Rx drug abuse in your ED- steps you take?

  1. I have been getting fed up with the number of people coming into my ED drug seeking. One of the PA's have access to a database of all providers, pharmacies and pt info related to schedule 2, 3 and 4 prescriptions written and filled. When we started looking up some of the frequent fliers, it was amazing. Amazing these people are still breathing, amazing the pharmacy isn't being investigated, amazing some doctors aren't being investigated.

    One lady got 2 different percocet rx filled, one for 100 tabs, the other for 80 tabs, at the same pharmacy on the same day from the same doctor. Just an example, but we strated printing, and printing, and printing some more.

    Now we are making up drug seeker/drug abuser/ doctor shopping packets. We have a list of names posted by the charge nurse desk. The ED docs are banding together to fight this crap, excuse the expletive.

    You guys know what I am talking about. These people either 1) don't work 2) are on medicare/medicaid 3) are on welfare/food stamps 4) drag family members into their addiction or 5) all the above. I am getting sick and tired of busting my hump and having 25%+ of my check going to taxes to pay for these people abusing the system. It's not like they pay their bill, nor does medicare/medicaid most of the time because their survey score isn't high enough, because the patient didn't get high enough.

    But what gets me is that administration does not care one bit. We called the SO on a patient last night because she lied straight to the doctor about seeking, after being warned at her last visit about seeking, and the SO did not care either. No arrest, just forwarding the info for 'investigation by the SIU' (special investigations unit).

    So now my rant is over, what have you guys done to reduce recurrence and abusers? I am tired of seeing resources being wasted.
  2. Visit thelema13 profile page

    About thelema13

    Joined: Jun '11; Posts: 287; Likes: 374
    Specialty: 3 year(s) of experience in ED


  3. by   Anna Flaxis
    I view addiction as a health issue and not a moral one. I think it's important to base the treatment plan on the clinical picture, not a moral judgment based on the patient's socioeconomic status. Also, while it may seem to us that drug seeking in the ED is out of control, especially at peak census times when we're also caring for real emergencies, keep in mind that ED physicians prescribe only a small percentage of all the opioids prescribed nationwide, less than 5%.*

    In addition, I think it's important to remember that even drug seekers can have medical emergencies, and to discount a person's complaint because of their history could have disastrous consequences.

    In my ED, doctors have frank discussions with patients they suspect of drug seeking behavior, and will refuse to prescribe opioids if they feel that opioids are not clinically indicated.

    Do some seekers get their payoff? Definitely. But I'm not there to play pain police, and when in doubt, I'd rather err on the side of providing compassionate care than to mistreat someone who is legitimately suffering just because I feel morally superior.

    Yes, these people can be incredibly annoying; self centered, overly dramatic, demanding, and will attempt to monopolize your time with their problem. But I have found those qualities to NOT be unique to drug seekers. Even patients with real medical emergencies can act like that, unless they're tubed and sedated; but then you can count on family members to take up the slack.

    *Medical Newsrug-Seeking Patients No Strangers to ED Docs - in Pain Management, Pain Management from MedPage Today
    Last edit by Anna Flaxis on Feb 25, '12
  4. by   tyvin
    In Hawaii they have the pharmacies on a link with each other. It's impossible for anyone to cash more then they are suppose to have (so to speak). When ever a schedule II or III is processed the data base system will alert pharmacist to what else they have done in the past month (it's all online so the minute a Rx is cashed it's available to everyone). People try to doctor shop here but it's hard unless you have several alias. Since rules are that no one can fill a scheduled script without photo ID it's even harder for the drug seekers/shoppers.

    Of course all of this is in compliance with the Feds and their own monitoring program. It's my understanding that there are still some states that aren't online or don't have a monitoring program in place for tracking scheduled drugs and the abuse of them.

    I don't know about the ERs here but I would be surprised if they catered to frequent flyers.
  5. by   thelema13
    I am not discounting their complaints, nor only pegging it to socioeconomic status. They could be millionaires and seeking, I don't care. When you have talked yourself blue in the face about rehab, dangers of addiction, extend referrals to pain management doctors, etc and the patients do not change, nor want to change, that is when I lose compassion.

    When the story is the same every time, when they come in with report of seizure/chest pain and we take them straight back, and 99% of the time it is a lie, it gets wearing. The ED is busy enough, and yes it sucks to have to deal with all types, but I am here to save lives, not babysit. They are grown adults, they know what they are doing, they are not stupid.

    I agree it is not my job to police them. But if I see a felony being committed, or contribute to someone's addiction/ felonious behaviour, am I not somewhat responsible? I like my license and I would love to keep it. That is why we are starting to report. Not only patients, but the pharmacies and doctors as well. Everyone knows about the pain clinic crackdowns because it is a serious problem. And I live in a port state, where drug laws are the most strict, and out of the entire nation, Florida accounts for 85% of all oxycontin prescriptions being written. Problematic and will not resolve unless action is taken.

    When you keep doing the same actions over and over again and expect different results each time- is that not the definition of insanity?!?!
  6. by   DixieRedHead
    Treat 'em and street 'em.
  7. by   Anna Flaxis
    From your first post, I detected a lot of judgment based on socioeconomic status, but maybe I was just inferring it. Regardless, I do agree it's a problem, but where we depart is that I'm not as mad at those people as I am at the system. Addiction is a broader societal problem and public health issue, and I think our medical system and society both do a disservice to this population, similar to how the system fails the mentally ill. I think the ability to monitor prescriptions in the way you describe can be a helpful tool in identifying the drug seeking patient, but I have serious doubts about this actually making too much of a dent from the big picture perspective, without addressing the root causes.
  8. by   brainkandy87
    Quote from DixieRedHead
    Treat 'em and street 'em.
    Amen. I could care less what someone chooses to do with their life. My job is to treat the acute problem and then send them to the floor or out the door. If I wanted to cure addiction, I'd get into that area of nursing. If I wanted to crack down pharms and docs, I'd join the DEA.

    There is always some flavor of the decade when it comes to drugs. The 70's had heroin, the 80's had coke, the 90's had E, and the past ten years, it's been prescription drugs. People are always going to do drugs. Always. If I let someone's habit ruin my day, I'll have a lot of crappy days.
  9. by   sapphire18
    Medicare does not base reimbursement for an individual visit on that individual's survey results from that one visit... It is a facility's overall scores in certain areas. Also...we shouldn't judge anyone until we've walked a mile in their shoes. Just sayin.
  10. by   thelema13
    I am not passing judgment. I have been around plenty of addiction: father was a heroin addict, step father a crack head, worked for 2 years in a rehab facility for addiction and psychological problems, college roommate and lifelong friend became addicted to prescription pills and threw away a full ride to medical school. I guess you could even say I am addicted to coffee and endorphin rushes from exercising. I have been around it all; as I am sure many others on this site have as well. It is becoming all too common and unfortunately we as medical professionals have to deal with it many days of the week, if not every day at work.

    I agree it is a complex problem. The doctors for over prescribing and not paying attention because they are overworked; the pharmacies for not double checking the frequency and number of refills for one patient and not raising an eyebrow; the patient for not recognizing a growing problem or just not caring enough about their own life to change; the pharmaceutical companies for developing a highly addictive substance; the FDA for approving a man-made chemical substance nearly identical to heroin; the federal government for not cracking down harder on the more dangerous drugs; society in general. We could point fingers and play the blame game all day. I am trying to do something about it. So are our ED doctors.

    In my area of Florida, I live 50 miles away from the meth production capital of the US. I live on one of the major highways in and out of Miami. There is a grow house busted within a 100 mile radius every week and splayed across the front page. My county has one of the highest rates of prescription pill abuse and methamphetamine use in Florida. And my city is either 1st or 2nd in the nation on average elderly age- it truly is a retirement city of 65+ retirees. So not only do I see your grandchild for overdosing on grandma or grandpa's pills at a 'Skittles party' but I also have to deal with the elderly that are addicted to oxycodone due to their chronic back pain.

    In a 12 hour work day, I do not get paid for the first 3 hours; it goes to taxes alone. I am taxed at a little over 26%, and out of my hard earned money, some of it goes to pay for 1) the 'care' of the abuser/seeker coming in to the ED to get their high squared away 2) filling said prescription 3) paying for the doctor's time 4) supplies used, etc etc. Now with universal healthcare looming on the horizon (which I am an advocate for, coming from Canada), the problem is not set up to get any better.

    I am not here to police patients. That is what the police are for. If a patient threatens me with a gun, I call the cops. I report the crime. If a patient is raped by their stepfather/ neighbour/ stranger, I call the cops to report the crime. Why shouldn't I report the crime of obtaining controlled substances under false pretenses? Doctor shopping? Possible theft of prescription pad and forging prescriptions? I am very proactive, and I would love to live in a safer world. You cannot change the world, but you can make a dent.

    We warned them. We educated them. We pointed them towards pain management. We looked up their prescription activity on the Florida database and some of these people we amazing. They will go to some length to get their fix. One of our long time seekers actually fractures toes and finger and gets lacerations or sprained ankles to get her prescription filled. It is well documented, but no one is addressing the problem. My problem is that we are healers not drug dealers. So we fix them up, save their life, push that Narcan, and then it is dj vu all over again because of their addiction. Just like brainkandy said, the soup du jour in this decade is prescription pills. I never got into this line of work to be a drug dealer. I never meant to push dilaudid on a patient and actually watch as they relax and enjoy their high. Not what I pictured.

    I love every aspect of my job. It is very rewarding. Adding to the problem, being part of the problem, that is not what I had in mind. I started this post to see what, if anything, you guys were doing to help remedy the situation at hand. I did not want to start a moral argument, and no matter what the root cause, I think we are part of the problem and we can be part of the solution.
    Last edit by thelema13 on Feb 26, '12 : Reason: spelling
  11. by   Butterfly0328
    I commend you for doing what you can to take part in finding a resolution to an epidemic problem. The one thing I don't understand is why there is not a national data base in every pharmacy in every state-thus preventing someone from filling multiple perscriptions by just crossing state lines. I know there will always be those that beat any system but I believe that a national data base would prevent a lot of these problems. I know it all has to do with the almighty dollar because I know the technology is there. When will the government feel like it is important enough to make the investment?? Who knows....as far as the OP making the statement about the pharmaceutical companies developing highly addictive substances, there is a place for them and the need-in my opinion. Those suffering with AIDS, Cancer, and a host of chronic pain conditions can and do benefit from these medications. Those who are looking for a high, which I also believe is a very small percentage as the majority of those labeled drug seekers are actually just trying to achieve adequate pain control, will find that high somewhere- if it's not perscription drugs it will be crack, meth etc. Of course this is only my opinion. If there is a way to drastically limit multiple rx fills via a national data base, if doctors demand their patients to bring in their rx bottles to every visit every month to show the remainder of their pills, if they do toxicology checks via blood draw rather than urine as we all know the tricks related to urine checks, and last but not least, I believe doctors need to take the time to get to know their patients and verify as much as possible via MRI and CT scan what is causing their chronic pain. It has gotten too easy for people to walk into a clinic or doctor office and claim they are in pain and voila- here is a rx for pain pills. This is all only my opinion and I know there will always be issues - but I do think with some restrictions put in place and everything I mentioned above we can work towards a final resolution.
  12. by   VICEDRN
    I disagree with your take on the situation...

    Personally, I don't adminster narcotics to patients who I feel are seekers. (and I know there are people about to guffaw on me but I SWEAR in two years I have never had to.)

    First of all, narcotics have been shown to increase mortality in chest pain patients, worsen abdominal pain and migraines and psuedoseizures can be ignored until they "stop" when you threaten to foley them or give something other than ATIVAN. (even met a guy who fakes DTs for his!)

    Second of all, I have been blessed to work in two ERs in which the MDs and RNs have made a conscious choice not to medicate these folks. We did not STOCK dilaudid in the pyxis at my first job. At my second, it is sparingly dispensed in rare occasions. The two times I have been asked to adminster it that I did not feel comfortable, I refused and told the MD he could ask the charge. (It took him seven tries to find a nurse who would say yes.)

    Third, it is no longer considered the standard of care in the ER to dispense narcotics prescriptions for chronic pain in the ER. (This came from a journal article in the Annuals of Em Med I think? The residents and attending showed it to me.)When these back pain/knee pain/noncompliant sicklers appear in our ER, they get ibuprofen and a referral to our walk in clinic. Period. End of story.

    I do not blame medicare/medicaid/universal healthcare (because in Britain they can turn these folks away). I blame the culture of the particular ER that ameliorates and in fact supports this behavior. Once your ER learns to accep that acquiescing today means more of them tomorrow, you guys will truly be able to move past enabling this behavior.

    That's my 2 cents and my experience. If I were you, I would look for another job. (maybe another state?)
  13. by   NO50FRANNY
    This issue is huge for all ED nurses and often polarising. I'm pretty sure it's rarely because we are trying to be moral police, but I acknowledge that some of my colleagues try to be, but for me it comes from a fundamental desire to equitably care for our patients. Narcotic seekers are committing slow suicide so we feel we are enabling this behaviour or contributing to a dire health problem by administering hard-core pain medication when it is not clinically indicated. I've seen the long term effects of opiate dependence and will never willingly contribute to it. I have absoutely no qualms witholding narcotics from a person I believe is not genuinely in pain, none at all. And before anyone gets worried that I might miss the ones who are in pain, I don't. You will probably think I am a bit overconfident here but after 10 years of cancer nursing and 5 years in ED, I stand by my clinical judgement and experience, along with input from my colleagues, and I am pretty sure no one I have looked after has ever been denied appropriate analgesia. I always err on the side of caution but I am not obliged to provide opiates first line, there are other drugs. In our department we have a fairly good computerised alert system so patients will have alerts for malingering, narcotic/sedative seeking behaviour- this alert system is inter-facility also. We don't stock pethidine (demerol) or dilaudid- no-one has ever asked me for it or alluded to it in 5 years- this policy is in place in most EDs in my state- we simply don't have it.

    Also, it is not policy, but a reasonable stand from our doctors that it is not appropriate for an emergency physician to provide prescriptions for opiates to patients with ongoing problems, we are an EMERGENCY department, this is not their specialty nor should they have to bear this responsibility, so they don't do it. We always investigate, and every patient is treated and I guess a great benefit of working where I do is the backup of our doctors. We recently treated a chronic back pain (for 20 years) patient who (along with his enabling wife) within 2 hours of being in our department had already phoned the higher ups to complain that we had "refused" to treat his pain. This was in no way accurate and he had drawn other patients around him, including a man with #humerus, into the manipulation (the joys of narcissism). He had been seen by our very experienced physiotherapist, a resident, been given oxycodone orally etc. etc. He had been told at the hospital he usually went to not to come back! Our consultant physcician told him that if any of his junior doctors had given him what he demanded, IV morphine, he would have torn them to shreds- and that we simply won't do it as it is not appropriate managment for his condition, he also told him (as he was writing his name down) "please spell my surname correctly it's (spells it) it really annoys me when people get it wrong and before you ask for my superior, I'm it, so don't even ask (fun to watch). We have an excellent chronic pain service, who I deal with personally, that patients such as these get referred to. What bothers me is the distinct lack of useful literature on this matter. I've spent a great deal of time reading what I can but most of it isn't very helpful. The general consensus seems to be confront, offer detox etc. and surprisingly some will accept this. I'm all for any helpful suggestions.
  14. by   mybrowneyedgirl
    I'm not sure what is involved in this finally happening, but if someone has been detected to be a seeker, they get a letter to their home letting them know that they will no longer receive narcotics when they come in. Also, when they do arrive, a symbol of a finger pointing to the right automatically pops up on our computer screen as a reminder that they will not be receiving narcotics. Lately, these people have been found to have "eloped" when the doctor comes back into the room. It seems effective, but I don't know how many times this has to happen before the symbol finally appears.