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.
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.
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?
I worked at an ER where we frequently did that. If pt had multiple scripts in the California registry. The nurse and doc sat in the room together, explained we were not allowed to prescribe because of this and they needed to see their primary doc and we were happy to ensure a follow up with a pain specialist. Usually works better with both of us there in force. If we were not together they'd keep trying to manipulate one or the other. Where I'm at now I notice it's very physician dependent. I wish the rules were consistent across the board, it makes things easier for all.
The abuse from drug seekers is unacceptable. In Washington there is a law about disrupting a hospital that includes yelling and shouting or otherwise threatening nurses or physicians. I am pretty firm with the people who put on a show and point to that law...and then they usually walk out.
I have been advocating more and more the opioid-free ED (Home). This guy has studies and information about treating common painful conditions with alternatives to narcotics. He has run trials of "shifts in the ED without opioids" successfully. I think part of the problem is that numbing people to their pain with narcotics is the easiest way to deal with patients in a busy environment. Physicians and nurses need to take time and utilize their knowledge and evidence to address pain more deeply, rather than spraying everyone with happy juice. Then those with true pain get the relief they deserve and the abusers come out of the framework.
Back when I worked the hospital, you may slip by once or twice, and get some medication, you know, you have to give them the benefit of the doubt the first time or two. But we kept pretty close tabs on patients who were seekers (no, not the Harry Potter seekers, but if some of these people were so high they probably did think they were zooming after a golden ball on a broomstick) but anyway.. after a few times we found out who you were, tabbed your name into our memory, and bounced your name around the group. So when your name was tabbed in our ''almost no narcotic list,' you were found. If you argue with us, we told the nurse to get the AMA paper. Of course we ran full labs and imaging as needed to make sure nothing was wrong (big waste of money of course most the time) but you did not get what you want.
They learn after a few times. Our hospitalist group was very cautious with pain meds, in those who were proven to be seekers. But if you had an actual problem, you get the narcs to stay comfy, as anybody should that has an actual issue causing pain.
And if you take home narcotics, you get a drug test and a registry ran on you, then if everything checks out, you get them at your home dose. If you get hard to deal with, that Q6 just turned into a Q12 at half your regular dose.
ER worked the same way pretty much, almost always they only gave toradol.
It's usually out-of-the-box thinking that come up with better responses and patient care. My experience is when an opiate patient realizes there is not other course available, they will either seek help or move to street drugs. So the answer needs to be multi-faceted and extend outside the walls of the hospital.
Honestly, I'd rather deal with drug seekers than drunks.
That being said - my biggest problem with chronic users/pain management patients; is that they take ER beds away from patients with legit medical problems.
Nothing makes me more upset than having 80 year old grandma with severe abdominal pain and vomiting waiting in the waiting room or scrambling to 'squeeze in an extra stretcher' for the EMS squad that just brought in a nursing home patient with an obvious hip fracture for a stretcher; because the last open stretcher was occupied by a seeker.
It would help if the seekers were understanding and polite/co-operative. But they rarely are. All you get is abuse - usually verbal, sometimes physical. As a nurse, I sympathize they have an addiction and that they're in pain/withdrawal. But somehow they NEVER seem to sympathize with me and the fact that I have patients more critical than they are. Or the fact that the Doctor is busy dealing with critical patients. And THAT is what REALLY irks me off...
Wow, this is such a good post and really hits home as I have a family member who in the past was addicted to pain meds and its crazy to think how many people have this issues and the extremes they will take to get the meds (the gun point story).
Makes me think of the patient I had recently who had been getting Dilaudid for "side pain" (actual admitting diagnosis was PNA/COPD exacerbation). CT, Xray, and Ultrasound were all negative. Physician informs patient that pain is almost certainly pleuritic in nature and they would be DC'ing the Dilaudid, and she would have to just manage with her (very large) dose of home Percocet and Opana. She IMMEDIATELY says "So I can go home, right?" Physician tells her no, she still has Pneumonia and is still getting nebs Q4 while awake along with 3 different antibiotics and hi-dose solumedrol and that she needs to be in the hospital for that.
"But if you're not going to treat my pain, why can't I go home?"
"Because the pleural pain will go away on its own as the pneumonia resolves. You've had Dilaudid for several days now, the pleurisy should be resolving soon, and we are weaning you back to your home meds. You still have pneumonia, and if we don't treat that, it WILL kill you. Pain will not."
Needless to say, the patient was not happy. I just find it funny (in a sad way) that she didn't care that she had pneumonia, and that it could kill her. She just wanted pain meds.
These patients are often operating from a place of self-delusion, convinced the world is against them. It's their defense mechanism so they don't have to admit they are addicted.
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.
I have fibromyalgia. Many years ago, my PCP gave me a script for hydrocodone, which I rarely used--it makes me loopy, but does very little to actually relieve the pain.
I had a total abdominal hysterectomy 12 years ago. As I was leaving the hospital, the nurses tried to give me a script for hydrocodone. The nursing staff had all been pleasant, polite, and professional throughout my stay. I politely turned down the script, because I knew I had an almost-full bottle of hydrocodone at home. The nurses thought I was trying to be "stoic," and said "Trust us, honey, you'll need the script!" I smiled politely and said "No, *you* don't understand, I have an almost-full bottle at home!"
Instantly the nursing staff's attitude did a complete 180. "What do you mean, you have an almost full bottle at home? Where did you get it? *We* didn't give it to you!" and so on. It took about five minutes of convincing before they'd let me leave the hospital, *without* the script they'd tried to give me in the first place.
As I used to tell my late, lovely father-in-law it's OK to use pain meds if you have pain. He had an unusual late stage cancer of the bile ducts and he was afraid of getting "hooked" on pain meds. He was a retired Navy pilot and of the generation that toughed-out their pain. It seems to me the answer lies somewhere in the middle, but I do not have experiences such as yours to really have an insightful opinion. You sound tough, too. :)
Aww, thank you. I've been through 17 shunt surgeries (I'm hydrocephalic), so my pain tolerance is higher than most ppl, but after the hysterectomy I was popping the hydrocodone like candy. Take two, fall asleep for a few hours, wake up, take two more, fall back asleep, etc. I was basically awake long enough to bathe, eat, and go to the bathroom for the first two weeks post-surgery. Haven't touched any hydrocodone since.
Our society has catered to this behavior for so long. People expect to be pain free when they come to the hospital. It is a part of that "right now" mentality that has developed nationwide. And now we have suboxone clinics, which are supposedly opioid addiction management centers. Ha. It's like trading one addiction for another.
I wish people would see that when you continually take these opioids just to get high, and then actually need them for pain after mvc or surgery, these medicines won't work any more.
Until nationwide standards are set, we as health care providers will continue to deal with this problem. I wish more administrators were as supportive as you are. I think if more CEOs took phone calls from these people or had to come into the hospital in the middle of the night to deal with this, our plight would be seen and we may actually get the raises and support we deserve!
NickiLaughs, ADN, BSN, RN
2,387 Posts
I worked at an ER where we frequently did that. If pt had multiple scripts in the California registry. The nurse and doc sat in the room together, explained we were not allowed to prescribe because of this and they needed to see their primary doc and we were happy to ensure a follow up with a pain specialist. Usually works better with both of us there in force. If we were not together they'd keep trying to manipulate one or the other. Where I'm at now I notice it's very physician dependent. I wish the rules were consistent across the board, it makes things easier for all.