The Drug Seeking Patient

Shelley Ross BS, RN

California State University, Dominguez HillsDivision of Nursing

Nursing EthicsMSN 531

Kathleen F. O’Connor, PhD, RN, CNEDecember 4. 2008

Synopsis of Ethical Situation

• Patient presents with complaints of back pain

• FNP examines and treats the patient for pain with Vicodin

• FNP follows up with the patient for several months

• Patient reports Vicodin bottle fell into the toilet

• FNP renewed prescription

• Then patient reports: jumped over a creek, Vicodin fell into water

Anonymous FNP (Personal Communication November 14, 2008)

• FNP felt the story did not match up with patient’s complaints of pain

• FNP called area pharmacies

• Vicodin prescribed by multiple providers and many pharmacies used

• FNP did not renew the prescription at that point

• FNP reported the patient to the pharmacy board

• Patient did not return to the clinic

Anonymous FNP (Personal Communication November 14, 2008)

Synopsis Continued

Ethical Principles

emotional responsiveness

Beauchamp & Childress, (2009)

• FNP first believed patient: Benevolence and Compassion (Beauchamp & Childress, 2009)

• Beneficence provides basis for symptom management and enhanced quality of life (Latimer, 1998)

personal relationships

sympathy

compassion

fidelitylove

what is done

how it’s done

mutual interdependence

Ethics of Ethics of CareCare

(Beauchamp & Childress, 2009)

Justice Perspective

• FNP later suspected patient was dishonest

• Ethics of care alone was no longer sufficient

• Justice considers optimal outcomes for all based on existing universal rules of moral conduct

• Emotional ethics of care and rational justice were bridged

• Increased knowledge to guide decision making was gained (Boersma, 2006)

Decision Making

• American Counseling Association’s (ACA) 7-step model

• Based on Kitchener’s five moral principles:

• These moral principles are considered absolute truths

(Forester-Miller, & Davis, 1996)

AutonomyAutonomy JusticeJustice BeneficenceBeneficence Nonmale-Nonmale-ficienceficience FidelityFidelity

ACA 7 Steps to Decision Making

(Forester-Miller, & Davis, 1996)(Forester-Miller, & Davis, 1996)

1. Identify1. Identify

2. Apply2. Apply

3. Determine3. Determine

4. Generate4. Generate

5. Consider5. Consider

6. Evaluate6. Evaluate

7. Implement7. Implement

Identify the problemIdentify the problem

Apply Code of EthicsApply Code of Ethics

Determine the nature and dimensions of the dilemmaDetermine the nature and dimensions of the dilemma

Generate potential courses of actionGenerate potential courses of action

Consider potential consequences of options, choose course of Consider potential consequences of options, choose course of actionaction

Evaluate the course of action chosenEvaluate the course of action chosen

Implement the selected course of action, and evaluate resultsImplement the selected course of action, and evaluate results

ACA Decision Making Process By FNP

1. Identify1. Identify

2. Apply2. Apply

3. Determine3. Determine

4. Generate4. Generate

5. Consider5. Consider

6. Evaluate6. Evaluate

7. Implement7. Implement

Patient’s story did not match upPatient’s story did not match up

Considered the nursing code of ethicsConsidered the nursing code of ethics

Dishonest patient, illegal act, drug abuse problemDishonest patient, illegal act, drug abuse problem

Decline or renew prescription?Decline or renew prescription?

Please patient and potentially feed a drug problem or investigate Please patient and potentially feed a drug problem or investigate first and help prevent drug dependencefirst and help prevent drug dependence

FNP considered consequences to optionsFNP considered consequences to options

FNP investigated, reported findings to pharmacy board, patient FNP investigated, reported findings to pharmacy board, patient failed to return to clinic failed to return to clinic

Do complete evaluation and assess for:Do complete evaluation and assess for:

• genetic risk factors for drug dependencegenetic risk factors for drug dependence

• psychosocial stressorspsychosocial stressors

• manipulative or demanding behaviormanipulative or demanding behavior

Alternative Approaches for the Drug Seeker while Maintaining an Ethics of Care

(Longo, Parran, Johnson, & Kinsey, 2000)

If Patient has known history of drug abuse:If Patient has known history of drug abuse:

• Do not prescribe “as needed”Do not prescribe “as needed”

• Do prescribe for a minimum duration on a set Do prescribe for a minimum duration on a set scheduleschedule

(Longo, et al. , 2000)

• EducationEducation

• Pain control contractPain control contract

• Hold patient accountableHold patient accountable(Gerhardt,, 2004)

Alternative Approaches for the Drug Seeker while Maintaining an Ethics of Care

• BiofeedbackBiofeedback

• Relaxation techniquesRelaxation techniques

• Transcutaneous electric nerve stimulationTranscutaneous electric nerve stimulation

• Physical therapyPhysical therapy

• PsychotherapyPsychotherapy

• Refer to specialistsRefer to specialists(Longo, et al., 2000)

Alternative Approaches for the Drug Seeker while Maintaining an Ethics of Care

References

Beauchamp, T. & Childress, J. (2009). Principles of biomedical ethics. 6th ed. New York: Oxford University Press

Boersma, R. (2006). Integrating the ethics of care and justice or are they mutually exclusive? International Journal for Human Caring 10(2). pp 21

Forester-Miller, H., & Davis, T (1996). A Practitioner's Guide to Ethical Decision Making. American Counseling Association, Retrieved November 14, 2008 from www.counseling.org/Files/FD.ashx?guid=c4dcf247-66e8-45a3-abcc-024f5d7e836f

Gerhardt, A. ( 2004). Identifying the drug seeker: the advanced practice nurse’s role in managing prescription drug abuse. Journal of the American academy of Nurse Practitioners. 16(6), pp 239-242

Latimer, E. (1998). Ethical care at the end of life. Canadian Medical Association Journal, 158(13). pp 1741-1747

Longo, L. Parran, T., Johnson, B., Kinsey, W. (2000). Addiction: part II. Identification and management of the drug-seeking patient. American Family Physician, 61(8), pp 2401-2408