Drug seeking or real pain? How do you tell? - page 5

by JudyPRN

137,173 Views | 202 Comments

I'm a new nurse on the list so please pardon my ignorance. I was quite interested in the pain links and explored several and probably will use some for staff training. I did not see any mention of dealing with chemically... Read More


  1. 0
    (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.

    catlanta
  2. 0
    Quote from catlanta
    (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.

    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.
    Last edit by stevierae on Jul 2, '05
  3. 0
    Quote from stevierae
    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, 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. 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!

    catlanta
  4. 0
    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 burke@naddi.org

    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
  5. 0
    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



    Quote from stevierae
    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 burke@naddi.org

    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
  6. 0
    Quote from catlanta
    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.
  7. 0
    Quote from Stitchie
    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
  8. 0
    Quote from teeituptom
    Scary when people agree with me
    yeah, Tom, but you like it, don't you! Come on, we can take it... :blushkiss :angel2:
  9. 0
    ...we have pts. on PCA for pancreatitis or sickle cell crisis who want to go out to smoke. Some come back looking "higher" than when they left the floor. One pt. messes with his IV so it infiltrates, then goes down for a "smoke". I left early and saw this pt. walking in the parking lot like he was waiting for someone...can't do that with an IV pole attached to you! So, aside from documenting and assessing pt upon return, any suggestions? And these are the pts. who won't work with the meds, ie, quiet environment, low lights...no, the tv is blaring, lights are on, talking loud on the phone. When I suggest pain clinics I hear "I tried that it doesn't work for me".
  10. 0
    I didn't read through all these threads and I'm sure i will get slammed on some aspect of this, but I want to share what happened to me and a patient's point of view. Let me start it by saying I am a migraine sufferer since the age of 18 and when they get bad enough that I have to go to the ED I have had them for days and my home meds aren't working and I am either nauseated and/or vomitting.

    Well, I had one this week, brought on by the all wonderful monthly visitor. Unfortunately my home meds did not clear this up after 3 days along with trying ice packs, relaxation and massage. My S.O. takes me to urgent care. I tell the Physician all my history, what I take daily to prevent my migraines and what I have tried the last 3 days to get rid of this one (alternating Tylenol and Ibuprofen, ice pack, dark room, relaxation, massage and then my Tylenol #3). He asked me three times, very rudely, if I had taken my Topamax and Elavil that day to prevent my migraine. I assured him that I take my meds everyday and that the Topamaz is BID. Then he asked me what I usually get for my migraines when I come to the ED and I said, "Demerol with Phenergan IM and I can go home and sleep and it is usually gone." He then asked me, "how many times have you been to this hospital for your migraines?" and I told him "none". He asked me this 3 times and got nastier each time he asked it. I couldn't figure out why he was being such an a**, but as is the case when I have had to go get a shot for my migraines he was making me feel like a "drug seeker". He then asked me how often I "went and got shots", "Is it like 5 or 6 times a year?" I told him, "no, actually it is like 2 or 3. The last one was in November when my Dad died." All he said was, "Oh. Well, we don't have Demerol here we'll give you Stadol."
    They gave me the shot and he came in to ask if I had any relieve and I didn't, but I was afraid to tell him different because of the way he had treated me.
    Later today I got to thinking about why he kept asking if I had been to "this hospital for migraines" and didn't believe me when I had told him "none". I had been seen in the same urgent care by their PA for a URI. If he had just come out and asked me I would have told him and of course, they couldn't "pull it up" because they aren't computerized charting here
    I guess the point I want to try to make after this long spiel is don't just assume things...ask. And some of us after 23yrs of our condition do have an insight into what works and what doesn't and would like to be treated with a little respect. I wish my head hadn't been hurting so bad yesterday and I could've been thinking a little straighter...there is no reason to be rude and make assumptions......


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