Have you seen this video posted on KevinMD this month about drug seekers in the emergency department (ED)?  Take a look at this 4:31 video made by an ED physician.  Spoiler alert! If you love Taylor Swift, you will totes love this.

 Disclaimer:  If you are someone who does not manipulate physicians and nurses to obtain narcotics, then this video does not apply to you.  This video is referring to people that are not in physical pain; they are addicted and will do anything to obtain these substances.

This satirical video discusses the epidemic in America of prescription drug abuse.  As a bedside nurse, many have attempted to manipulate me into receiving copious amounts of pain medication.  Conversely, I have also advocated many times for appropriate pain relief.  There are definitely two sides to this issue.  Regardless of the situation, opioid pain medication abuse is truly an epidemic in America and we, as nurses, are on the front lines.

After reading the comments on the video, I realized that people in society don’t see what we, as health care providers, see every single shift.  Most people don’t see or realize how many people really are addicted to these medications.  However, those of us that work in a hospital and administer medications see it all the time.  The scenario discussed in the video (the man back in the same ED again, saying he lost his pills even though he was prescribed many recently or that they only lasted a day, requesting medications by their street name) happens many times in the emergency department every single day.  It happens in the clinics.  It happens in nursing units.  It happens everywhere, all the time.

Every day 46 people die from an overdose of prescription pain killers in the United States

The Center for Disease Control discusses this issue in depth here.  Take a look at this graphic…

for every single person that dies from an overdose, there are 825 people that use narcotics who are not using them for their intended purpose, and 130 people that are abusing the substances/are dependent.  

WHOA.  That is an insane number.

So, as health care providers we’re stuck between a rock and a hard place.  You cannot believe every single person – otherwise, the death tolls from overdoses would skyrocket (even more so).  But you also can’t NOT believe everyone either, because many people are truly suffering and need pain relief.  Desperately.

It’s hard because as the nurse you feel like you can’t win.  You either believe everyone or you believe no one – it’s so hard to discern who truly needs it and who is lying to your face.

Just give ’em what they want

I know what some of you may be thinking, “why can’t you just give them pain meds when they want it?  Is it that big of a deal?”  Yes.  It is a huge deal, guys.  The type and amount that people request by name are astonishing.

Patients know which medications and which doses to request specifically.  Some will claim they are allergic to all pain medications except the heavy hitters and claim they need high doses to feel any relief at all.  Some will say oral pain medication won’t do and demand IV pain medication until the physician says they can go home and suddenly Norco will do just fine.  People know what to say and how to say it so that you’re left with no other option but the most potent pain medication in the highest allowable dose.

Additionally, these medications are no joke.  They are chemically very similar to highly addictive street drugs.  For example, we give a medication called Fentanyl frequently in intensive care.  It provides great pain relief for those in severe acute pain (think multiple broken bones after a car accident with a breathing tube), during bedside tracheostomy placements, for managing chronic severe cancer-related pain, or with hospice patients, but not appropriate for many other scenarios.  The Institute for Drug Abuse noted that “Like heroin, morphine, and other opioid drugs, fentanyl works by binding to the body’s opiate receptors, highly concentrated in areas of the brain that control pain and emotions. When opiate drugs bind to these receptors, they can drive up dopamine levels in the brain’s reward areas, producing a state of euphoria and relaxation” (2012).  It causes people to relax so much that causes respiratory depression.  Your respiratory drive can be so suppressed that you just stop breathing.  And you die.

Also, did you note that they compared it to heroin?  Heroin, guys.  Heroin.

We would be negligent health care providers if we pretended this wasn’t a problem and just continued to give a script to everyone claiming they needed one.  People are literally dying because of this.

Here’s another phenomenal article was written by a physician that explains this epidemic in a really black and white, evidence-based sorta way.

Why does this happen?

A few years ago, a nurse from the United Kingdom was shadowing our unit.  I was curious about her thoughts on socialized medicine and our health care system in America, so I asked what she thought about working as a nurse in both systems.  Her response surprised me, as we weren’t talking about pain medication at all.  She said, “when I got to America and started working, I was absolutely astounded at how much IV pain medication is given.  In the UK, patients never get IV pain medication, everything is oral, and rarely are narcotics prescribed.  I just couldn’t believe it.”

Needless to say, that’s not what I expected her to say.  I just assumed that everyone, everywhere, administered pain medication this way.  I had no idea people handled pain differently outside of America.

So, why does this happen?  Why America? Why us?

An interesting thing to consider is the influence of the Press Ganey Patient Satisfaction survey.  These are surveys given to patients after their visit to a medical facility.  In most facilities, an aspect of reimbursement from the government is based on patient satisfaction.  So, if your patients are happy, you get reimbursed for the care you provided (this applies to physicians and nurse practitioners/physician assistants, and hospitals as a whole, not nurses individually).  Keep in mind, this is just an aspect of reimbursement.

So the scenario is that a patient comes to a medical facility with their mind made up on what they need.  They think they need an antibiotic for the minor viral illness from which they’re suffering.  Or they decide they need 2 mg IV morphine for their sprained ankle and a Percocet script for the road.  And if they don’t get what they’ve decided they wanted, even though it is not medically appropriate, they will fill out a negative Press Ganey survey after their visit.  The hospital is then not fully reimbursed for this visit and therefore suffers financially.  Physicians are encouraged to increase their Press Ganey scores.. but how does one go about doing that exactly?

Now, I’m not saying that these surveys are the direct cause of this epidemic in America, but it is definitely something to consider.

Here’s an article entitled I’m Addicted to Prescribing Pain Medications, written by a physician experiencing this stressor.  And here’s another article written by a physician called Why Patient Satisfaction Surveys are Riddled With Problems, which explains surveys a little more in-depth.  And according to a 2014 article in Medical Economics, two US Senators are urging the Centers for Medicare and Medicaid (CMS) to investigate if Medicare’s patient satisfaction surveys are contributing to the abuse of prescription opioid pain relievers.

This is a very real and very serious issue that has not only resulted in deaths of epidemic proportions but it also negatively affects the physicians being pressured into prescribing and the nurses manipulated into administering these medications.

What about the nurses that are actually giving the medications?

In nursing school, you’re taught to believe everyone when they tell you they’re in pain.  And let me tell you, it’s not as easy and straightforward as it sounds.

It is truly stressful when you’re caring for an unstable patient and their family, and your other patient hits the call bell every 2 hours, on the dot, to remind you to bring in their 2 mg Dilaudid, 50 of Benadryl, and 25 of Phenergan, and to push it fast … all while their vital signs are stable, and they’re talking and laughing on the phone.  And this was after a standard procedure that typically has minimal pain and they have no medical history.  You ask them to rate their pain on a scale of 1-10, 10 being the worst pain in the world and they rate it a 12, as they yawn and send a few Snapchats.  You defer to the doctor, who then discontinues the medications.. and then it’s your job to tell the patient.. who is not happy and says the oral medications you give never work and they must have IV medication.  And they demand you call the doctor back.

You feel manipulated.  You feel tired.  And your other patient needs you.  You just don’t know what to do.

Let me tell you – nursing school did not prepare me to handle patients addicting to prescription pain medications.

How do you handle this?

So.. what do you do?  Have you ever been in a similar situation? What did you do?  What worked, what didn’t work?  And have you ever thought that you were being taken advantage of but you misjudged the situation and the patient actually was in pain?

How many of you actually gave the patient the ordered pain medications, only to get yelled at by the physician for over-medicating them?  Been there.  That was so defeating.  What a terrible bind to be in.

And to those of you that are not nurses in America – how do you handle pain management in your country?  Do you administer IV pain medications frequently or is that unheard of?

Again – I realize so many people are in real pain and I don’t want to take that away from anyone.  I want to use this post for nurses to talk about how they manage pain within this specific patient population and how they professionally and respectfully handle patients that repeatedly request/demand/pressure them into administering alarming amounts of pain medication.  

I am a nurse.  I want to care for the sick.  I want to alleviate suffering.  I want to emotionally support patients and their loved ones.  For those that are addicted, I want them to receive the specialized rehabilitation they so desperately need in the appropriate setting.  Not in the emergency room.  I don’t want to spend time arguing with someone demanding an unsafe amount of pain medication when I could be hugging the crying daughter whose mother is dying in the next room.

Note:  all sources that were cited contain links to the original article

Addendum:  Beth over at nursecode.com posted about this topic as well!  Here’s her article, which I think you may find helpful!