I felt physically threatened as the patient’s grandson pushed too close to me, face red, eyes angry, and yelled, “There was no way I am taking those missing drugs! And I have no idea where they are!” He continued to yell loudly at his grandfather while I used a phone call to my boss as an excuse and eased out of the corner I had gotten pushed into. I stopped only to grab my bag in a fluid motion as I moved on out the door to my car, making a quick exit to safety.
We ended up discharging that patient from hospice after they called to say that they didn’t want us to come back.
The very next week, we had another case of drug diversion, this time by a paid caregiver who cared for a man with aphasia whose family did not live nearby. The caregiver was trusted and used this trust to maintain a supply of narcotics for personal use. When we came to admit the patient, she was completely impaired and unable to stay awake even to sign where needed. After taking necessary measures to protect the patient and remove him from the situation, the family notified authorities.
While the problem is more pronounced in West Virginia, Southwest Virginia and Tennessee, none of the states in our country can claim an exemption from this pervasive and deadly problem. It besieges the cities, the heartlands and everywhere in between, threatening to pull our country apart at the seams.
As nurses, how do we even begin to cope with drug diversion issues in the context of patient care, especially as concerns hospice patients?
1. Acknowledge the Problem
First, we have to acknowledge that there is a big and growing problem with narcotics and sedatives of all types. Daily, the Emergency Medical Systems are flooded with overdose calls and Narcan is becoming a familiar household name, with some households having the EMTs return more than once in one day to revive an overdosed family member. (NEW YORKER, June 5 & 12, p.75)
2. Teach, Teach Teach
During the admission process, we must devote more time to helping families fully understand the medication contract, the pill counts, and the logs. Many families are narcotic naive, in the common sense of the word, and simply don’t understand the possible dangers for themselves, family members and caregivers. Teaching and prevention can keep away a world of trouble during an already troubled time. Assessing the home situation, and the intellectual capabilities of the caregiver can help the nurse guide the discussion about what type of pain management would be most helpful. When pills are a known potential problem from the beginning, this assessment can lead the physician and providers to look at pain pumps or patches from the beginning of therapy.
3. Use the team
In hospice, we must use our team as the problem-solving, trouble-shooting group that it was meant to be. When we see red flags during a visit, then it is important to convene a phone or an in-person discussion about the problems so that we are all on the same page in terms of interventions and plans. If we set out timelines and goals, then the nurse, administration, and social workers are all working in concert to take the best care possible of the patient.
4. Know your role
We are not the police. We are nurses. Our job is to treat our patients. We don’t have to understand what is going on or figure out who is taking what. Our role, especially in hospice, is to do our best to make sure the patient has what they need and that they are getting what is prescribed to them. When there is a question, we call our team. When there is an expected confrontation or difficulty, we go together. We remain calm, professional, non-judgemental. We do not need to engage the offending party. We simply keep the patient safe—however, we can—and then allow other professionals to do their job in finding out what happened and when.
5. Keep the numbers small
Order small quantities of drugs and keep them under lock and key. Often a one or two week supply is a gracious plenty. Yes, it is hard to get refills but it is also hard to count a lot of pills at each visit. The added benefit is that changes can be made each week or two in dosages without having a lot of waste.
6. Use alternative medications/treatments
Tylenol, Advil, Melatonin, Prednisone, Gabapentin all top the list of non-narcotic symptom relievers to consider before upping the dose of opioids. Additionally, careful assessment for other symptom management problems such as urinary retention, constipation, and bedsores can contribute to a big-picture approach that stays away from the reflexive use of narcotics to address all discomfort. More hospices are beginning to look carefully at incorporating music therapy, aromatherapy, and massage as part of their overall dedication to comfort.
7. Consider spiritual support instead of, or in addition to, narcotic pain relievers
Sometimes, we find conflict and unresolved issues in the home. Patients and their families are working through issues that pre-date the hospice diagnosis, and narcotics are not the best treatment for that kind of emotional distress. In fact, when the pain is not physical, there is no amount of opioid that will ease the suffering—this is apparent from the scourge of abuse that our society currently observes. A listening ear, compassionate care, a therapeutic touch, a prayer, an intervention, sometimes these are the true deliverers of relief.
As we navigate these troubled waters of narcotic use, overuse, and abuse, let us, as professional nurses, lead the way to find solutions that work for us all. As we advocate for our patients’ comfort and pain relief let us be dedicated to uncovering root causes of discomfort and also be being creative in addressing them.
Where have you come across a problem with drug diversion and how did you handle it? Do you have some creative ideas that are not addressed here?