Drug-Seekers

Whispera, MSN, RN · Mar 1, 2010

I'm with you on all you said, and want to put forth the other side...

Addiction is a medical problem and being an addict and not having your drug is physically as well as mentally terrible. Withdrawal can kill a person. So, addicts do anything they can to get their drugs, including clogging up the ER. If only there was a way to get them into treatment that they both would WANT, and that would be effective and lasting! Until that can happen, I think having addicts in the ER will continue. It's a huge problem, but a bigger problem for them than it is for you, I think.

inteRN · Mar 1, 2010

yeah... I guess I just don't understand it. That's why there is an entire specialty devoted to addiction! I always thought it was dangerous to drug them up more than they are, but when you speak of withdrawals, I guess that's even more dangerous...so how do you stop the cycle? How come PCP's can say, "sorry, not refilling" but ER docs have to?

Whispera, MSN, RN · Mar 1, 2010

ER docs don't have to refill the meds either. Some are jerks, most aren't. They just consider the benefits to everyone if they refill the Rx compared to the negatives to everyone. I bet they have some inner battles with their thoughts in this, quite often.

Sadly, there aren't enough addiction programs, and they cost alot, and they aren't tremendously effective in the long run. I wish I was wise enough to come up with something that would work!

Editorial Team / Moderator · Mar 1, 2010

The cycle usually stops when the person fatally overdoses, or realizes he/she has a problem and seeks treatment. I know, it's tough to deal with from many perspectives, but I keep in mind that it's much, much worse for them than me. I try hard not to judge, and to treat them with compassion; after all, he/she has to live his/her life, and it probably isn't great with this constant need hanging over them.

Some of our docs have now been given access to a website (sponsored by the DEA, I believe?) that will allow them to see narcotics recently dispensed to patients. Many of them are refusing to write narcotic scripts to people who just had 90 Oxycontin dispensed a few days before. It seems that there is a greater awareness of the problem, and many of our docs refuse to give our more frequent visitors their narcotics of choice any longer.

I know one patient who had a naltrexone implant placed when she went to rehab, after she realized she was an addict ... it really worked for her, and she's doing great!

NurseGloria · Mar 1, 2010

With your attitude, you need to work elsewhere. While it is true that there are patients who have a substance abuse problem, there are patients who have pain from undiagnosed, painful conditions.

I know this from personal experience. A couple of doctors made errors concerning a cervical spine fracture I sustained in an automobile accident. They assumed that the severe right shoulder pain that I had every few months was related to my cervical spine.

The pain that kept coming back and that also caused me to have nausea and vomiting forced me to go to the ER. It was unendurable, but was usually relieved by Demerol IM but not by natural opiate medication.

Some ER docs did cervical spine xrays and always decided the pain was from my cervical spine. Then somebody decided I did not really have pain and that I was just a drug seeker. I couldn't get a doctor to see me outside the ER. I was terminated from every position at 90 days even when I was told I was doing a good job.

I was treated horribly by doctors and nurses in ERs for many years. I was arrested for "criminal trespassing" at one ER. I was wheeled into the parking lot on a cart through the waiting room at another. I don't know how to describe what it feels like to be in excrutiating pain and have a doctor shouting in your face that you are not getting drugs from his ER.

Eventually, I became jaundiced, got pneumonia, and had other symptoms that led me to my own diagnosis of gallbladder disease. I was refused care at a local ER again and made may way to the DON's office. She called a nurse practitioner to the office who tried to get me care in the ER. The doctor still refused, so she got me an appointment right away with a hospitalist.

I finally was diagnosed and had my gallbladder out. I have had no more pain since 2003. There is much more to this story, but at least I am alive after 22 years of being treated quite badly and suffering a lot.

Listen to your patients and have compassion for them. If you can't, do something besides nursing.

BrnEyedGirl, BSN, MSN, RN, APRN · Mar 1, 2010

Another sad part of this is that yes,.some docs will go ahead and do a full work up,..addicts can and do get sick also. We have pt's that have had 20 plus CT's over the last year or two in our ER alone. What kind of health problelms is that going to cause over the years! It won't get better until people are forced to take some responsiblitly for there own health. If we refer you and you don't follow up, who's fault is that? If we work you up 47 times in 2 yrs for your chronic belly pain and NEVER find anything wrong,...then the one time the doc who has seen you 30 of those times says no more,..and you do have something wrong, how is that all the doc's fault?

I understand that addiction is an illness that needs to be treated,...but not in the ER.

allennp · Mar 1, 2010

its a tough issue, with your family background the ED might not be a good place for you to practice. Though I wish to point out to another poster that narcotic withdrawal will not kill you, other rx will but not narcs, you just wish you could die. That being said until tort reform happens it is safer and easier to treat pain and not get into judgements. You need the support of the facility you practice in to restrain overuse of a ED for narc refills, and dosing. Policy an procedure is helpful eletronic records for rx history, ID's required for rx. et et et

ap

NurseGloria · Mar 1, 2010

Referrals from the ER are no good to someone with no health insurance. I was not allowed to follow up unless I had $300 up front for the initial appointment and labs. I didn't have $300.

As for tort reform, that turns out to be unnecessary when doctors can and do blacklist patients, their families, and malpractice lawyers. Most people know it. Everybody needs a doctor sooner or later.

When the state politicians are in the insurance business, maybe they have some pull with the ARDC and the DPR to get help protecting their interests. Ya think?

I don't mean to seem harsh. But when ER employees get burned out, they should do something else.

Virgo_RN, BSN, RN · Mar 1, 2010

Withdrawal can kill a person.

Alcohol withdrawal can kill a person. Opiate withdrawal is rarely fatal.

We have a lot of patients with chronic pain who have medication agreements on file. This is a contract that specifies what medications they will be prescribed, the amount, and the need for the patient to follow up with their pain specialist if the medication is not working (rather than going to the ED). A plan for acute flareups is included. This plan might state something to the effect that the patient agrees to only seek treatment at the ED related to their chronic condition twice a year, and that the drug they will receive will be a maximum of 2mg of Dilaudid on each visit, for example. Our ED docs are able to access these medication agreements via the computer system, and know when someone is violating their medication agreement.

We also have a referral system for followups for those that do not have a PCP. Physicians who practice under the umbrella of the healthcare organization that operates our hospital are obligated to take these referrals, whether the person can pay or not. Beyond the follow up appointment, I don't know how obligated the physician is to continue to see that patient, but they have to at least see them for their follow up. If the patient is an inpatient, then social work will get involved to get them on the state run health care plan or find them the appropriate resources.

The way I see it is that if addiction is a medical problem, then it is a medical diagnosis that any doctor, including an ED physician, can make. If the physician makes the diagnosis of narcotic dependence/addiction, then there ought to be resources in place to offer these patients, such as low cost detox and continuing support. If every time the addict came to the ED for their fix, the doctor diagnosed them with narcotic dependence/addiction and gave them a referral to a detox program, then the EDs would see less and less of this type of abuse of the system, and more addicts would truly be helped. There are low cost resources like this in my community, but not enough. Like the mental health system, addiction services are woefully underfunded (because there is no money in it), and this is one of the things at the root of the problem.

I'd like to point out that just because a nurse might have their own opinion on the use of the ED for the purpose of obtaining pain medications inappropriately does not mean that she or he is unfit to work in the ED. I have strong opinions on the inappropriate use of the ED, but I still treat every patient with courtesy and professionalism.

Whispera, MSN, RN · Mar 1, 2010

"Alcohol withdrawal can kill a person. Opiate withdrawal is rarely fatal." Agreed. However, the operative word is "rarely." Then there are benzos....

screamin mimi · Mar 1, 2010

Please. Just because someone is frustrated with the VERY real problem of drug seekers in the ER does not mean they shouldn't be working in the ED.In fact, I'd argue that it's irresponsible to council our new nurses to ignore the issue and their own instincts for some pollyanna world view.

Nursing should be patient advocates. However, truly advocating for a patient does not mean that we give them whatever they want, especially if what they want can (and will) hurt them.

The attitude du jour of the "patient is always right" came out of a right-minded effort towards patient empowerment and education but has gone too far. The patient is not always right. We are medical professionals and as such we are obligated to do what is right for the whole patient. And sometimes that means saying "no."