Drug Seekers- the Wrongfully Accused

FutureNrse · Feb 16, 2005

Oh, so true!!!! My husband is a big, macho guy who never lets pain get him. However, he had a kidney stone, and was in such severe pain, that all he could do was chew on a towel and scream. I took him to the ER, and the doc was gonna give him a muscle relaxer and send him home. The doc thought my husband looked like a drug seeker (he has never taken anything stronger than a Tylenol), and told the ER nurse this. well, the doc failed to remember that I was a nurse at the hospital, so the ER nurse told him he better talk to the patient's wife (me) before giving a muscle relaxer and ending him home. The doc came back, and I told him that he was NOT going to send my husband home without doing a spiral CT and giving him some Toradol. He asked me how could I possibly think that would help a pulled muscle. I told him " It is not a pulled muscle, it is a kidney stone, you moron!" He asked me how I knew that and I told him "Why don't you ask your ER nurse how I know that?" She was in the background laughing her #ss off as she told him I was a nurse there!
He immediatly apologized and did what I asked!! And don't you know, that pulled muscle turned out to be a kidney stone afterall!!

Your husband is lucky to have you on his side. It's too bad that the average person doesn't have you to go to bat for them, and instead they get the muscle relaxer ( if that ) and get sent home.

FutureNrse · Feb 16, 2005

OOH, and another story!!! I was down in the ER one night. A young guy comes in ( a known drug abuser) and says that he is taking Oxycontin 60 mg for his back pain and it not killing the pain. He said he talked with his pain control doc and the doc told him to come to the ER to get something stronger than Oxycontin. Well, imagine his surprise when I informed him that there was nothing stronger than Oxycontin!!! He then left without another word!!!!

But is this actually true? I was under the impression that "stronger" doesn't really apply when discussing pain meds. It's also quite common for different people to have different reactions to different drugs. So if his Oxycontin wasn't helping his pain couldn't he have been given Morphine, or Dilaudid to see if it was more effective? Also, he might have just needed something for breakthrough pain to take with the Oxycontin. If that was the case, he could have been given a shot of something and instructed to contact his pain management doctor for a regular prescription for break through meds.

I just don't feel that it was accurate for you to tell him that there is nothing stronger than Oxycontin.

I would like to hear other opinions on this please.

FutureNrse · Feb 16, 2005

Pain control in the ER is such a dilemma.
I want everyone with pain to be appropriately treated.
I want everyone who has a prescription drug abuse problem to be appropriately treated.
It's just kinda hard to sort out the two.
Everyone on the pain bandwagon knows that it's poor medical care to undertreat or not treat a patient with pain. As a matter of fact, you can be held legally liable.
However, it's also poor medical care to treat patients with substance abuse issues inappropriately. And you can certainly be held liable here as well.
So, what do we do?
I pretty much think we need to find our own comfort zone. For me, it's pain medication for those with acute pain complete with a 'script for enough meds until they can see their own doc.
For those with chronic pain, it's a shot in the ER and then home to rest. No prescriptions here - I believe that's the responsibility of the pain control doc and the patient to ensure they have the appropriate medication at home at all times. However, there are those rare times that a something else is needed.
For our frequent fliers (and we all know who they are), I'm not sure. One of our docs always drug screens them before giving any medication (and you would be surprised what shows up - "I have no idea how that got there...."). I often sit down with the patient and tell them that their behavior is consistent with people who are using medications inappropriately and ask them if they have a problem. Sometimes people tell me yes. So I offer to call the mental health folks, and occasionally someone agrees to go off to rehab. If not, I give them referral numbers and hopefully something to think about.
Please don't forget that prescription drug abuse also ruins the lives of the patient, their family and friends.
Nobody said it was an easy job.

What a great post, no one has said it as well as you just did. It seems like you really and truly try to do the right thing for all patients. I have thought of some possible ways to deal with the FF's.

First, if the FF always has the same complaint, Migraines for example, then they should be informed that they are visiting the ER too often, and be told that they will no longer be seen for this and they must seek the proper care for this outside the ER. If they already have a PCP then advise them that the PCP will be notified of the excessive ER use and asked to work out a better care plan.

If they still return to the ER after that, they will be assesed, but will not receive narcotic pain medication. It may also be necessary to inform the very stubborn FF that other ERs in the area will be notified as well. I think that this will either force the FF to handle the problem appropiately, or if nothing else it will cut off thier supply. I think that it should be stressed that this type of plan only be used for the truly troublesome FF's.

I know that this will create a little more paperwork, and require some dedication in order to follow up and see the plan through, but I really believe that it will save the ER's a lot of time and money in the end.

Some do not have medical insurance, and may use the ER to treat chronic conditions out of desperation. If this is the case with a patient, they should be referred to a social worker to see if they can qualify for any free or reduced insurance, or sliding scale clinics. When I worked in social services, I was always amazed at how many people knew nothing about state medi-cal programs, and clinics that cater to low income patients. I was always happy when I was able to get a person in need the proper medical care.

Thanks again for a wonderful, compassionate post. Good job! :balloons:

FutureNrse · Feb 16, 2005

When I was 18, I had two wisdom teeth pulled. Got dry sockets. Other than childbirth (which hadn't yet occurred for me!), I don't think I've ever had pain like that. I called my dentist and he automatically assumed that I was drug-seeking.
Was I ever P*ssed! I have never had that experience since then, and will not subject my patients to that kind of treatment either.

Ohhh how awful for you. I've been through dry socket too and I agree that it's excruciating and there is no let up in the pain until it's healed. So that means days and days of unrelenting agony. I'm so sorry you went through that and hope your dentist gets a nice case of something equally painful and ends up with you as his nurse! haha

FutureNrse · Feb 16, 2005

I think all patients should be given a menu, and allowed to choose their own medicine. Maybe even have a specialty flavor of the day.
Pina Colada Demerol
Tomato Juice with Methadone
Dilaudid Martinis
Stadol and Tequila Sunrise
Nubain and Tonic
Long Island Talwin

Can I just have mine with a coffee chaser?

FutureNrse · Feb 16, 2005

Please don't take this the wrong way...but the problem with drug seekers in the ER is that they are taking up beds that are needed by real sick patients! And all we are doing is feeding into their behavior by giving drugs that they don't need. I am in an ER that sees 90,000 pt's a year. It is crazy, chaotic busy all the time. We have 3 hallway that we house up to 4 pt's in almost everyday. And I for one am tired of seeing the same people come in every other day for the same bogus complaint of a migraine. I for one feel that the doc's need to stand up to these patients and stop giving them narcotics so that they will stop coming in for the BS complaints. Now that being said I am a very big advocate of getting my patients pain under control the minute that they get into the room. I will hunt doc's down to get an order for pain meds for people that have flank pain and are probably a stone, people that really do have migraines etc. I am not a person that judges you just because you were here with a migraine 6 months ago. But I am sorry I do judge you if I know your name, hx, allergies and complaint the minute that you walk up to the desk and sign in. If I see you more than I see my family...that is a problem!

I understand what you're saying, patients like you described have to be a drain on the staff. They should be cut off when the number of visits becomes extreme. They should be given proper notice that they're being cut off and why, and given appropriate referrals so that they can deal with the problem the right way.

If it's a FF who has a chronic pain issue, and they have a PCP or pain management doc, then maybe they should find a new one. If they keep coming to the ER when they have regular care, it would seem to me that the regular care isn't adequate, give them a list of other MD's. Heck, make up packets to give to FF's when you inform them that they're being cut off. It can contain lists of local doctors, clinics and specialists. Information on medical insurance, low income programs, and clinics with sliding scale fees. Social service information, for help with chronic pain, drug abuse and addiction. The point is, don't leave them high and dry. Give them plenty of options while making it clear that although they will no longer receive narcotics in your ER, there are other options available and they need to utilize them. You can even include a form for them to give to thier PCP, that must be faxed to the ER from the PCPs office number, that allows them to use the ER again if the doctor feels that it may be OCCASIONALLY necessary. The doctor should even have to list what medications would be appropriate for the patient if they should need to visit the ER again.

Make them work for it, make them prove that are taking thier healthcare seriously and handling it responsibly. If they truly need ER services sometimes, then they will do what is necessary, if they won't do what is necessary then chances are they were just looking to get high.

The best part is, that you know you're doing the right thing either way. You'll be able to either give them the shot with positive feelings or say good riddance without a drop of guilt.

teeituptom, BSN, RN · Feb 23, 2005

Just have a vending machine in the waiting room, insert you credit card, make your slection, demerol,morphine,dilaudid,whatever, drop your drawers and bend over and get an injection of your choice

Make life simple.

Keep it in the short grass yall

curleysue · Feb 23, 2005

What a great post, no one has said it as well as you just did. It seems like you really and truly try to do the right thing for all patients. I have thought of some possible ways to deal with the FF's.
First, if the FF always has the same complaint, Migraines for example, then they should be informed that they are visiting the ER too often, and be told that they will no longer be seen for this and they must seek the proper care for this outside the ER. If they already have a PCP then advise them that the PCP will be notified of the excessive ER use and asked to work out a better care plan.
If they still return to the ER after that, they will be assesed, but will not receive narcotic pain medication. It may also be necessary to inform the very stubborn FF that other ERs in the area will be notified as well. I think that this will either force the FF to handle the problem appropiately, or if nothing else it will cut off thier supply. I think that it should be stressed that this type of plan only be used for the truly troublesome FF's.
I know that this will create a little more paperwork, and require some dedication in order to follow up and see the plan through, but I really believe that it will save the ER's a lot of time and money in the end.
Some do not have medical insurance, and may use the ER to treat chronic conditions out of desperation. If this is the case with a patient, they should be referred to a social worker to see if they can qualify for any free or reduced insurance, or sliding scale clinics. When I worked in social services, I was always amazed at how many people knew nothing about state medi-cal programs, and clinics that cater to low income patients. I was always happy when I was able to get a person in need the proper medical care.
Thanks again for a wonderful, compassionate post. Good job! :balloons:

I think that is a good idea. When a frequent flyer does come in why doesn't the nurse take a minute to sit down with them and tell them straight up that this behavior has been recognized and it not acceptable and to let them know the exact thing Future Nurse has said, the PCP will be notified and asked to help you find out a good care plan for the patient when this happens instead of seeking narcs in a ER.

I think a lot of patients who have this behavior get away with it in the ER and nobody attempts to sit down with them and let them know that they are being watched closely cause of the behavior. I have seen a lot of nurses just shut their mouths cause they are afriad of opening them in fear they will uncontrolably go off on the patient. But seriously the FF who come in and don't hear anything about being watched will just continue coming in and getting what they want not knowing its unacceptable.

I also think its a great idea to get Social Workers somehow involved in getting help for them if they don't have a PCP and are experiencing chronic conditions. I know Social Workers might have a big problem with that saying they don't have the time to deal with FF but then maybe we need more Social Workers?!

I think instead of keeping the frustation of it all to ourselves, let the patients know that yes, this is unacceptable behavior and next time you will not recieve narcs. I don't know if that would work, but something needs to happen. Course there will be those FF who work the system and still get away with it but I do believe that we could get lucky with a few FF and they may admit they have a problem.

Just an idea. Curleysue :confused:

UM Review RN, ASN, RN · Feb 23, 2005

I think that is a good idea. When a frequent flyer does come in why doesn't the nurse take a minute to sit down with them and tell them straight up that this behavior has been recognized and it not acceptable and to let them know the exact thing Future Nurse has said, the PCP will be notified and asked to help you find out a good care plan for the patient when this happens instead of seeking narcs in a ER.
I think a lot of patients who have this behavior get away with it in the ER and nobody attempts to sit down with them and let them know that they are being watched closely cause of the behavior. I have seen a lot of nurses just shut their mouths cause they are afriad of opening them in fear they will uncontrolably go off on the patient. But seriously the FF who come in and don't hear anything about being watched will just continue coming in and getting what they want not knowing its unacceptable.
I also think its a great idea to get Social Workers somehow involved in getting help for them if they don't have a PCP and are experiencing chronic conditions. I know Social Workers might have a big problem with that saying they don't have the time to deal with FF but then maybe we need more Social Workers?!
I think instead of keeping the frustation of it all to ourselves, let the patients know that yes, this is unacceptable behavior and next time you will not recieve narcs. I don't know if that would work, but something needs to happen. Course there will be those FF who work the system and still get away with it but I do believe that we could get lucky with a few FF and they may admit they have a problem.
Just an idea. Curleysue

I think that the problem is that someone could be misidentified as a drug seeker and then the hospital and all caregivers would be open to a lawsuit, as an earlier poster describes.

BabyRN2Be · Feb 23, 2005

But is this actually true? I was under the impression that "stronger" doesn't really apply when discussing pain meds. It's also quite common for different people to have different reactions to different drugs. So if his Oxycontin wasn't helping his pain couldn't he have been given Morphine, or Dilaudid to see if it was more effective? Also, he might have just needed something for breakthrough pain to take with the Oxycontin. If that was the case, he could have been given a shot of something and instructed to contact his pain management doctor for a regular prescription for break through meds.
I just don't feel that it was accurate for you to tell him that there is nothing stronger than Oxycontin.
I would like to hear other opinions on this please.

Well, the OP said that the guy was a known drug seeker.

If he was in real pain maybe he wouldn't have just walked right out the door. He might have insisted a little bit or even thought to ask if there was something else that could be given.

Maybe if he did insist, and they did find out that he had a REAL pain doc that the pain doc could be contacted and that he should be given a one time injection of (whatever) to see if it would help. This might be tieover until he could get in to see his pain doc.

I don't feel it's the ER's job of finding out what might work. If this was the case, a nurse could spend all night with a drug seeker saying, "it didn't work, got anything else?" with glazed over eyes and a BP about ready to hit the deck.

This is just my opinion though.

teeituptom, BSN, RN · Feb 24, 2005

I think that the problem is that someone could be misidentified as a drug seeker and then the hospital and all caregivers would be open to a lawsuit, as an earlier poster describes.

And the problem also is those that use their meds or hit other ERs and come in denying any other treatment prior to arrival and get a shot and then OD and crash and burn. Have I seen that happen,,,,,yes indeed. Some died.

Thats a bigger problem

FutureNrse · Feb 26, 2005

I think that is a good idea. When a frequent flyer does come in why doesn't the nurse take a minute to sit down with them and tell them straight up that this behavior has been recognized and it not acceptable and to let them know the exact thing Future Nurse has said, the PCP will be notified and asked to help you find out a good care plan for the patient when this happens instead of seeking narcs in a ER.
I think a lot of patients who have this behavior get away with it in the ER and nobody attempts to sit down with them and let them know that they are being watched closely cause of the behavior. I have seen a lot of nurses just shut their mouths cause they are afriad of opening them in fear they will uncontrolably go off on the patient. But seriously the FF who come in and don't hear anything about being watched will just continue coming in and getting what they want not knowing its unacceptable.
I also think its a great idea to get Social Workers somehow involved in getting help for them if they don't have a PCP and are experiencing chronic conditions. I know Social Workers might have a big problem with that saying they don't have the time to deal with FF but then maybe we need more Social Workers?!
I think instead of keeping the frustation of it all to ourselves, let the patients know that yes, this is unacceptable behavior and next time you will not recieve narcs. I don't know if that would work, but something needs to happen. Course there will be those FF who work the system and still get away with it but I do believe that we could get lucky with a few FF and they may admit they have a problem.
Just an idea. Curleysue

Curleysue, let's you and me get together and write a proposal for this new program and rid the hospitals of FF's. :) But let us not forget another segment of the FF population, those poor patients who follow doctors orders. I've dealt with many PCPs who are too busy, lazy, or uninterested to take the time to see me, so they send me to the ER. What's worse is that they lie about it. about a year ago I called my doc, had a migraine on top of my regular back/neck pain and I was miserable. Called first thing in the morning, but he couldn't get me in, someone would get back to me before closing. At 4:55pm, I called the office, phones had been rolled over to answering service. Left an urgent " you BETTER call me back" kinda message, and about 3 hours later, I called again only to be told "Dr says you should go to the ER." I went, they were kinda b$#chy about it, didn't believe doc had said to come in. ER did nothing, got in to see doc the next day and he denied telling me to go to the ER. I explained what the answering service said, and he replied " They don't speak for me" Huh? So I kept asking repeatedly " so, you're saying that they suggested the ER with NO help from you?" Never got an answer...fired him on my way out the door. :)