Drug Seekers

Anna Flaxis, BSN, RN · Jun 20, 2014

If I can't find compassion for young unmarried women in labor I shouldn't work in L&D,
If I can't handle crying and screaming children I shouldn't work in pediatrics,
If I can't tolerate walking into a cluttered filthy home to provide nursing care I shouldn't work in home health,
If I can't find compassion for those who suffer from addictions and substance abuse I probably shouldn't work in the ED.

The flaw in this logic is that the *purpose* of the L&D unit is to deliver babies. The *purpose* of a pediatrics unit is to care for sick kids. The *purpose* of home health is to care for people in their own homes.

The purpose of the Emergency Department is to rule out or stabilize and treat those with life or limb threatening conditions.

The fact that people use the Emergency Department as a primary care clinic, or to obtain drugs to support their addiction, or in an attempt to get a diagnosis for Symptoms That Have Been Ongoing Over An Extended Period Of Time But Are Clearly Not An Immediate Life Threat Because The Person Is Not Dead Yet is actually a problem that leads to Emergency Department overcrowding which results in loss of life and limb in the USA every day.

Imagine if a man was admitted to your L&D floor because he wanted an epidural for his back pain. Or an adult was admitted to your pediatrics unit because they were of small stature, or if the family member of your home health patient demanded the nurse's care since s/he is there anyway. These would be mis-uses of the services offered. And yet, when it comes to the ED, we're just supposed to suck it up and accept it as part of the package?

Give me a break.

I won't treat someone badly who comes to the ED for a simple cold or a blister on their finger. There's no reason to be disrespectful or rude to them. But they are not going to be at the top of my priority list. I will not be rude or disrespectful to the patient who is known to us from their multiple visits always demanding a take home pack of Percocet when it's not medically indicated, but aside from providing for their safety while under my care, they are not my priority- and it can be frustrating when their manipulative nickel and diming of my time takes me away from the person in the next room who is truly sick.

The healthcare system in our country is messed up. There aren't enough primary care physicians or family nurse practitioners to be able to adequately handle the public need. This is why so many come to the ED- because they know they can get rapid service compared to waiting weeks to be seen by their PCP. Many can't even get in to see a PCP because they are not accepting new patients or don't take Medicaid or that individual person's insurance.

Because of these things, I don't blame the patients who use the ED inappropriately- I get that there are real life reasons that they do this and I might even do the same were I in their shoes. But do NOT tell me this is what the ED is for and we should just suck it up, because it's not true. We are on the front lines of the health care crisis in this country, and the fact that this is true should be a big alarm bell and wake up call that something is terribly wrong.

Anna Flaxis, BSN, RN · Jun 20, 2014

You're correct that I don't have professional experience in ER. Just personal experiences that leave a sour taste in my mouth. Mother with Lupus who was labeled a drug seeker and hypochondriac for 10 years before finally being diagnosed. Also experience with my own round of inappropriate labels. I can see how it's easier to laugh but your OP still seems as though the patient is being ridiculed.
In any case I'll chalk it up to posts not expressing the correct inflection.

I'm sorry that your mother has Lupus, but the ED does not typically diagnose Lupus for a number of reasons.

In most cases, the ED physician is "ruling out" immediate life threats. This is not the same as "diagnosing". So, if your mother presented with neurologic symptoms, for instance, the ED physician would rule out the most life threatening neurologic conditions, such as stroke. Further testing to find out the cause of her symptoms will be the domain of the physician that she is referred to for follow up.

Often, the process of diagnosing a condition such as Lupus is a process of elimination that occurs over time as there is no single definitive test for Lupus. This is not the domain of the Emergency Department.

Unfortunately, it is true that a person who keeps coming back for years and years with vague complaints that never result in an emergent diagnosis will often be labeled as someone who may be attention seeking, drug seeking, or malingering. This is true, and I won't deny it. However, the wise clinician takes each visit seriously, because there really *could be* something wrong this time. It is not wise to become jaded toward this patient population lest we overlook a true life threat.

By the same token, it is also true that people malinger, for a variety of reasons. Not every patient is truthful, and many manipulate for secondary gain. It's a fact, and sometimes the behaviors and machinations displayed by this population can range from amusing and entertaining to downright tragic and can have a significant impact on us, the caregivers, hence our need to cope- sometimes using dark humor or even making fun of them.

For a person who is not an ED nurse to come into a forum for Emergency Nurses to vent and discuss their frustrations and admonish us for the way we choose to cope is really pretty rude.

If you've never walked out of an unsuccessful code to be lambasted by a patient with chronic back pain/migraines/cyclic vomiting (who visits your ED on a weekly basis and never fills their scripts or follows up as directed and has a million excuses why) for "what took you so long to get here, I've been lying here in pain, I'm going to get you fired blah blah blah", then I don't feel like you have much room to criticize.

toomuchbaloney · Jun 21, 2014

The flaw in this logic is that the *purpose* of the L&D unit is to deliver babies. The *purpose* of a pediatrics unit is to care for sick kids. The *purpose* of home health is to care for people in their own homes.
The purpose of the Emergency Department is to rule out or stabilize and treat those with life or limb threatening conditions. Give me a break.

I agree...that is the purpose of the ED philosophically and ideally. Realistically what service does the ED provide in many communities? While we all strive for the idealistic we live and work in the real world where substance abusers come to the ED regularly. Increasingly and as you have mentioned, too many people found themselves without access to other healthcare and have been reduced to using the ED as their primary source of health care. That fact is not a secret and health professionals who are going to have a personal or professional issue with the care of those folks might want to reconsider that area of work, IMHO.

I surely didn't intend to annoy you or anyothers, but it seems pretty straight forward that if dealing with drunks, people with drug abuse problems, people with chronic pain issues, or poor people who have no where else to go, is going to cause you to feel annoyed and used you might want to think twice about working in the ED.

malamud69, BSN, RN · Jun 21, 2014

Humans....we are talking about humans...right? Nothing....I say...NOTHING surprises me when we are talking about humans...why view the behavior with such a narrow lens?

Anna Flaxis, BSN, RN · Jun 21, 2014

I surely didn't intend to annoy you or anyothers, but it seems pretty straight forward that if dealing with drunks, people with drug abuse problems, people with chronic pain issues, or poor people who have no where else to go, is going to cause you to feel annoyed and used you might want to think twice about working in the ED.

As I stated in my post, I do understand why people mis-use the ED, and as I also stated, I might find myself doing the same were I in their circumstances. Also as I stated, I see no reason to be rude or disrespectful to such patients. They will simply not be my top priority- caring for those who are actively trying to die are my priority. It is the "Emergency" Department, after all.

And again, if you have never walked out of an unsuccessful code only to be berated by someone who is *not sick*, you don't really have any room to criticize how those of us who experience that regularly for how we cope.

Guests · Jun 21, 2014

While it is true that there are many people drug seeking, I urge you to remain compassionate and LISTEN to your patients before you judge them. I have a very dear friend who has been unable to keep a job and therefore insurance because she has a rare disorder called Sphincter of Oddi disease that has just been diagnosed now that she has insurance under the ACA after finally undergoing and ERCP. I mention her because of the countless times she has gone to the ER over the past several years in excruciating pain to be dubbed a drug seeker and under medicated and discharged. She has nearly died a couple of times due to dehydration and electrolyte imbalances related to vomiting and been septic due to undiagnosed pancreatitis. As an RN I am embarrassed when she relays the barriers she has received to care. We must be careful not to stereotype people, even the frequent flyers who drive us crazy, without ensuring that there isn't an underlying, legitimate cause to their pain. As her friend, I have instructed her to carry MD documented medical history/summary with her in hopes that any future episodes that she has are met with understanding and compassion.

People like your friend are precisely why so many of us have grown so impatient with the people looking to score a hit of the good stuff... they suck up scarce resources which limits care for people like your friend who are in genuine need.

When people come in allergic to Toradol, morphine, hydrocodone, compazine, reglan, zofran, haldol, and Benedryl but demand treatment for their 20/10 pain and intractable nausea, it's hard not to be jaded. So all that we can give you is Dilaudid and phenergan... and we won't even be able to treat an allergic reaction? Yeah, I've even had people claim an allergy to epi...

Guests · Jun 21, 2014

it seems pretty straight forward that if dealing with drunks, people with drug abuse problems, people with chronic pain issues, or poor people who have no where else to go, is going to cause you to feel annoyed and used you might want to think twice about working in the ED.

It's not the *people* with the issues that are the problem, it's the behavior that some of them choose to manifest.

I've come across plenty of respectful junkies and drunks... but the junkie who screams at me because I can't easily get an IV in the veins that they themselves have destroyed... I have not much compassion for them.

The drunk who is quiet and understanding of my workload... fine... the drunk who's a "instant a-hole, just add alcohol" type who calls the ladies the c-word and spits and hits... honestly, I don't give a rat's behind what becomes of them... I'll keep 'em alive to the best of my ability but they're low on my priority list.

My reserve of compassion and empathy is not limitless and some do everything in their power to wipe it out.

ICURN3020 · Jun 21, 2014

Kudos for you for taking that attitude.
I think it's really sad that "drug seekers" have become fodder for "tell me your funny stories" here on All Nurses. These people have issues with drugs and need help, not you laughing behind their backs because the doctor didn't prescribe them pain meds.

Yes, these people likely are dealing with personal/social problems that have led them to self-medicate as a coping mechanism. They need to be offered and encouraged to use available services (social services, counseling, rehab) that are in place to help them live a better life.

Anna Flaxis, BSN, RN · Jun 21, 2014

Yes, these people likely are dealing with personal/social problems that have led them to self-medicate as a coping mechanism. They need to be offered and encouraged to use available services (social services, counseling, rehab) that are in place to help them live a better life.

These services aren't readily available. Inpatient rehab can have long waiting lists and be unaffordable. Outpatient services can be few and far between. Plus you can't force anyone to use them. You can only suggest, but they have to be ready to make the change, and typically folks who come to the ED for narcotics are not ready to change.

I have cared for a few people intentionally withdrawing from opiates, but they are few and far between.

Anna Flaxis, BSN, RN · Jun 21, 2014

Yes, these people likely are dealing with personal/social problems that have led them to self-medicate as a coping mechanism. They need to be offered and encouraged to use available services (social services, counseling, rehab) that are in place to help them live a better life.

And, I wanted to add but couldn't edit my post because too much time has passed, this is a big "Duh". Any ED nurse is totally aware of how we "should" handle patients with substance abuse problems. You try offering a Narcotics Anonymous referral instead of a Percocet take home pack and see how well that goes over. It's nice to be idealistic, but then there is reality.

ICURN3020 · Jun 21, 2014

These services aren't readily available. Inpatient rehab can have long waiting lists and be unaffordable. Outpatient services can be few and far between. Plus you can't force anyone to use them. You can only suggest, but they have to be ready to make the change, and typically folks who come to the ED for narcotics are not ready to change.
I have cared for a few people intentionally withdrawing from opiates, but they are few and far between.

I understand how my comment may appear simplistic or, using your vocabulary, "Duh" when taken out of context and inserted into the middle of your argument. I was not replying to a thread titled "The Complex Issues of Substance Abuse Patients and the Difficulties ER Nurses Face"

Please don't take this as an apology for my original comment, as I meant what I said. Let me explain though - the OP's first post comes across (to me at least) almost as though they are looking for "drug seeking stories" for amusement/entertainment purposes. My comment was made based on my interpretation of what the OP was looking for. I was repying to the OP, not taking into account how the thread had developed. Lesson learned. Apparently I should have directed my comment directly at the OP.

I have noticed many threads that change direction or even topic entirely based on replies posted. So perhaps before making a rebuttal about a certain comment, one should take this into account. To me, this thread has went from a simple "tell me your drug-seeking patient stories" to "why we should or should not have sympathy for drug-seeking patient" to "ER nurses feeling like they must defend themselves and their views of drug-seekers". I posted my first comment based on my interpretation of the original thread topic. I think my intention was pretty obvious based on the quote I chose that I was responding to the OP seemingly seeking amusing drug-seeker stories. You chose to take my comment and refute it as if I was disputing how ER nurses handle drug-seekers?!?! Reading over a few of the other early posts, I don't think I am the only one who interpreted the OP's request as one for simply "funny stories" about drug-seekers.

binzy · Jun 21, 2014

I was on an oncology floor for clinicals and this lady would scream nurses names all day long for some opiods lol she fired her doctor and nurse for not administering them. But still if someone has this sort of illness why the heck not!