How do you handle the drug seekers?

wooh, BSN, RN · Jul 14, 2012

The kid was ridiculous. But abdominal pain sucks. I had intractable abdominal pain for about 2 years, with every test done, before it was finally diagnosed.

I'd rather medicate someone that "doesn't need" it than not medicate someone that does.

MissRN2012 · Jul 14, 2012

Pain is pain, whether it be physical, emotional or social, when you have a pt that you think is a pain seeker, or a frequent flyer that means we haven't done our job as healthcare providers. For example: Maybe she felt stomach pain from stresses in her life and needed a social worker consultation, who could provide referrals which could help her current situation and prevent her for returning to the ER. Always explore other possibilities of pain holistically. I'm no expert but this is how I was taught by my nursing school. Hope it helps :)

itsnowornever, BSN, RN · Jul 14, 2012

Thanks. I will keep that in mind. I know that we are taught pain is pain, I just didn't know how to deal with it in this patient's case.

kbucksn · Jul 14, 2012

I have to agree with the other comments, pain is pain. I am really glad to hear advice about dealing with pts holistically, I think that is something we all should keep in mind. MissRN2012 you made a good point that if they are "frequent flyers" or med seeking we have not done our job be it due to stress, mental illness or something that has not been found yet. My husband dealt with ongoing pain that they could not find a cause to for a couple if years, finally it was discovered that he had a herniated disc. And as far as pain, it is SUBJECTIVE. What worries me when we start deciding that our pts aren't REALLY in pain, the next thing that leaks in is judgment and profiling. A pt present with pain and maybe they "look like druggies" or have certain things that some person may think "bad people" have (tattoos,long hair,etc)and next thing we start making judgement calls based upon personal feelings. For example I live in a very conservative very religious community where although there are many good non-judgmental people, there are just as many that ARE judgmental. They see someone with a tattoo, or a girl with short shorts or even a freaking tank top and instantly treat the person different like they are criminals, prostitutes or drug addicts. It is RIDICULOUS!!! Example my husband and I were in a store and my husband has tattoos the woman working there followed us around like we were casing the place. Mind you my husband TEACHES SUNDAY SCHOOL! We cannot and should not judge a book by its cover.

I also agree with the previous comment that says I would rather medicate someone who doesn't need it than cause someone who is in pain to suffer. What if I am wrong?? Something to think about.... Once upon a time doctors pretty much diagnosed anything a woman complained of as "hysterical woman syndrome". One of those things later became known as Chronic Fatigue Syndrome, women would complain of muscle aches and extreme fatigue and drs wrote it off as "in their head". Correct me if I am wrong but I am pretty sure that is what we know call Fibromyalgia. As it turns out it is not something that can be definitively diagnosed by a lab test, but by other types of testing in regards to certain points on the body upon physical exam but it took time to figure this out. One other thought, there are times that even people who have suffered or do suffer from addiction have pain too. Do we just write them off? Or there are certain meds used to treat addiction such as Methadone that cause people to actually need higher doses of pain meds to treat their pain and often I have seen that ignored as well, out of sheer judgement. i think we just need to give out pts the benefit of the doubt UNLESS of course they walk in nodding with sub-normal vital signs and are obviously intoxicated asking for Demerol,etc and of course that is for safety reasons. Anyhow just my 2 cents :)

itsnowornever, BSN, RN · Jul 15, 2012

But, now here's the question---do we give morphine or oxy because that is what they ask for or do what this doc did and give motrin? Technically and legally he DID medicate her.

brainkandy87 · Jul 15, 2012

One of the tools you have as an ER nurse is the ability to view previous visits. If they've been in the ER once a week for a year for dental pain, back pain, abd pain.. mainly pain issues.. well, there's your answer. After a while, you'll learn to pick up on the drug seekers. However, don't always assume you're right when it comes to drug seekers. One day, that drug seeker can actually have something serious going on with real pain and you, as the health care provider, ignored it. What you need to do is look at what's indicated for the complaint. Do we give Dilaudid and Morphine for abdominal pain? Yep, all the time. However, there are other drugs you can give, other non-narcotic drugs, that meet the standard of care (Toradol, Tylenol PO or IV, Motrin). If that pt sues you and says you and the MD didn't take their pain seriously because you didn't give morphine or Dilaudid, well that's not a lawsuit they'll win. You clearly attempted to treat their pain with meds that are indicated for abdominal pain.

There's always pain management you can give that's non-narcotic for those you suspect of seeking. Never, ever deny their pain to them, even if you know it's fake. Simply go grab the Toradol and tell them "Here's your pain medicine."

ecerrn · Jul 15, 2012

All is true, I think you did the right thing, next time, don't wait till your close to loosing it, pt and family members are to stay in their rooms, simply because it's not safe, and others right to privacy. Don't worry it's too late to change the offsprings opinion, she'll be well taught by mother. Indiscriminately giving potent narcotics for pain with out basis will just multiply the number of seekers you get everyday. I agree, pain should be treated, but the er is no place to diganose some obscure chronic condition....and perhaps they should be educated on that......referral to pain management who can deal with all the aspects of that condition.

**canoehead, BSN, RN** · Jul 15, 2012

I've said to patients after the third or fourth dose of pain meds, "if your pain is still 10/10 this drug isn't working for it, and you are obviously getting some side effects. It would be dangerous to give more, so let's try something else." Then we either have an improvement in the pain score (usually without further meds) and/or I ask the doc for an antiinflammatory, or an order for heat/ice. Something always changes, or the patient gets huffy and goes AMA. I'm not saying they aren't in pain, but I don't think narcotics are the answer. In some cases long term counselling might be the answer, and pain is their motivation to stick with it, I'm not trying to be mean, but realistic. I think people should be treated with respect, and part of that as a nurse, is drawing out for them the A causes B, causes C, so now what would you like to do? It's wise to go in the room with the next alternative instead of leaving them to float along without ideas, they get irate because they are OUT of ideas.

Marshall1 · Jul 15, 2012

If a patient is truly a drug seeker/addict..you are NOT going to change this behavior in one or two or two hundred ER visits..simply notate, as others have said, past visits and go from there.

Patients can request whatever they want but what is followed is doctors orders - so if he only orders motrin go w/that - if that order is reasonable for the situation - explain that to the patient and if the patient isn't happy with that - let the doctor explain it to them. Or the supervisor. Where I work there are a LOT of drug seekers who come in..some get the drugs, some don't - depends on their documented medical history and even then they do not get to dictate to the doctor what they want. The doc takes into consideration everything about them - from other medications, past history, if they work, etc. Some leave happy, some not so much.

As far as the kid, agreed - she should never be out of the room w/o adult supervision. Period.

itsnowornever, BSN, RN · Jul 15, 2012

Thanks guys! You gave me some good tools to use for the future. I agree, I should have talked to mom before hand, but since no one else was bothered by the kid, I thought, "Ok...guess this is normal" and when I saw she could have gotten hurt, that's when I put my foot down. I think this was either my first or second day in there. I was more in shock than anything else.

Thank you for the replies! I love this place! So many opinions and all of them are good!

SwansonRN · Jul 15, 2012

You were right to finally say something to the daughter. It's not appropriate or safe for a young girl to be walking around a busy ED by herself.

Where I work we are considering discontinuing the numeric pain scale and changing the way we think about and treat pain. I can't eloquently explain their reasoning at the moment, but I think it has to do with pain being too subjective/complex to be reduced to a number. I don't know, that's just what this post made me think of. I think we need to constantly remind ourselves not to think of pain in concrete terms.