Drug seeking or real pain? How do you tell?

z's playa · May 31, 2005

:rotfl: :rotfl: :rotfl:

That was soooooo funny !

Cool website too. :)

As for the ER visits while under a narcotics contract. Totally happens all the time but for the legit pts....who get a set amount of narcs a month...they're told to go to the ER if they run out to receive IV treatment. What the doc doesn't want to happen is the pt going to a clinic and acquiring another PCP to prescribe meds. This way the ER sheets get sent to the pt's doc and everyone is aware of the visit and a reassesment of the contract is in order.

The pt doesn't ask for a pain Rx but receives treatment.

That's how we do it here. :)

Z

mattsmom81 · May 31, 2005

As for the ER visits while under a narcotics contract. Totally happens all the time but for the legit pts....who get a set amount of narcs a month...they're told to go to the ER if they run out to receive IV treatment. What the doc doesn't want to happen is the pt going to a clinic and acquiring another PCP to prescribe meds. This way the ER sheets get sent to the pt's doc and everyone is aware of the visit and a reassesment of the contract is in order.

The pt doesn't ask for a pain Rx but receives treatment.That's how we do it here. :)
Z

I think thats a great way to handle the situation. :)

grannynurse FNP · May 31, 2005

Here's what's confusing to me about people who have genuine chronic pain conditions for which they are under the care of a chronic pain specialist, and have an agreed to (often signed) treatment plan, including a narcotic or two.
Why would they ever have to go to an ER (particularly to get refills of those prescribed narcotics) in the FIRST place? Just like diabetics or asthmatics or any other patient with a chronic disease, they HAVE (or SHOULD have, if they are willing partners in their own health care) a physician managing their treament plan and prescribing their narcotics according to a fixed schedule. Why should they ever be caught in a position where they have run out, and have to go to an ER where people don't even know them, their hx, or how their pain has been managed, since they have no access to their outpatient charts?
I mean--if you have chronic back pain, or chronic migraines, you have a doc managing that chronic pain; a chronic pain specialist, if you've gone to the trouble to seek one out and have worked out a mutually agreed to treatment plan and are compliant with it--and that means keeping your scheduled appointments and getting your narcotic prescription refills as ordered and as agreed to in your treatment plan.
If you've done that, then you have the meds you need and should be using them as prescribed. Why would you ever be caught in a situation where you have run out and have to visit an ER, essentially behind your doctor's back, for more of the same meds, or the same meds, but in IM or IV form? To me, that's non-compliance and in violation of your agreed to treament plan.
I am anything but judgemental, and I, too, agree with the adage that "the patient's pain is whatever he says it is" but that adage is referrring to ACUTE pain----not chronic pain.
Chronic pain is a whole different ball game, and needs to be managed by chronic pain specialists. Chronic pain patients should know better than to be using emergency rooms as drop-in clinics--they need to be compliant with their own agreed to treatment plans, and I am betting those treatment plans have detailed instructions as to how to avoid running out of medication before a weekend (which includes taking the prescribed meds ONLY according to the schedule prescribed) and therefore having to drop into the friendly neighborhood ER, expecting them to become a partner in a chronic pain treatment plan to which they don't have access, and are therefore reluctant to interfere with.
For those of you ER nurses who frequently hear the story, "My meds fell down the sink" (or the toilet) check out http://www.placebojournal.com
There is an amusing animated picture called "Narcotic Mystery--just click on it.

I find your comments both amusing and judgemental. I am a chronic pain suffer, as well as an insulin dependent diabetic and an asthmatic. And guess what, I am under the care of physicians, on a regular bases. However, there are times, late in the evening, at night, on the weekend, or holiday, where I call my doctor and am advised to go to the ER for treatment and to instruct them to call him. Chronic pain suffers rarely go to the ER for pain management. The attitudes, of most staff, are too judgemental to deal with. Many would rather suffer then have to deal with the staff and their attitudes. :angryfire

Back in the early 90s, when I first began to suffer, I was label as a drug seeker. I was seeking drugs, from my physician, to help control the pain that I was experiencing. The nursing staff was the most difficult to deal with, given their outdated attitudes towards anyone seeking pain medication. Fortunately, I found a pain management physician, who has successfully treated my pain. And I no longer have to deal with the attitudes.

Please remember this:

Pain is whatever the pain suffer says it is. It is not up to you to determine if it is real or not. And you will be unable to determine if it is. And please do not pass your suspicions on to the physician, only your direct observations. And even those should be done carefully.

Grannynurse :balloons:

1Tulip · May 31, 2005

This is a pretty long thread and there is a lot of great information and valuable observation and opinion. Let me add one caveat (and I hope I didn't overlook it if someone else has posted this.)

Drug seeking behavior (or insert your label of choice here) is a bad thing and generally involves deliberate manipulation and (call a spade a spade) lying.

But there is a close cousin that is often confused with DSB. People with chronic pain, or episodic severe pain (I'm a migrainer... full disclosure time) absolutely fear their pain. They don't want to be disarmed and helpless. They want to be sure they have a bottle of Vicodan handy if needed. And they can get really panicky if they start to get on the wrong side of the pain/med-on-hand ratio. When this happens, yeah... they'll start "seeking drugs". But it's fear of pain that is driving the behavior.

These are the patients that you can really do some good for with treatment contracts and alternative management approaches. They will agree to do ANYthing if you can take the fear factor away. I know several migrainers whose narcotic use dramatically decreased after they were started on a triptan type drug. Other migrainers I know have been managed with a prophylaxis med (usually an anticonvulsant). But the point is that they stopped begging for narcotics. As long as they had enough for their breakthrough pain, they were cool.

So the point is... some people are really "seeking drugs" but are not "drug seekers". It's a fine point, but a very important one, I think.

Catlanta · Jul 2, 2005

(i appreciate stevierae inviting me to this forum; she's right; this could be addictive on its own!)

while one never openly challenges the patient's description of the pain, in today's dea environment and scrutiny, writing whatever the patient asks is called being an "easy score" and can result in severe harm to one's license to practice, even jail time. drug seekers all talk to each other and they all know where they can get good drugs fast. the challenge is to balance screening the small group of bad actors without unduly inconveniencing the real patients.

(i'm also a pain patient and can strongly relate to the "eek" factor of having inadequate meds to solve my problem. there is a group of pseudo-drugseekers, who are really under-medicated or poorly-controlled pain patients but i'll address that another time.)

as to real pain vs. drug seeking, it is never easy or quick to distinguish which from the other, though after a time, you do develop a 6th sense about the 5th vital sign. :rolleyes: one very effective technique is to give the patient the first rx then give 30 days to complete a behavioral assessment or no refills. ask the behavioral assessor to use the medtronics protocols. (if they don't know what they are, find an assessor who does.) the medtronics psychosocial assessment protocols for implanted pain technologies include standardized testing, are excellent, thorough and cover the waterfront. a patient may fool the doc, nurse, or interviewer, but cannot fool all the tests. there's just too much stuff. (personal preference - no particular need to do mmpi-2, and the millon behavioral medicine diagnostic is a better choice for all but the actual implanted device pain patients. mbmd was designed for use in physicians' offices, to identify behavioral factors acting on medical presentation, including pain.) the behavioral interviewer is usually a psychologist but in some states may be a licensed counselor, or a nurse-practitioner working with a psychometrist. the psychometry is a crucial part of the evaluation.

a drug seeker will rarely go to all that trouble, or will try to talk you out of it, give you five dozen reasons why you should make an exception for him/her. if really skilled, they might skip the assessment and return for the refill to test whether you really meant it when you said you would not refill the meds at the next appt unless they got the behavioral assessment done. if really, really skilled, they might try to play the game with the behavioral assessor, but that won't work, either, if the assessor understands the medtronics protocols. once they "get it" that the rx-writer is not an easy score, they move on. real pain patients may complain about the inconvenience but will comply.

it sounds like a lot of work to screen one patient but there is a ripple effect that eventually nets many benefits. the bad guys all talk to each other and word spreads that your facility is not an "easy score" which is exactly what you want. you might get an occasional newbie but the locals leave you alone.

in a one-visit situation, where you don't even want to risk one rx, a good quick screen that the doc or nurse can do in the clinic is the hendler 10-minute screening test, developed for chronic back pain but actually works with most painful conditions. it was published in the journal psychosomatics: hendler 10-minute screening test for chronic pain patients, december 1979, vol. 30, no. 12. the higher the score, the more likely you have psychosocial factors (including potential drugseeking) acting on the exacerbation and perpetuation of the pain complaints. the lower the score, the more likely the pain complaints are based on objective physiological complaints. it's really good in the extremes of the range. it's not as helpful right in the middle, where you've got someone with some physiological pathology but some psychosocial factors acting on their pain perceptions. however, even in the middle, it will help you identify red flags that can aid your clinical assessment of how much risk you want to take with that patient.

hope this helps. :balloons:

catlanta

stevierae · Jul 2, 2005

(i appreciate stevierae inviting me to this forum; she's right; this could be addictive on its own!)
while one never openly challenges the patient's description of the pain, in today's dea environment and scrutiny, writing whatever the patient asks is called being an "easy score" and can result in severe harm to one's license to practice, even jail time. drug seekers all talk to each other and they all know where they can get good drugs fast. the challenge is to balance screening the small group of bad actors without unduly inconveniencing the real patients.
(i'm also a pain patient and can strongly relate to the "eek" factor of having inadequate meds to solve my problem. there is a group of pseudo-drugseekers, who are really under-medicated or poorly-controlled pain patients but i'll address that another time.)
as to real pain vs. drug seeking, it is never easy or quick to distinguish which from the other, though after a time, you do develop a 6th sense about the 5th vital sign. one very effective technique is to give the patient the first rx then give 30 days to complete a behavioral assessment or no refills. ask the behavioral assessor to use the medtronics protocols. (if they don't know what they are, find an assessor who does.) the medtronics psychosocial assessment protocols for implanted pain technologies include standardized testing, are excellent, thorough and cover the waterfront. a patient may fool the doc, nurse, or interviewer, but cannot fool all the tests. there's just too much stuff. (personal preference - no particular need to do mmpi-2, and the millon behavioral medicine diagnostic is a better choice for all but the actual implanted device pain patients. mbmd was designed for use in physicians' offices, to identify behavioral factors acting on medical presentation, including pain.) the behavioral interviewer is usually a psychologist but in some states may be a licensed counselor, or a nurse-practitioner working with a psychometrist. the psychometry is a crucial part of the evaluation.
a drug seeker will rarely go to all that trouble, or will try to talk you out of it, give you five dozen reasons why you should make an exception for him/her. if really skilled, they might skip the assessment and return for the refill to test whether you really meant it when you said you would not refill the meds at the next appt unless they got the behavioral assessment done. if really, really skilled, they might try to play the game with the behavioral assessor, but that won't work, either, if the assessor understands the medtronics protocols. once they "get it" that the rx-writer is not an easy score, they move on. real pain patients may complain about the inconvenience but will comply.
it sounds like a lot of work to screen one patient but there is a ripple effect that eventually nets many benefits. the bad guys all talk to each other and word spreads that your facility is not an "easy score" which is exactly what you want. you might get an occasional newbie but the locals leave you alone.
in a one-visit situation, where you don't even want to risk one rx, a good quick screen that the doc or nurse can do in the clinic is the hendler 10-minute screening test, developed for chronic back pain but actually works with most painful conditions. it was published in the journal psychosomatics: hendler 10-minute screening test for chronic pain patients, december 1979, vol. 30, no. 12. the higher the score, the more likely you have psychosocial factors (including potential drugseeking) acting on the exacerbation and perpetuation of the pain complaints. the lower the score, the more likely the pain complaints are based on objective physiological complaints. it's really good in the extremes of the range. it's not as helpful right in the middle, where you've got someone with some physiological pathology but some psychosocial factors acting on their pain perceptions. however, even in the middle, it will help you identify red flags that can aid your clinical assessment of how much risk you want to take with that patient.
hope this helps. :balloons:
catlanta

great post, catlanta! this, too, goes into my "pearls" file---you know the one. :)

i did not know about the medtronics protocols, even though i have been involved in the surgical process of medtronic epidural implants-- glad you shared that info. didn't know about that hendler testing, either. one thing i do remember you saying a while back, and it's stuck with me since, is that when we cite what we have learned in regard to "the patient's pain is what he says it is" to remember that this is valid when we are dealing with acute pain patients---but it is a whole different ball game when dealing with chronic pain patients, and/or drug seekers.

glad to see you posting here--we can all benefit from your experience.

Catlanta · Jul 2, 2005

great post, catlanta! this, too, goes into my "pearls" file---you know the one. :)
i did not know about the medtronics protocols, even though i have been involved in the surgical process of medtronic epidural implants-- glad you shared that info. didn't know about that hendler testing, either. one thing i do remember you saying a while back, and it's stuck with me since, is that when we cite what we have learned in regard to "the patient's pain is what he says it is" to remember that this is valid when we are dealing with acute pain patients---but it is a whole different ball game when dealing with chronic pain patients, and/or drug seekers.
glad to see you posting here--we can all benefit from your experience.

thanks for your kind words, stevierae. the medtronics protocols for psychosocial assessment of implanted technologies were co-authored by dan doleys, phd and another psychologist, may be obtained via the medtronics website, http://www.medtronics.com. they'll send you the monograph. i don't think they mention mbmd or hendler, but i have seen those included in assessments and both are useful tools. the monograph explains the multifactorial approach of the psychometry and why each factor is important. mmpi-2 by itself is not especially helpful, though is included in the protocols for implants and should be done for that reason. (one study uses scale #2 (depression) of mmpi-2 as a predictor of success for stimulator implant.)

acute pain vs. chronic pain vs. drug seeking vs. suffering is a vexing discussion for another day. :uhoh3: the meaning of the patient's descriptions may be wayyy different but use the same words. depending on the underlying meaning, opioids may or may not work effectively. the patients who successfully defeat high dose opioids and all the sophisticated medical interventions almost invariably are classically "suffering" and can do really well with behavioral interventions. they are hurting, for real, but not in the parts of their brains that opioids can help. front line pain management is not for the faint-hearted.

thanks again for inviting me. this is a great forum! :biggringi

catlanta

stevierae · Jul 7, 2005

I read something interesting in an MD forum today. It was about reporting drug seekers. In the ER forum here, there have been posts from RNs who state that it is against the law to report drug seekers to any agency (I am not sure whether they are worried about HIPAA, or what) but I think that NOT reporting drug seekers (I am talking about those who go from ER to ER to ER, seeking meds that they may be selling on the street) would be worse.

This interests me, because I just think it's wrong to look the other way with the attitude that "the patient's pain is whatever he says it is" (and therefore simply writing a script for whatever narcotic the patient demands---being "allergic" to all NSAIDs, as they all claim to be) particularly in an emergency department, where this "pain" that these people are seeking scripts for is either fictitious or chronic---not an emergency.

I am glad I don't work ER---I'd be far too judgemental and suspicious when dealing with repeat narc seekers.

Anyway, here is what I read on the MD forum--thought it might prove interesting for discussion:

"In response to John who recently wrote regarding drug seeking patients, expressing a desire to report them, I would suggest he contact the National Association of Drug Diversion Investigators. He may find them quite useful!

NADDI may be found on the web at: http://www.naddi.org/

Alternatively, he may wish to contact Mr. John Burke, Vice President at 513-336-0070 or via email at [email protected]

During my nearly 20 years of employment with the State of Nebraska's Investigation Division of the Credentialing Bureau of the State Health Department, I was an active member of NADDI and became the Midwest Director. NADDI is composed of members from Law Enforcement, State Health Dept. Investigators, Pharmacists, Physicians, Prosecutors and other interested individuals. The Association's main goal is to curb the illegal diversion of pharmaceutical drugs by working with members of the medical profession to identify and prosecute doctor shoppers, drug diversion rings, and other similar individuals."

Sincerely,

Tim G. Bate, MPH

Catlanta · Jul 7, 2005

stevierae - i haven't had to address the reporting issue but i wouldn't be surprised if hipaa precluded reporting. i'll have to look that up, as that's an interesting question. i'm wondering if reporting could be addressed in an opioid contract, that most pain clinics require now?

the policy in the last pain clinic where i worked was to give the patient medication management assessment and behavioral instruction, which i provided, and we had a no treat list, for which a patient could land for a variety of reasons, not just opioid misuse. i can't remember our clinic ever initiating a patient report to authorities, except to call 911 for a threatened suicide. we disciplined patients in-house but there were some who took full advantage of front office discrepancies, nursing changes, etc. etc. and it drove the docs nuts. i told them i was the clinic enforcer, only half-joking, and it was not a popular job. an excessively sympathetic front office can encourage and reward bad patient behavior.

however, we had several patients who ignored the behavioral instruction and engaged in bad behavior, usually culminating in a phone call from an astute pharmacist. state law requires pharmacists to report anything suspicious with controlled substances. one particularly bad actor had five sources of vicodin, that he took to five different pharmacies, paid cash. he got caught when he forgot and took the wrong rx to the wrong pharmacy. (if it's dr. smith, this must be acme pharmacy, if it's dr. jones, this must be acme pharmacy south, if it's dr. brown, it must be acme pharmacy east... etc. ) :chuckle :uhoh3: :uhoh3: :chuckle another upper middle class housewife couldn't talk the rns into more meds, so she rewrote the rx, pharmacist called the doc, who requested that she return to the clinic for immediate counseling but the pharmacist had to call the police; they led her away in handcuffs. one patient claimed that her purse with her opioids meds was stolen 3 times in nine months, filed police reports each time; her doc wrote her a 30-day letter advising her that he would be happy to treat her pain but would not write opioids because she was exhibiting irresponsible behavior by failing to keep up with her purse. she went to another clinic.

the more that medical professionals can appropriately raise the behavioral stakes, inappropriate users of pain meds usually vote with their feet. it would be ideal to screen them out of the system and with increasing interest in statewide computers, that could happen. until then, a few simple requirements will often cause drugseekers to identify themselves. if one cannot screen them out of the entire opioid system, then one can make it more difficult to bamboozle one's own facility personnel.

catlanta

i read something interesting in an md forum today. it was about reporting drug seekers. in the er forum here, there have been posts from rns who state that it is against the law to report drug seekers to any agency (i am not sure whether they are worried about hipaa, or what) but i think that not reporting drug seekers (i am talking about those who go from er to er to er, seeking meds that they may be selling on the street) would be worse.
this interests me, because i just think it's wrong to look the other way with the attitude that "the patient's pain is whatever he says it is" (and therefore simply writing a script for whatever narcotic the patient demands---being "allergic" to all nsaids, as they all claim to be) particularly in an emergency department, where this "pain" that these people are seeking scripts for is either fictitious or chronic---not an emergency.
i am glad i don't work er---i'd be far too judgemental and suspicious when dealing with repeat narc seekers.
anyway, here is what i read on the md forum--thought it might prove interesting for discussion:
"in response to john who recently wrote regarding drug seeking patients, expressing a desire to report them, i would suggest he contact the national association of drug diversion investigators. he may find them quite useful!
naddi may be found on the web at: http://www.naddi.org/
alternatively, he may wish to contact mr. john burke, vice president at 513-336-0070 or via email at [email protected]
during my nearly 20 years of employment with the state of nebraska's investigation division of the credentialing bureau of the state health department, i was an active member of naddi and became the midwest director. naddi is composed of members from law enforcement, state health dept. investigators, pharmacists, physicians, prosecutors and other interested individuals. the association's main goal is to curb the illegal diversion of pharmaceutical drugs by working with members of the medical profession to identify and prosecute doctor shoppers, drug diversion rings, and other similar individuals."
sincerely,
tim g. bate, mph

Stitchie · Jul 7, 2005

stevierae - i haven't had to address the reporting issue but i wouldn't be surprised if hipaa precluded reporting. i'll have to look that up, as that's an interesting question. i'm wondering if reporting could be addressed in an opioid contract, that most pain clinics require now?
the policy in the last pain clinic where i worked was to give the patient medication management assessment and behavioral instruction, which i provided, and we had a no treat list, for which a patient could land for a variety of reasons, not just opioid misuse. i can't remember our clinic ever initiating a patient report to authorities, except to call 911 for a threatened suicide. we disciplined patients in-house but there were some who took full advantage of front office discrepancies, nursing changes, etc. etc. and it drove the docs nuts. i told them i was the clinic enforcer, only half-joking, and it was not a popular job. an excessively sympathetic front office can encourage and reward bad patient behavior.
however, we had several patients who ignored the behavioral instruction and engaged in bad behavior, usually culminating in a phone call from an astute pharmacist. state law requires pharmacists to report anything suspicious with controlled substances. one particularly bad actor had five sources of vicodin, that he took to five different pharmacies, paid cash. he got caught when he forgot and took the wrong rx to the wrong pharmacy. (if it's dr. smith, this must be acme pharmacy, if it's dr. jones, this must be acme pharmacy south, if it's dr. brown, it must be acme pharmacy east... etc. ) :chuckle :chuckle another upper middle class housewife couldn't talk the rns into more meds, so she rewrote the rx, pharmacist called the doc, who requested that she return to the clinic for immediate counseling but the pharmacist had to call the police; they led her away in handcuffs. one patient claimed that her purse with her opioids meds was stolen 3 times in nine months, filed police reports each time; her doc wrote her a 30-day letter advising her that he would be happy to treat her pain but would not write opioids because she was exhibiting irresponsible behavior by failing to keep up with her purse. she went to another clinic.
the more that medical professionals can appropriately raise the behavioral stakes, inappropriate users of pain meds usually vote with their feet. it would be ideal to screen them out of the system and with increasing interest in statewide computers, that could happen. until then, a few simple requirements will often cause drugseekers to identify themselves. if one cannot screen them out of the entire opioid system, then one can make it more difficult to bamboozle one's own facility personnel.
catlanta

i agree w/tom: i've given up trying to tell the difference. i do not control the universe, after all.

if the physician's clinical judgement is what i depend on, that drives the decision, as appropriate. my job is not to diagnose!

this is far too time-consuming to happen in any er that i've known, unless the problem is so glaring you'd be blind not to see it.

teeituptom, BSN, RN · Jul 8, 2005

I agree w/Tom: I've given up trying to tell the difference. I do not control the universe, after all.
If the physician's clinical judgement is what I depend on, that drives the decision, as appropriate. My job is not to diagnose!
This is far too time-consuming to happen in any ER that I've known, unless the problem is so glaring you'd be blind not to see it.

Scary when people agree with me :rotfl: :rotfl: :rotfl:

Stitchie · Jul 9, 2005

Scary when people agree with me :rotfl: :rotfl: :rotfl:

yeah, Tom, but you like it, don't you! Come on, we can take it... :blushkiss