An Open Letter to the Opiate Epidemic: One Nurse's Stance
As many of you are aware of, the push for nurse's to treat a patient's pain completely and entirely, until their subjective rating is zero-nilch-none, has led me to feel frustrated and terrified at how my actions are initiating or exacerbating a patient's dependence on opiates.
I want to explain to you, my reader... a very real, uncensored example of what goes on inside a nurse's head during a 12 hour shift related to pain management. Some of you may not agree or appreciate my depiction, however it is the honest truth and the truth must be told.
Within the past year, I can say without a doubt that I administer a considerably higher volume of pain medications in stronger doses than ever before. Employers expect me to manage a patient's pain so precisely, that most of my time in a 12 hour shift is spent arranging, explaining, and dispersing pain regimens. Yes, patients are comfortable both physically and emotionally, but the comfort is short lived, only to wake up after an opiate-induced nap to their fingers hitting the call bell for another dose. Here's how the process usually goes:
1. I bring them their next dose, most of the time early because it is easier and less stressful for both myself and the patient to treat their pain right away, than to stall or explain why I can't give them their medication early. This usually results in a salty relationship going forward and I desperately need to preserve the trust I've worked so hard to establish with them. I get a warning sign on the MAR that alerts me that I'm giving the med too early- sometimes only 15 or 30 mins early but nonetheless, early. I ignore this warning and proceed, and my patient is relieved to hear me opening the package and hearing the pill drop into the flimsy plastic cup that I pass their way. Relief is coming to them and I'm the one to provide it. I get a bit of satisfaction myself because I know they will be happy with me.
2. Then, I am expected to walk over to the white board write the time I gave the medication and approximately (to the minute) that the next dose is due. By doing this, it looks like the narcotic is scheduled and even though I explain what PRN means, often times the lingo is misinterpreted as "due." I write the name of the medication, usually the strongest one on the MAR, often ignoring the option of tylenol because I anticipate that the patient will be more interested in the stronger medication that produces both a pain relieving and emotionally soothing effect. Most of the time, I am correct.
3. I carry on with my day, alternating between 5 rooms, usually 3/5 patients are on clock work pain medication schedules. I offer non-pharmacologic options, and patients are grateful for this option and at times take me up on the alternatives, but most of the time they prefer to take a pill or an IV injection. I know they are in pain, and although I cannot perceive their pain objectively, I try to imagine that what I'm doing is helping. I also feel relieved that I can offer them a quick fix because my phone is ringing and I'm already being called to the next task or request.
4. Every now and then, I have a patient that does not want narcotics, and insists on either nothing or simply tylenol. Surprisingly, tylenol is very effective for them because their pain receptors have not yet succumb to a toxic relationship with opiates. However, I usually to push them to take something stronger so that I can bypass the tylenol not working, which then results in calling for an order for stronger medications. If the tylenol doesn't work and the patient is still in pain, they will mostly likely not want to do much and will opt for little movement or activity, making their underlying problems worse. Knowing this, I push harder and eventually they cave.
THIS is the robot I've become. As a nurse, I have completely lost sight of how pushing opiates on my patients will effect them long term when they leave. Some are already dependent, but for most I am setting them up for failure. Most patients do not understand how to take medications properly, nor do they care. Some patients DO CARE, and they fear getting addicted, however we lie, telling them that if they take narcotics properly and wean off slowly, they will not get addicted. We cater to this. We want them to complain less, relax more, call less.
What I am most irritated about is the push from hospital organizations for nurses to manage pain perfectly. Do I think that displaying an addictive (not potentially... it is addictive) medication on a white board for my patient to stare at while they sit in their room all day, fixating on their pain and the next dose is in the "best interest of the patient?" No. I don't.
From here on out, I will no longer display the next dose due for narcotics on the white board. I will continue to properly assess for pain, listen to my patient's physical and emotional needs, and make them as comfortable as possible. However, my PRIMARY goal is to give my patient the tools to go back out into the world and heal themselves, and by pushing pain medications on them... I am creating more problems than I am helping.
If healthcare organizations care more about patient -centered care than they do about reimbursement (which they claim), then nurses need to speak up about the urgency of investing in alternative therapies, such as on- site reiki, acupuncture, and massage therapy. Volunteer services can also help buy providing more music therapy, singing, pets, and activities that patients can do while they sit in their hospital rooms, such as adult coloring books or offering books on tape. Doctors and nurses can also be more transparent when they suspect addictive behaviors by suggesting or offering rehabilitation therapies at discharge, and practice speaking to patients in a nonjudgmental way so that they can open up about their struggles.
I believe, ethically, the my role as a nurse is constantly shifting and changing with the tides of time, and right now time is telling me to stand up against the opiate epidemic and no longer contribute to it. I don't think that my role is to rehabilitate those who're addicted. However, I believe that as a nurse I still have a choice, and my choice is to contribute to the greater good of the community as a whole, as well as make the biggest impact on my individual patients within the 12 hours I have with them. I believe my stance to be evidence-based, and coincides with my personal philosophy of nursing.
According to the American Society of Addictive Medicine, prescription pain medication overdose deaths have increased by 400% since 2000. It is 2016 and there are no signs of it slowing down. Most people have either battled dependence on opiates themselves, or know someone close to them that are struggling with addiction. It will be a powerful statement if nurse's take a stand against this controllable epidemic.
This is my stance. What is yours?