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  1. Brooke, Penny Simpson RN, MS, JD

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To treat her rheumatoid arthritis, my patient takes methotrexate tablets (Trexall), which is contraindicated in patients with alcoholism. I have reason to believe that she abuses alcohol, although she flatly denies alcohol use when her health care provider and I question her about this. Before giving her a dose of Trexall, I raised my concerns with the health care provider. He agreed with my assessment but said, "Our hands are tied-her blood alcohol level right now is negative and she's telling us she doesn't drink. Give her the Trexall."


Should I have refused to administer the drug based on my suspicions, particularly since the health care provider shared them?-P.L., WASH.


You have the right and responsibility to refuse to administer a drug that, in your professional opinion, was ordered in error or will harm a patient. If a drug order is confusing or potentially harmful, you must take steps to clarify the order before giving the drug, as you did in this case.


But if a patient needs a medication regularly to treat a serious condition such as rheumatoid arthritis, you'd have a hard time justifying withholding the drug based on suspicions that aren't backed up by blood tests or other objective evidence. You don't mention the signs, symptoms, and behaviors that lead you to believe she's abusing alcohol. As you know, many conditions can cause signs and symptoms that mimic alcoholism. The physician checked out your suspicions through a blood test and decided that the results didn't support withholding the medication.


Still, you're right to be concerned. Trexall can cause serious adverse reactions if used with alcohol, such as hepatotoxicity, fibrosis, and cirrhosis. Use your nursing communication and teaching skills to help your patient feel safe talking with you. Educate her about the risks of mixing her medication with alcohol and encourage her to be frank with you and her health care provider about her use of alcohol and any other drugs or substances. Be careful to avoid a judgmental or accusatory tone; instead, emphasize your desire to protect her health.