Confessions of a Hospital Administrator: I Feel Your Pain...Pill

A former hospital administrator shares what he learned about opioid pain addicts in the middle of the night and how the ACA holds promise to make life easier for all nurses.

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  • Specializes in Administrator inspired by nurses. Has 25 years experience.

As a hospital CEO, I listed my home phone number in the admission kit for each of the three hospitals where I served. I invited patients to call me at anytime if they had a concern or problem they didn't feel was getting resolved. I did this because I had such confidence in the nursing staffs and House Sups to deal with patients, that I knew that I would not get many calls. And for the most part, this was the way the scenario played out.

The exception was the disappointed narcotic pain med patient seeking a refill in the ER. While I know I don't need to explain the drill to ER nurses, it was a learning experience for me. Of the phone calls I received in the middle of the night (always after midnight), 80 percent were from patients who were angry they could not get the pain pills they wanted in the ER.

Getting Fooled By Pain Pill Addicts

I'll admit, I was naive at first - I was sympathetic to their suffering (and remain so to their addiction). I was like the new family doc right out of residency I hired who wrote a pain script on his first day of practice for one of the area's most notorious doctor shopper. When advised about this patient, he looked rather shocked and said "Well, he sure fooled me."

It turns out, a lot medical scrip writers get fooled. There has been much recent data and attention on the increased use of prescription pain meds - I'm not going to restate what we all know. But two recent observations strike me as especially telling. Dartmouth economist Jonathan Skinner was recently quoted in a New York Times article about the rapid rise in overdose deaths among whites (turns out docs are more cautious in writing scrips for black patients, but that's a story for another day...) that: "It is like an infection model, diffusing out and catching more and more people." And according to The Association of Community Affiliated Plans, between 1993 and 2012, inpatient admissions for prescription opioid overdoses increased by 150 percent. ER nurses get to see those patients too on the way up to the floor.

A Gun in the Face

My late night calls from a narcotic pain med seeking patient always went through three stages. First (apology) the caller would say they were so sorry to wake me up in the middle of the night. The second (self-pity) was the longest part, which included a run down of the patient's medical condition and pain issues. I would dutifully explain that I was not a physician and could not tell the ER doc what scrips to write. I also explained that pain meds were highly addictive and the patient should consider the damage the meds could cause, including accidental overdose. Then the third stage (anger) would kick in. I would get yelled at and threatened with lawsuits. I would urge the caller to see their primary care doctor and whatever specialists were needed to resolve the cause of their pain. But it was obvious these callers mostly did not have underlying medical conditions for pain - they just wanted the pills, because they were addicted.

As inconvenient as it was for me to get rousted out of bed in the middle of the night, it paled to what nurses and other staff had to endure in the hospital. At one hospital, a staff member ducked out of a back door in the middle of the night for a cigarette. Rather than use the secure smoking area in a well-lit area in front of the ER, this staffer propped a door open with a rock in a dark courtyard. A minute later, a man stuck a gun in her face and marched her up to the main medical floor where the House Sup was summoned. She had to unlock the Pyxis machine and hand over all the narcotic pain meds to get him to leave. From that day on, wherever I served as CEO, nighttime and armed guards were standing operating procedure. Also, any staffer who was found smoking via a secure door got to come talk to me so I could share the same story with them.

I know that on any given night ER nurses are the first responders in this growing epidemic. Addicted pain pill patients take up an enormous amount of your time. The Huffington Post succinctly summed up the problem in an article on 1/25/2016: "Most agree on the causes behind the problem, citing uneven prescribing guidelines, marketing of the drugs by the pharmaceutical industry, few limitations on access to the drugs, economic factors and an inadequate number of treatment facilities for drug misuse, abuse and dependence."

Taking Care of Patients Outside the Hospital

Some hospitals have taken to posting signs in the ER that that no pain med scrips will be written. But a growing number of health systems and insurance companies are taking a more integrated approach, which is the often-unrealized benefit of the switch to value-based medicine under the Affordable Care Act. The days are gone where patients are discharged without support, knowing that if they returned the hospital would be reimbursed again (or not paid again, depending upon the patient). Hospitals are getting better at following-up with caseworkers, discharge nurses and social workers to stay in contact and support ER super utilizers - formerly called frequent flyers, which is now deemed pejorative. But you know the patients of whom I speak. NPR recently highlighted a program by CeltiCare Health Plan in Massachusetts to preventively deal with the growing opioid epidemic among its mostly 50,000 Medicaid members.

If you are unaware of what steps your hospital is taking to proactively manage population health to keep patients out of the hospital - ask. I think you will be surprised at how healthcare is changing right before our eyes. It is my hope for all nurses that the promise of reinventing healthcare will eventually make your job easier and more enjoyable.

John W. Mitchell is a retired hospital administrator and author of the hospital novel “Medical Necessity”. In 2009, he and his administrative team were named "Top Leadership Team in Healthcare for Mid-Sized Hospitals" by HealthLeaders Media.

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Emergent, RN

2 Articles; 4,062 Posts

Specializes in ER. Has 30 years experience.

Can you please come out of retirement and work for my hospital? :yes:

ServantLeader

6 Articles; 42 Posts

Specializes in Administrator inspired by nurses. Has 25 years experience.

You are too kind Emergent, this is a fine compliment, thank you.

Lev, MSN, RN, NP

9 Articles; 2,803 Posts

Specializes in Family Nurse Practitioner. Has 10 years experience.

You might find this video interesting.

russianbear

210 Posts

As long as physicians continue to enable drug addicts nothing will ever change. I have a patient right now who comes in every two weeks with vague pain, cries, yells, calls supervisors until they give him IV Dilaudid. He gets it every three hours and Percocet as well every three. Same routine every time he comes. Treats staff like garbage as well.

bgxyrnf, MSN, RN

1,208 Posts

Specializes in Med-Tele; ED; ICU. Has 10 years experience.

The counter to this is that many docs are now stingy with pain medications and rather than simply give the nurses the tools to manage pain at the bedside, they "nickel and dime" us with the most unrealistic pain management tools and require us to solicit a new order each time.

The narcotic epidemic is bred, born, and nurtured in the clinics and the community, not in the ED.

Wrench Party

823 Posts

Specializes in Cardiology, Cardiothoracic Surgical. Has 3 years experience.

^ Agreed on this point. Off-service providers will barely write any pain Rx for various conditions, and I have to spend a good deal of wasted time arguing with them to even get some Tylenol or oxy. Just give me a PRN order for both and that would save half the calls.

1sttime

299 Posts

We must all have short term memory loss- somebody came up with the idea that a hospital should be like a hotel- patients became guests. Around this same time we were told "Pain is the 5th vital sign" and administrators gave us "No Pain" buttons, and said that the goal for patients was no pain.

Prescriptions were written, and the bar was set. Now like magicians first line clinicians are supposed to change the culture of addiction, without resources. We demonize these patients that we helped to create instead of having a real alternative to their suffering.

ServantLeader

6 Articles; 42 Posts

Specializes in Administrator inspired by nurses. Has 25 years experience.

I agree that the there is a tendency to be unsympathetic to narcotic pain addicts. It would be cheaper in the long run and better patient care to develop the addiction resources to treat them.

ServantLeader

6 Articles; 42 Posts

Specializes in Administrator inspired by nurses. Has 25 years experience.

HA - that's poignant and funny.

NutmeggeRN, BSN

8 Articles; 4,569 Posts

Specializes in kids. Has 40 years experience.
We must all have short term memory loss- somebody came up with the idea that a hospital should be like a hotel- patients became guests. Around this same time we were told "Pain is the 5th vital sign" and administrators gave us "No Pain" buttons, and said that the goal for patients was no pain.

Prescriptions were written, and the bar was set. Now like magicians first line clinicians are supposed to change the culture of addiction, without resources. We demonize these patients that we helped to create instead of having a real alternative to their suffering.

THIS... a thousand times over!

Specializes in ER.

as a pretty new (3yr) nurse, I must ask... why do we cater to these types of "I have allergies to toradol and morphine and must have my dilaudid with phenergan/benedryl" kind of people? Please, there is no need to get "liberal" with me, you know we all have too many of these kinds of pain seekers coming in making a show for narcotics or benzos or what not. What is in for the hospital or ER docs to cater to them? I just don't get this. Registration tells me their ER bills disappear after 7 yrs, most of them have no insurance and don't even pay the bills, so there is absolutely no financial gain from these people, let alone reimbursement (or is there?). So why not just firmly tell every single one of these opiate-addicts who frequently come that we will not give them anything? Why can't we do that?