WORK/LIFE BALANCE FROM A MOM AND NURSE PRACTITIONER

5/2/16


I have wanted to write a post about prescription drug abuse, as it is such a real and worsening problem that I encounter on daily basis, however I felt challenged by the breadth of the problem. On twitter and other social media outlets, I often see posts from people in the medical field addressing this issue. This issue is tough to tackle, as it's so complex and there are so many driving factors behind this problem. This article I loved because it really dives into all the pieces behind the prescription drug abuse epidemic. Prescription drug abuse has been an epidemic for years, however only recently have policies and political awareness increased around this issue. The most commonly abused controlled substances I encounter are opioids (Norco, Percocet, Morphine) benzodiazepines (Klonipin, Ativan, and Xanax), and stimulants (Adderall, Zenzedi, Dexedrine). Working as a ER nurse I saw the worst-case scenarios prescription drug abuse, and it didn't take long to become completely jaded and fed up with the problem. Of course there were plenty of overdoses on opioids and sometimes benzodiazepines. So many times a patient would have run out of  narcotics prescribed by his primary care doctor or even pain management doctors, and in desperation turn to the ER to fill a prescription or get a IV dose of narcotics. These particular patients use sob story after sob story to get the medications they want. If the sympathy card didn't work the patients often resorted to temper tantrums, or at worse case scenario threats against the staff. I also saw people working in the medical field fall victim to prescription drug abuse. A coworker of mine in the ER died from a drug overdose, and another coworker of mine was caught stealing opioid narcotics from the medication dispenser. The access to these controlled substances makes nurses and doctors especially more susceptible to this type of abuse.


Although it is awful to see people in desperation as their physical dependence on prescription drugs worsens, as a ER nurse dealing treating drug-seeking patients was more of an annoyance than a concern. Taking care of a drug-seeking patient takes up precious time away from actual sick patients. Having to go withdraw morphine from the medication dispenser or pixus, find another nurse that wasn't busy with charting or patient care to cosign the drug, monitor the patient for adverse reaction, and then reassess the pain in another 15 minutes, takes a lot of time. Trying to tell a patient after receiving a dose of Morphine, they cannot have another dose and need to go home, also takes time and energy.
I was rarely concerned about administering high doses of IV narcotics to patients in the ER setting (which I did literally on a daily basis) mostly because the patient was in such a controlled situation to monitor heart rate, respiration and oxygenation status. If a patient was to go into respiratory depression, the reversal agents were readily available, as well as a crash cart, doctors, nurses and other trained staff. In the ER the indications for IV high dose opioid narcotics, such as appendicitis, dislocated bones, kidney stones, etc were mostly appropriate. Now that I am a provider that is able to prescribe controlled substances, I do feel concerned about the danger of narcotic abuse for myself as a prescriber and for the patients prescribed these drugs. I don't have the ability to monitor the patient in a controlled environment when I write a prescription for a controlled substance. I have no way of knowing if that patient will take the 30 tabs of Norco I prescribe for a month all at once and wash it down with a fifth of vodka, or if they will sell them on the street. There is a California state tracking system (CURES) that shows the controlled prescriptions filled, and there are standardized screening tools for potential for drug abuse which can be helpful tools to prevent abuse, but both are not fool-proof. I am conservative with my prescription of controlled substances, however the problem arises when patients have been prescribed controlled substances, in particular benzodiazepines and opioids (and often are on both of these) for years and years and have not been reassessed for the need for the long-term use of these medications. Granted, there are valid reasons for long-term use of these medications, and in these cases where documentation and records have been provided and no history of substance abuse exists, I am comfortable refilling certain controlled medications. When these physically addictive drugs have been continued for years and years, withdrawing abruptly from them can be life-threatening, and usually requires detox at hospital or other medical facility. The dilemma is if they are continued on these medications unnecessarily and an adverse event or overdose occurs, I am liable. On the other hand however if I discontinue the medication and an adverse withdrawal affect occurs, I am also liable. The other concern is a patient who does not receive a refill of their medication legally, will go to buy them on the blackmarket (I have had a patient tell me straight to my face she intended to do this when I wouldn't refill a prescription in the ER).  Now with the concern of Fentanyl showing up on the black market and being sold as Norco, the danger of overdose from  prescription drugs sold illegally is even more serious.  Convincing a patient to taper down from a medication they have been physically dependent on for years, is a huge challenge. The ideal situation for patients is to have pain management specialists control and manage patients on long-term narcotics, or have psychiatry manage patients with long-term need for benzodiazepine and stimulant use. These are specialties that have expertise in managing chronic pain and panic and anxiety and thus have a better understanding of when and how to use these particular controlled substances. The problem is waiting times for these specialties can take several months and require additional time and money expenditure for the patient. In the end these patients often bounce back to primary care or ER, even when not appropriate. I don't know how all of these issues will be addressed to create a more safe culture of prescribing controlled substances, however I hope changes will continue for the improvement of patient safety. Here is the link for the updated CDC guidelines for prescribing opioids for chronic pain.

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