Rx drug abuse in your ED- steps you take? - page 3

I have been getting fed up with the number of people coming into my ED drug seeking. One of the PA's have access to a database of all providers, pharmacies and pt info related to schedule 2, 3 and 4... Read More

  1. Visit  farmerjane profile page
    2
    I've been a lurker here for a long time, but I joined today so that I could reply to this. While I understand your frustration completely---we work so hard to provide good education for patients to truly promote a lifestyle that will help them maintain health---I find the part I quoted below to be really offensive.

    Quote from thelema13
    You guys know what I am talking about. These people either 1) don't work 2) are on medicare/medicaid 3) are on welfare/food stamps 4) drag family members into their addiction or 5) all the above. I am getting sick and tired of busting my hump and having 25%+ of my check going to taxes to pay for these people abusing the system. It's not like they pay their bill, nor does medicare/medicaid most of the time because their survey score isn't high enough, because the patient didn't get high enough.
    You said in a later post that you weren't trying to make judgments based on socioeceonomic status, but the direct quote from you above tells me otherwise. That makes it really difficult for me to treat any part of your post with the respect it deserves---and, again, I would say that parts of what you wrote do have merit. But I read so much resentment and assumption into your post that I really wonder what the patient feels when he or she is in your ED.

    Also, as someone else pointed out, the survey results of one patient (and let's not even assume that patient is going to receive, fill out, and mail a survey) are not going to affect the payment for that episode of care.

    As for the poster who said that frequent fliers are flagged in their system and will not be given narcotics when they come in...that poses some risk, IMO. Even those who have tried to scam the system for drugs before deserve adequate pain control if they have a situation in which they truly are in pain. It goes against everything I believe in about each patient presentation needing individualized attention to flag someone as "never, ever, ever" going to receive a narcotic, forever and ever, amen.
    mrsmamabear2002 and sapphire18 like this.
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  3. Visit  Altra profile page
    3
    Quote from farmerjane
    As for the poster who said that frequent fliers are flagged in their system and will not be given narcotics when they come in...that poses some risk, IMO. Even those who have tried to scam the system for drugs before deserve adequate pain control if they have a situation in which they truly are in pain. It goes against everything I believe in about each patient presentation needing individualized attention to flag someone as "never, ever, ever" going to receive a narcotic, forever and ever, amen.
    I feel confident that if a flagged patient comes in with their arm hanging off, they'll be medicated appropriately. The flag just highlights the patient's history of a chronic pain issue, probable chronic noncompliance, and/or outright fraudulent drug-seeking behavior that is not an emergent medical condition.
    LalaJJB, noahsmama, and mybrowneyedgirl like this.
  4. Visit  farmerjane profile page
    0
    Quote from Altra
    I feel confident that if a flagged patient comes in with their arm hanging off, they'll be medicated appropriately. The flag just highlights the patient's history of a chronic pain issue, probable chronic noncompliance, and/or outright fraudulent drug-seeking behavior that is not an emergent medical condition.
    I think you're probably right. I am new to posting here and was unable to see that part of the thread while I was replying, so I was going by my memory of what the poster reported happens in her hospital. Now that I can see it, it does of course look as though it's a general "We aren't going to give you narcotics" policy that would serve to make the patient think twice about trying to get meds in that ED for fradulent reasons but leaves it open to clinical judgment if it is a true pain emergency.

    Still, I do worry that someone could have something non-visible like kidney stone pain or the like. But I also realize that until that patient is standing in front of me, I of course have no idea what the likelihood is that this is the time when their pain is genuine.
  5. Visit  NO50FRANNY profile page
    0
    I probably should have been clearer about our flagging system- it's just an "alert" that we can view which describes behaviour, it in no way directs care unless a consultant physician has put a written directive or management plan in place. It does not mean that they won't receive narcotics either, as every presentation is treated as new. So the alert may read something like "pt demanded IV morphine at triage and stated he would leave if he was placed in the waiting room" or "pt became verbally and physically abusive when offered oral analgesia". The alert system is broken into different categories, anti-social behaviour, allergies, special treatment protocols, falls risk and so on. Regardless of these alerts, the patient will always receive analgesia of some kind and be thoroughly investigated- I guess all it really does is make us think twice before administering narcotics first line to certain patients. It also means that usually when there is any doubt / question, a more senior physician will be brought in to assess the patient and prescribe appropriately. I am extremely careful when I place alerts, and will only ever write exact observations, not opinions.
  6. Visit  farmerjane profile page
    1
    Quote from NO50FRANNY
    I probably should have been clearer about our flagging system- it's just an "alert" that we can view which describes behaviour, it in no way directs care unless a consultant physician has put a written directive or management plan in place. It does not mean that they won't receive narcotics either, as every presentation is treated as new. So the alert may read something like "pt demanded IV morphine at triage and stated he would leave if he was placed in the waiting room" or "pt became verbally and physically abusive when offered oral analgesia". The alert system is broken into different categories, anti-social behaviour, allergies, special treatment protocols, falls risk and so on. Regardless of these alerts, the patient will always receive analgesia of some kind and be thoroughly investigated- I guess all it really does is make us think twice before administering narcotics first line to certain patients. It also means that usually when there is any doubt / question, a more senior physician will be brought in to assess the patient and prescribe appropriately. I am extremely careful when I place alerts, and will only ever write exact observations, not opinions.
    I had actually been referring to the system mentioned by mybrowneyedgirl in post# 12:
    I'm not sure what is involved in this finally happening, but if someone has been detected to be a seeker, they get a letter to their home letting them know that they will no longer receive narcotics when they come in. Also, when they do arrive, a symbol of a finger pointing to the right automatically pops up on our computer screen as a reminder that they will not be receiving narcotics. Lately, these people have been found to have "eloped" when the doctor comes back into the room. It seems effective, but I don't know how many times this has to happen before the symbol finally appears.
    I think the system that you describe, carefully recording exact observations, is smart medicine.
    NO50FRANNY likes this.
  7. Visit  nurse2033 profile page
    2
    Colorado has an awesome program called the Electronic Prescription Drug Monitoring Program. Anyone with a DEA number can check on recent Rxs. That makes it really clear. I've seen many patients discharged with no prescription after being confronted by the Doc about their recent prescriptions. Check it out here Prescription Drug Monitoring Program
    I even heard about one doc that had the patient arrested for lying about it. Yeah!
    emtb2rn and Altra like this.
  8. Visit  LalaJJB profile page
    0
    I can totally understand and sympathize with what you are saying. Being a new nurse, I still struggle with getting frustrated with these pt's and I find it so freakin annoying. When i see the same patients 3 or more times a week it makes me lose compassion. About 2 months ago, a wise old ER nurse gave me the best piece of advice ever... you cannot change them unless they are willing to change so dont waste your time trying to teach them a lesson there are other legitimate people in need of your care. And if they are coming into the ER with a new story every time, they are not ready for change but at least they put effort into something. You do your job, and do it well. Also, she reminded me that they will probably be dead from liver failure by the time they are 60 years old. As bad as that sounds, it made me re-gain my compassion for these types. Also, it made me appreciate and respect my life that much more. And I know that you weren't judging based on socioeconomic status, it just happens that a majority of the pt's are of lower SES.. I have seen many of the medically insured as well as MANY high-profile and wealthy people seeking drugs. It's unfortunate, but it's true.
  9. Visit  Aliakey profile page
    1
    The way the nationwide medication shortages are going, you may only be able to offer a couple of Tylenol to the seekers pretty soon anyway. You would literally have nothing else available...
    whichone'spink likes this.
  10. Visit  thelema13 profile page
    0
    Yeah, what is up with that? It seems like more and more drugs are backordered, now that I think about it.
  11. Visit  NO50FRANNY profile page
    0
    I was just reading through some literature about malingering- very surprising, also very frustrating. According to one article, the cost of untruthful claims (relating to malingering) in the US in 1995 was 59 billion dollars, or for the average family, an extra $1050 per year on health insurance premiums. So, feigning illness really is BIG money. Makes me so, so angry.
  12. Visit  Nataayy profile page
    0
    I am currently looking at a drug-seeking pt as I read this. The pt comes in a minimum of three times a week seeking pain meds. He comes in so often, I know his allergies and medical history by heart. At times the pt has come into the ED already high seeking narcotics. The pt always has a story on how he has a future appointment with a pain management doctor. In short I am just getting just plain tired of it. I am one of the nicest and most patient RN's in the ED and this pt ****** me off. We have some doctors that will not give him anything more then toradol, while another doctor would order 2mg dilaudid when the pt is already slurring and glazed over.

    There is no point to my comment. I guess I am just venting.
  13. Visit  Blacky4130 profile page
    0
    thelma13, thankyou for being proactive and being a real change agent in nursing. as a formeraddict (i've been clean and sober for over 5 years now) and new rn working atan inner city hospital in philadelphia, i am very aware and conscious of thisproblem. our hospital is flooded with "patients" wanting their fix.the dispensing and over-prescribing of narcotics in and out of the hospitalsetting has turned patients into customers and dr.'s into drug dealers. i feelcaught in the crossfire. i know what we are doing is wrong and yet i amcompelled to administer pain medications and the like. shame on us! afterreading many of the posts on this issue, i believe that many of your detractorsare living in fairytaleland. "pain is what the patient says it is" isa dangerous adage, used to justify this harmful behavior and help naive nursestolerate the overuse of prescription narcotics and has contributed to ourcurrent national predicament.
    do you know when an addict gets clean? when the pain gets great enough. onlywhen the consequences of using cause enough emotional pain is change possible.anyone who stands in the way of those consequences is an enabler and is doingthat individual great harm and a huge disservice. i became a nurse to relievepain and suffering not to contribute to it. by participating in a person'sactive addiction, you are robbing them of the joy of truly living. prescriptiondrug abuse has become an epidemic and is killing americans. recent statisticsshow that more people die in 1 year from prescription drugs than from motorvehicle accidents. if this was a class of let's say "statins," theiruse would be only in cases where the need was significant and the benefitsoutweighed the negatives. so why are drugs that only mask pain and not bringabout prevention or resolution to a health problem so readily available topatients?
    i was becoming so disenchanted with nursing because of this reason and thanksto your post thelma13, i now see that there are initiatives i can advocate forat my institution and a means to become part of the solution; to do what i knowto be right, and break the complacency and mindless acceptance of negativeinterventions nurses have been ordered to perform to the detriment of theirpatients. as i begin my nursing career, i hope that this problem doesn'tcontinue to grow even more out of control than it already is, and thatprescription narcotics will begin to be used conservatively and cautiously incases where they are necessary not just a casual order set for any complaint ofpain.

  14. Visit  Jsnap1 profile page
    0
    Quote from thelema13
    When you have talked yourself blue in the face about rehab, dangers of addiction, extend referrals to pain management doctors, etc and the patients do not change, nor want to change, that is when I lose compassion.

    When you keep doing the same actions over and over again and expect different results each time- is that not the definition of insanity?!?!
    I have dealt with addictions both in my family personally and professionally, this is not what we call "insanity" it is was we call "the DISEASE of addiction" and although it can make us on the outside feel insane trying to treat/fix/help these people, we must remember that they are suffereing from a disease, and until they are ready to get better they just won't. I agree with the fact that not all docs/nurses/health care professionals are not all on the same page, but at the same time, who are we to judge, it is our job to provide care and compassion, even when we may disagree. I think all docs should be mandated to attend and become certified through ASAM and maybe this would help some.

    We are stuck between a rock and a hard place I hear ya


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