I have a very good friend who is a nurse who recenty admitted to me that the reason s/he "dropped off the face of the Earth," was s/he had an addiction problem. This person is on the road to recovery and offerred to write about what occurred. Interestingly, over the years, I have come across many healthcare workers in EMS with addictive problems. Some with alcohol, some with other substances. Regardless – please read and share comments. This clearly is an important topic to discuss
Creating and Maintaining Drug Addictions in the EMS/ED Setting
Addiction and associated drug-seeking behaviors have reached, to use a cliché, epidemic proportions. The sad thing is that patient satisfaction surveys, patient “rights”, and lack of support from administrators when confronting behaviors has contributed to this problem far more than the addicts themselves. In days gone past, we had our heroin junkies, our pot smokers, and our valium-grandmas; these patients we could see coming from a mile away. Today’s addicts come from all walks/occupations, all age groups, and are less easily identified than in the past. They can be lawyers, hamburger-flippers, homemakers, mechanics, car salesmen; or in my case, an ER nurse.
No one was more surprised than I was the day I entered rehab for opioid dependence. An experienced ED nurse of 15 years, with a great reputation as a leader, teacher, mentor; I was a junkie. Popping or snorting oxycodone or shooting up dilaudid was my daily routine, in between taking care of patients. But as with all addicts, I could rationalize, minimize, or bullshit my was out of any situation. Until I hit the bottom. I tell this not for sympathy, understanding, or shock value; but to underscore my understanding of these addicts which I always hated taking care of. After all, they were taking up my time, lying to me and expecting be to believe their pain scores, and generally being a waste of space.
Our role in the problem is creating the addict, maintaining the addict, then condemning the addict. First we create them. Unlike the days of gateway drugs leading to heroin, today we prescribe Percocet and oxycontin for pain. Legitimate drugs for legitimate reasons, we keep giving these meds and keep writing the refills… Then one day the patient tries to cut down or stop and get “dope-sick”, a horrible withdraw constellation of pain, anxiety, cramps, shakes, nausea, and feeling of impending doom. All these go away as soon as another “oxy 30” hits the GI tract.
When I was in rehab, I met many addicts, some as young as 19, who were addicted to narcotics secondary to a back injury, a surgery, or other legitimate illness/injury. It would be impossible for me to count the number of prescriptions for percocet, vicodin, oxycontin that I handed over for a sprained ankle, broken finger, or even a peritonsilar abscess. Imagine how many more are given upon discharge from an inpatient setting after injury or surgery. Oxycontin is so powerful and addictive that one 21 year old addict that I spoke with turned to heroin after his doctor cut him off from oxycontin, if given the choice between IV heroin or snorting an oxy 30 would take the oxy every time. Heroin was what he turned to when he couldn’t get his drug of choice. Imagine that; heroin is second best to a pill.
The second problem is maintaining the addict. We’ve all gotten calls for patients with intractable back pain who can’t drive to the hospital, after they’ve run out of their narcotics. So we roll our eyes, load them on the litter, and dump “another drug-seeker” into the ED. Then the ED doc, who knows that his paycheck is based, at least in part, on his “patient satisfaction scores, is torn between giving a shot of dilaudid and a script for “enough narcotics until you can see your doc”, and dealing with a negative patient survey than translates to less dollars in his/her paycheck. Add to this a crazy busy night in the ED, overloaded, and its often just easier to give them what they want and get them out of the ED “so we can take care of real patients”.
If we call the patients on their drug-seeking behavior, then we’re called to the carpet from a director, a manager, or a charge nurse who quotes something from an ancient text; “Pain is subjective, it’s whatever the patient says it is..”. After all, the ED/EMS setting is a business, and “we have to keep the customers happy”. I’m guilty of this myself. Many times I’ve told a doc “Look, this morons is just drug-seeking, but causing all kinds of ruckus. He’s tying up two of my nurses, the tech, and three security guards, and I just got a call from the ‘patient advocate’. And there’s thirty patients in the waiting room to come back. Can you just write for whatever he wants so I can empty the bed and get back to the patients who are really sick? Please…”
Then we condemn them. I’m as guilty of this as anyone, perhaps more so. Addiction is a disease, right? What a load of crap! It’s just a lack of willpower or some loser who wants a free high. Or they come in to get into detox and rehab, perhaps legitimately wanting help or just making their parole office or family happy, and we let them sit for hours, in pain, while waiting for social services to find a bed for them at some rehab facility. To keep them comfortable, we “might” give them 1mg PO ativan and some zofran. Then we wonder, after sitting for eight hours in withdraw, the sign out AMA while yelling “you people don’t want to do anything for me”. I sat in the intake office at a detox for five hours while waiting for insurance to clear, in full blown withdraw, and believe me it was not fun. Only the thought of permanently losing my nursing license and fear of my wife kept me there.
Why don’t we treat the withdraw while waiting for placement? If someone is withdrawing from narcotics, who are we not giving them narcotics? Detox centers use a tapering program of Subutex to bring patients down over a period of three to five days. Patients are using upwards of 240mg of oxycontin a day or 4-10 bags of heroin, yet we thing nothing of giving them a little ativan and zofran, thinking that will keep them quiet until we can get them placed. Are we withholding the narcotics to punish them? Would we withhold D50 from a diabetic whose blood sugar was 20? Are we not withholding medical treatment?
So what is the answer? If I knew that, I’d be heading up the presidential council on drug addiction, rather than going to Cocaine, narcotics, and alcoholics anonymous. Perhaps, rather than condemning the addict, we need to look at our own behaviors and attitudes towards them. We created many of them, then we crush them and withhold care. Perhaps we need to worry less about patient satisfaction surveys driving our standards of practice, and more about the patient. While its true that “if we don’t give them what they want, they’ll just go somewhere else”, that can’t be our guiding principle. If a patient wanted another medication, say a cardiac med that they heard was good, would we give it to keep the patient satisfied?
Somehow, and I’m still trying to figure out how, I crossed the line from social drinker and occasional Percocet user for back pain to a full-time junkie, shooting up between patients in the bathroom. Yet still able to provide care for the most critically ill patient. Only through the grace of God did I not harm anyone other than myself. I’ve reached the bottom of a hell that I wouldn’t wish on anyone (other than a nursing administrator or two). But if there is a good side to this addiction of mine, I’m becoming a better person than I was before; less selfish, self-centered, grandiose and ill-tempered. And when the state decides it’s time for me to begin practicing as an ED nurse again, I’ll have a very different perspective for this unique group of patients who can be very challenging to care for. Perhaps God made me an addict to allow me to care for other addicts. Stranger things have happened.