Narcotic Administration in ER

Esme12, ASN, BSN, RN · Aug 23, 2011

oh dear as usual for AN a combination of judgemental Posters and Narcotic panic ....

Before you judge too quickly or too sterotypically.........let me clairify... because I am sure you wouldn't want to be too quick to judgement... :rolleyes:

In America our views of narcotic administration and drug seekers are very different than in the UK. History has proven for the US that narcotic abuse (of patients and staff) IS an issue and lawsuits ( with HUGE payouts I might add) regarding patients driving under the influence, having accidents, and doing stupid things and blaming the meds they recieved in the ED has made it necessary for us to adopt these policies, attitudes, and beliefs in dealing with these people. I hope you never experience this in your practice at the epidemic levels that it is here in the US.

I appreciate your point of view, however, making mean spirited comments about something you haven't experienced in your practice isn't fair or nice. We as nurses need to be kinder to each other, in general, nationally and internationally. I remain mystified as to why we are so critical of each other and brow beat each other so much...... :cool:

I think we should be respectful of each other and each others opinions.......:)

F.E.R.N., BSN, RN · Aug 24, 2011

oh dear as usual for AN a combination of judgemental Posters and Narcotic panic ....

Not sure what else you had to say. If you think of something that is either helpful to nurses or to patients, people would probably read it.

ZippyGBR, BSN, RN · Aug 24, 2011

Policy isn't the issue , attitudes and belief are

there appears to be a number of issues which are impeding discussion and it appears the provision of adequate care.

1. 'Narcotic panic' Yes opiates and benzos are subject to necessary 'extra' legal controls over and above other Medications but this seems to be blown out of all proprtion by some people

1a. this had left to sub therapeutic doses becoming the norm especially with regard to morphine salts 0.1 mg /kg means that for the 'average' 70 kg adult a therapeutic dose of Morphine is going to be 7mg which is smack bang in the middle of a range dose of 5 -10 mg and a dose which you will find plenty of literature to support ...

which then leads to morphine being seen as less effective etc hence the demand for alternate drugs

2. the assumption of drug seeking -

- Of course you are going to say you can't have morphine if the one time you did get it before you were given one third to one fifth of an appropriate therapeutic dose so yes you are going to be angling for the different agent which is given at a therapeutic dose.

- certain opiates are reported to give a 'better' buzz - pethidine / merperidine is one , especially given that it was at one time the analgesia of choice for renal colic which is relatively easy to fake - especially as the old school diagnostics were examination and a urine dip - faking blood in urine is possibly the easiest piece of faking to do unless you are directly observed at all times when you have the pee sample pot in your possession.

- people in chronic pain and on extensive scripts have 2 reasons to seek emergency care

a- they have exhausted their prn / rescue options

b- they feel they are not in control

equally how often have you seen people abandon other analgesics in favour of an opiate once prescribed because no one has taken the time to sit down and explain that each of the different medications they are on for pain works in different ways and just because you have been prescribed an opiate doesn't mean the others don't work ... this is both a patient issue - whith sticking to prescribed regimes and a provider issue for pandering to patients rather than taking the initiative and doing , shock horror,some teaching.

3 the phrasing of things - ' no ride no narcs' strikes me as the kind of statement made by some slovenly dosshouse or dive bar keeper pointing at a 'so shirt , no shoes = no service' sign .... an opportunity to wield power of others ...

Esme12, ASN, BSN, RN · Aug 24, 2011

Policy isn't the issue , attitudes and belief are
there appears to be a number of issues which are impeding discussion and it appears the provision of adequate care.
1. 'Narcotic panic' Yes opiates and benzos are subject to necessary 'extra' legal controls over and above other Medications but this seems to be blown out of all proprtion by some people
1a. this had left to sub therapeutic doses becoming the norm especially with regard to morphine salts 0.1 mg /kg means that for the 'average' 70 kg adult a therapeutic dose of Morphine is going to be 7mg which is smack bang in the middle of a range dose of 5 -10 mg and a dose which you will find plenty of literature to support ...
which then leads to morphine being seen as less effective etc hence the demand for alternate drugs
2. the assumption of drug seeking - It's not an assumption
- Of course you are going to say you can't have morphine if the one time you did get it before you were given one third to one fifth of an appropriate therapeutic dose so yes you are going to be angling for the different agent which is given at a therapeutic dose.
- certain opiates are reported to give a 'better' buzz - pethidine / merperidine is one , especially given that it was at one time the analgesia of choice for renal colic which is relatively easy to fake - especially as the old school diagnostics were examination and a urine dip - faking blood in urine is possibly the easiest piece of faking to do unless you are directly observed at all times when you have the pee sample pot in your possession. Demerol is seldom used as front line in the US anymore
- people in chronic pain and on extensive scripts have 2 reasons to seek emergency care
a- they have exhausted their prn / rescue options
b- they feel they are not in control
equally how often have you seen people abandon other analgesics in favour of an opiate once prescribed because no one has taken the time to sit down and explain that each of the different medications they are on for pain works in different ways and just because you have been prescribed an opiate doesn't mean the others don't work ... this is both a patient issue - whith sticking to prescribed regimes and a provider issue for pandering to patients rather than taking the initiative and doing , shock horror,some teaching.
3 the phrasing of things - ' no ride no narcs' strikes me as the kind of statement made by some slovenly dosshouse or dive bar keeper pointing at a 'so shirt , no shoes = no service' sign .... an opportunity to wield power of others ...

The best predictor of future behavior is past behavior. Have you worked in the US? You are 100% correct on one thing.......No ride NO Narcs.....No shirt No shoes NO service........and the seekers treat the ED as a corner bar. And if you are too impaired to drive whether by alcohol or drugs....prescription or other wise....you are liable. Our laws differ here ans we have different regulations...that's all...

ZippyGBR, BSN, RN · Aug 24, 2011

The best predictor of future behavior is past behavior. Have you worked in the US? You are 100% correct on one thing.......No ride NO Narcs.....No shirt No shoes NO service........and the seekers treat the ED as a corner bar. And if you are too impaired to drive whether by alcohol or drugs....prescription or other wise....you are liable. Our laws differ here ans we have different regulations...that's all...

There is an assumption that everyone who attends an ED and requests opiate analgesia is a seeker, it is abundantly clear that this has become so ingrained into the culture of healthcare providers in the alleged 'land of the free' you are not even able to see your own disgustingly biased and judgemental attitudes and how they create the very conflict you allege to avoid.

If there is law that requires 'no ride no 'narc' ' then i'm sure you can provide reference as such of much like many of the other assertions of 'law' made on AN there isn't actually a law and it's utter male bovine excrement...

Esme12, ASN, BSN, RN · Aug 24, 2011

there is an assumption that everyone who attends an ed and requests opiate analgesia is a seeker, it is abundantly clear that this has become so ingrained into the culture of healthcare providers in the alleged 'land of the free' you are not even able to see your own disgustingly biased and judgemental attitudes and how they create the very conflict you allege to avoid.
if there is law that requires 'no ride no 'narc' ' then i'm sure you can provide reference as such of much like many of the other assertions of 'law' made on an there isn't actually a law and it's utter male bovine excrement...

i am not sure what has upset you to make such inflammatory and derogatory remarks toward the us lately.....the revolutionary was ended sometime ago........but that's your business and problem.

it is illegal in the us to drive while under the influence of intoxicating substances that impair one's ability to operate dangerous machinery. the vendor (dispensor) here in the us has been increasingly held accountable for allow the impaired person to drive impaired and held responsible if said impaired person causes and accident....a felony in this country.

http://www.nida.nih.gov/infofacts/driving.html

http://www.duiconsequences.com/

drunk driving is a factor in nearly half of all fatal vehicle accidents. a 2008 study by the federal substance abuse and mental health services administration found that 20% of adult drivers – or one of every five motorists aged 18 or older -- had driven in the past year while under the influence of alcohol. that same study found that 6.8% of adult drivers operated their vehicles in the past year while under the influence of illicit drugs with another some addtional estimated 20% under the influence of prescription drugs.

when a drunk driving accident results in serious personal injury or death to an innocent victim, legal action can hold the responsible party liable for their reckless and dangerous conduct. if you are hurt by a drunk driver, you may be able to file a lawsuit against the driver or the company that employed the driver if a commercial vehicle is involved

in some cases the bar or liquor store that served the driver can be held accountable for injuries to an innocent third party.

establishments can be liable for "negligent" or "reckless" service in certain cases where the person they served later caused an accident. these statutes are dram stop laws and social host liability laws. in medicine we adhere to standards of practice and act acordingly. an examle ......accident victims may file a claim of negligent service if the driver who was served alcohol was a minor or visibly intoxicated or a hospital allowing an imparied patient to leave without a responsible party to sign responsibility for the patient. the driver can also bring a negligence claim against the bar if he or she was a minor. a bar may be liable for reckless service if the server encouraged the driver to drink excessively. a hospital my be held responsible for willfully and knowingly allowing a patient to leave under the influence of drugs and causes harm.

laws affecting prescription writing

types of drugs

legend drugs: these drugs may not be dispensed by a pharmacist without a prescription from a physician, osteopath, dentist, etc. federal and state drugs are "legend." labels on these medications carries the legend: "caution! federal law prohibits dispensing without a prescription."
controlled drugs
: in addition to requiring a prescription, these drugs require additional safeguards for storage. refills are also limited. both state and federal government agencies promulgate regulations regarding these drugs. the federal agency is the drug enforcement administration and the state agency is the division of narcotics and dangerous drugs of dhhr.
over-the-counter (otc) drugs: these drugs do not require a prescription.

controlled substances act of 1970

schedules of controlled drugs: the drugs that come under the jurisdiction of the controlled substances act are divided into five schedules. drugs can be scheduled, unscheduled, or moved from one schedule to another as the need arises. schedules are as follows:

schedule i

drugs in this schedule have no accepted medical use in the united states and have a high abuse potential. examples are heroin, marijuana, lsd, peyote, etc.

schedule ii

drugs in this schedule have a high abuse potential with severe psychic or physical dependence liability. included are certain narcotic analgesics, stimulants, and depressant drugs. examples are opium, morphine, codeine, hydromorphone, methadone, meperidine, oxycodone, anileridine, cocaine, amphetamine, methamphetamine, phenmetrazine, methylphenidate, amobarbital, pentobarbital, secobarbital, methaqualone, and phencyclidine.

schedule iii

drugs in this schedule have an abuse potential less than those in schedules i and ii and include compounds containing limited quantities of certain narcotic analgesic drugs, and other drugs such as barbiturates, glutethimide, methyprylon, and chlorphentemine. any suppository dosage form containing amobarbital, secobarbital, or pentobarbital is in this schedule.

schedule iv

drugs in this schedule have an abuse potential less than those listed in schedule iii and include such drugs as barbital, phenobarbital, chloral hydrate, ethchlorvynol, meprobabmate, chlordizepoxide, diazepam, oxazepam, chloroazepate, flurazepam, etc.

schedule v

drugs in this schedule have an abuse potential less than those listed in schedule iv and consist primarily of preparations containing limited quantities of certain narcotic analgesic drugs used for antitussive and antidiarrheal purposes.

registration

physicians ....every physician who administers, prescribes, or dispenses any of the drugs listed in the five schedules must be registered with the state and the federal drug enforcement administration.
"administer" to instill a drug into the body of the patient
"prescribe" to issue a prescription order for the patient
"dispense" to deliver controlled substances in a container to the patient
the registration must be renewed annually, and the certificate must be maintained at the registered location. if more than one office is maintained where controlled substances are kept, then each office must have a separate registration.
federal procedure: obtain form dea-224
united states department of justice
drug enforcement administration p. o. box 28083, central station washington dc 20006 (form dea-224 may also be obtained from local or regional dea offices.)

interns, residents, and foreign physicians.......interns, residents, or foreign physicians may dispense, administer, and prescribe controlled drugs under the registration of a hospital or other institution by whom they are employed, provided that:

the institution is registered;
the physicians are authorized or permitted to do so by the jurisdiction in which they are practicing;
the dispensing, administering, or prescribing is in the usual course of their professional practice;
the institution has verified that the physicians are permitted to dispense, administer, or prescribe drugs within the jurisdiction;
the physicians act only within the scope of their employment in the institution;
the institution authorizes the intern, resident, or foreign physician to dispense or prescribe under its registration and assigns a specific code number for each physician so authorized, as shown in the following example:

dea hospital

registration # code #

ab123467 021 and;

a current list of internal codes and the corresponding individual prac-titioner's code is kept by the institu-tion and is made available at all times to other registrants and to en-forcement agencies upon request, for the purpose of verifying the authority of the prescribing physician.

records

physicians do not have to keep additional records if they:

prescribe controlled drugs; or administer controlled drugs.

physicians do have to keep additional records if they:

dispense controlled substances as a regular part of their professional practice, for which the patients are charged, either separately or together with other professional services.

the records must indicate all drugs received or dispensed.

the records must be kept for a period of two years.

in addition to keeping records, every two years the physician must take an inventory of existing drugs stocked.

physicians who order controlled substances for dispensing or admin-istering must use special order forms (dea 222c) to order the drugs.

requirements for prescriptions written for controlled substances

required information on the prescription

must be dated and signed on the day it is issued.

must have the full name and address of the patient.

must have the name, address, and dea registration number of the physician.

may be prepared by the secretary, but must be typed or written in indelible ink and signed by the physician. the physician is respon-sible for having all the pertinent in-formation on the prescription.

telephone orders

telephone orders may be placed for drugs in schedules iii, iv, and v.

a written prescription is required for ordering drugs in schedule ii.

in an emergency, a prescription for schedule ii drugs may be telephoned to a pharmacy. if the pharmacy is willing to accept the telephone order, only enough drug to cover the emergency may be prescribed. the physician is then required to supply a written prescription to the pharmacy within 72 hours. the pharmacist is required to call the "feds" if he doesn't receive the prescription within 72 hours.

"emergency" means that the immediate administration of the drug is necessary to proper treatment, that no alternative treatment is available, and that it is not possible for the physician to provide a written prescription order for the drug at that time.

refilling prescriptions for controlled substances

refills for schedule ii drugs are not permitted.

refills for schedule iii, iv, and v drugs are permitted if the number of refills is indicated on the prescription. however, the prescription order may be renewed only up to five times within six months after the date of issue. after five renewals or after six months a new prescription order is required.

http://www.madd.org/laws/law-overview/dram_shop_overview.pdf

http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_content.htm

http://www.arbd.com/medical-provider-liability-to-non-patient-third-parties-for-negligent-medical-care-and-prescribing-p

http://prescription-drug-abuse.com/drug-abuse-articles/prescriptiondrugabuse/doctor-liability-for-patients-who-drive-under-the-influence-of-prescription-drugs/

i hope you have found this information informative and educational...........:)

ZippyGBR, BSN, RN · Aug 24, 2011

Esme the only concieveably relevant part of your dissertation there was the stuff about 'reckless service'.

there's a slight difference between 'no opiates if there isn't someone to drive you home ' and not allowing someone who is intoxicated to leave.

however despite being 'the land of the free' it seems many people in the US consider that they have the power to impose their views on others when it comes to drugs and alcohol, this is abundantly clear when it spills over into the scandalously judgement moral high ground stuff that is spouted about 'narcotics' as if by giving appropriate dosages when clinically indicated magically you render people legally incapable ...

Esme12, ASN, BSN, RN · Aug 24, 2011

Esme the only concieveably relevant part of your dissertation there was the stuff about 'reckless service'.
there's a slight difference between 'no opiates if there isn't someone to drive you home ' and not allowing someone who is intoxicated to leave.
however despite being 'the land of the free' it seems many people in the US consider that they have the power to impose their views on others when it comes to drugs and alcohol, this is abundantly clear when it spills over into the scandalously judgement moral high ground stuff that is spouted about 'narcotics' as if by giving appropriate dosages when clinically indicated magically you render people legally incapable ...

I magically render no one incapable.......policy, standards of practice and the ever present lawyer waiting to sue and the patient looking to make a buck. I disagree with many aspects of hospital policy and personally I eblieve you give the narc but they have to stay 4 hours which in and of itself presents issues with refusal to stay and liability.....be here it is what it is....good or bad.

Besides no one said freedom was free...... :smokin: Peace. :clown:

LilgirlRN, ADN, RN · Sep 4, 2011

Whoa Nellie!!! What does the ER do? We treat emergent things that may kill you until proven otherwise. If you have a chronic condition that requires pain medication given to you by either your regular doctor or by a pain management doctor then you know the rules. They will NOT call in narcs on weekends or after hours. It's your responsibility to keep up with when your meds will run out. If you're gonna run out over the weekend call your doctor! Yes come on into the ER, we will make sure you don't have something besides your previous diagnosis, if we find nothing we aren't going to change your medication. Chronic pain is just that, chronic. It's not an emergency.

In our ER you have to have a driver to get narcs. We do not provide a ride home. Sometimes we are generous and keep you the 4 hours is it's in the middle of the night. However, I've seen people call a friend to pick them up, get in the car with the friend, drive around the corner so we think they're gone and then the friend brings them back to their car and they drive home. That's when we call the cops and they go to jail. (small town)

VaFrank · Dec 24, 2013

No matter what ERs should be, they're typically also outpatient clinics, afterhours urgent care centers, backstops for PMDs who don't want to see their own patients (even for conditions that would be appropriately treated in doctors' offices), etc., etc..

Pain is a genuine medical condition, and acute pain -- such as extremity injuries, renal stones, burns -- is usually well managed in an ED setting. Not treating those conditions or delaying their treatment just because a certain percentage of patients are seekers or fakers or will try to drive home when they shouldn't is not providing the best care we can.

Don't discharge the patient until their rides arrives in the ED, fine; not treating a reported 8/10 pain until a ride arrives, and it's easy to imagine how that could be a considerable time for some people... not fine, IMO, and I doubt one person here would tolerate that for themselves or for their family members. Cynicism is our greatest job hazard.

The Patient Is Not The Enemy (repeat as often as necessary.)

turnforthenurse, MSN, NP · Jan 21, 2014

Patients do not get narcs unless they have a ride home. Period. If they are calling for a ride, the providers like to make sure that their ride is physically in the room (and we see them there) before getting medicated. I've had patients lie and say their ride is in the room with them only to find out no one is there.

If they don't have a ride or whatever, then they need to hang out with us for awhile.

TheGooch · Jan 22, 2014

There is an assumption that everyone who attends an ED and requests opiate analgesia is a seeker, it is abundantly clear that this has become so ingrained into the culture of healthcare providers in the alleged 'land of the free' you are not even able to see your own disgustingly biased and judgemental attitudes and how they create the very conflict you allege to avoid.
If there is law that requires 'no ride no 'narc' ' then i'm sure you can provide reference as such of much like many of the other assertions of 'law' made on AN there isn't actually a law and it's utter male bovine excrement...

My sister was issued a DUI for driving while under the influence of psychiatric drugs so yeah, I think there is a law against driving while under the influence of them.