sounds lame but its the practical thing to do on a psych floor most times. My biggest issue with drug addicts is that they have absolutely no tolerance for any type of discomfort at all. For Pete's sake, life itself is uncomfortable folks! :angryfire
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SunnyAndrsn
561 Posts
I hope so, but I did get off on a bit of a tangent, sorry! The problem remains how do we as nurses provide quality care under these circumstances. I do believe the pt. I was talking about in my previous post has pain, but I think it could be better managed by other means...I think we are creating a situation where he has become dependent on the medications. 20mg of hydrocodone in 5 hours is a hefty dose, and I see the guy swinging his legs that are "off the charts" in pain around, meanwhile he falls asleep when I tell him I can't give him anything but an ice pack or the aquaK until 4am, and then he falls back asleep and gets mad when I didn't wake him up.
This is an issue I struggle with, I have chronic pain r/t tendonopathy in my right foot. I take upwards of 400mg of tramadol a day, depending on where I'm working and how much I'm working.