Prescribing narcotics to drug seekers

tencat · Feb 8, 2011

How do you know they are all drug seekers? Sometimes frequent fliers use the ER as primary care, and if they have a chronic pain condition, then you WILL see them all the time. There are people with chronic pain that is not adequately controlled who have no other resources but the ER. How can you tell the difference? You probably can't. So the best thing to do is treat a patient's pain, regardless of their 'addiction' status.....putting a label on a patient does nothing to help him/her with the need at hand. You can't rehabilitate the 'drug seekers', nor is it your job to do so. You CAN treat a patient's pain and not judge him/her. There is no need to punish those who ARE truly in pain, and since it's so hard to adequately judge who those folks are, it's better to treat. JMHO.

Djuna · Feb 8, 2011

If you can't answer my specific question then please don't respond. I'm not interested on a debate on who needs narcotics for chronic pain. I am interested in helping our community address the prescription drug problem and ways our ED can control the wanton prescribing of narcotics.

HiHoCherry-O · Feb 8, 2011

The ED I worked in a few years ago had pain contracts for certain patients who frequently came to the ED requesting narcotics. We were able to track how frequently they came, what resources were provided to them for follow up and what they received (narcotic, RX wise).

A care manager would then contact the patient, while in the ED, and present them with a pain contract which would spell out what would and would not be available to them when they come to the ED. This contract would be available to view by anyone in the ED who provided care to the patient. This would help deter some patients from coming to our ER (but not all).

To Tencat: yes, I agree, people's pain should be treated despite what our personal interpretation of the situation is. However, these individuals were also provided plenty of resources to establish PCP to manage their pain issues. Individuals would either, never bother to seek a PCP (even if a small to non existent co pay was required--it just took too long to get in), have an existing pain contract with their PCP of which they were now in violation of when coming to the ED seeking Rx for narcotics (and well aware of this) or, as you mentioned use the ED as a Primary care. This is unacceptable, expensive and inappropriate use of resources.

BabyLady, BSN, RN · Feb 8, 2011

The ED where I work is inundated with drug seekers as I assume all US EDs are. I have brought to my Managers attention numerous people who are frequent fliers, but nothing is ever done about it. I am not at the point where I want some serious questions answered and some changes made to our narcotic prescribing policy but I am unsure how to go about it.
Does anyone have any ideas?
Medical Board, the media, higher management? Who would I speak to?

I look at it this way....

My job as a nurse is to do the assessment and pass on the information to the physician...including the fact that I suspect that a patient is a drug-seeker.

Physicians, are responsible for prescribing and therefore, they are also the ones held liable.

To me, I don't care if they get their fix or not...drug seekers are addicts by choice...when you start popping pills for fun, none of them should be surprised when they cannot stop. Granted, a hospital isn't the place for it, but then again, I didn't create the system.

The trouble you are going to find in your complaint is that the tiny fact that it is the PHYSICIAN that makes the final call, not the nurse.

So, that is where the hospital's loyalty is going to lie.

Djuna · Feb 8, 2011

Thank you HiHoCherry-O and BabyLady for your posts. The contract sounds like a great plan. We have people on pain contracts from their PCP yet the ED Providers still give narcotics.

BabyLady your points are very valid and I realise this is the stumbling block. As an RN I hand out starter packs of narcotics and I personally feel it is a breach of my ethical standards to be complicit in actually providing drugs. It is a huge problem when Drs do not want to confront a patient and say "No".

A while back we had a drug seeker receive a starter pack of Percocet and was witnessed selling it in the parking lot. The Police got involved and it was all documented. He came back the next day and was given another starter pack.

If the Medical Director isn't on board with wanting to control this epidemic then I guess as an RN I can do nothing it would appear.

BrnEyedGirl, BSN, MSN, RN, APRN · Feb 8, 2011

This is a huge issue in every ER I've ever worked. It's also a slippery slope. Drug addicts can and do have pain also. I've never heard of a "starter pack". We are not allowed to dispense meds from the ER, under any circumstances, ever! I can give a dose to take in front of me, then it's up to the pt to fill a Rx.

We recently had a big uproar in our ER about similar problems. The ER physicians were angry about the meds and time consuming million dollar work ups for the drunks that are found down with mental status changes. Of course a mental status change gets you a CT and many of these guys would show up twice in one 12 hour shift, as our EMT's aren't allowed to leave them where they are even if they are intoxicated, high etc. Our docs were also questioning the safety of so many CT's, as some of these folks are sent to the scanner 3-4 times a month! Management said to tx them like any other mental status change! They get the full work up, often spend many hours in the ER taking up a bed until they are sober enough to walk out.

Not sure what the answer is, but I do feel your frustration. It is such a huge wast of resources when there are so many people who really do, by no fault of their own, need us!

Djuna · Feb 8, 2011

Thank you RN-Cardiac for your post.

We dispense starter packs which consist of up to 6 tablets depending what the drug is, because we have no 24 hour Pharmacies in this State. Sometimes when Drs don't want to write a 'script they will give s starter pack to take home.

I am certainly feeling the lack of power we RNs really have.

systoly · Feb 8, 2011

If you can't answer my specific question then please don't respond. I'm not interested on a debate on who needs narcotics for chronic pain. I am interested in helping our community address the prescription drug problem and ways our ED can control the wanton prescribing of narcotics.

What are your specific questions?

You said, "I am not at the point where I want some serious questions answered..."

Djuna · Feb 8, 2011

Oops.

I meant I am at a point.

JKL33 · Feb 8, 2011

I am interested in helping our community address the prescription drug problem and ways our ED can control the wanton prescribing of narcotics.

I understand your concern and frustration. I don't think my comment is exactly the type of suggestion you're looking for but I want to offer a couple of ideas, in all sincerity.

I agree with you, I think this is a ridiculous, frustrating, and dangerous problem. It is easy to become angry at the idea of being taken advantage of repeatedly (and forced to do it with a smile!). I think both the medical and nursing professions have enabled this atmosphere....first by under-treating patients with horrible, unbearable pain, for fear of causing someone to become "addicted". It wasn't very long ago that we were seriously under-treating the chronic pain of even those patients with painful terminal disease processes, and it still happens sometimes. I see our current environment as the opposite extreme. Now we say "Pain is what the patient says it is", and "Pain is the 5th vital sign". I will take heat for my opinion on these catchphrases....but I feel they have had the opposite of their intended effect. I think they have proven to be disastrous over-simplifications about pain and what we should do about it. Instead of simply making us aware that each patient perceives pain differently and deals with it differently....these phrases about pain have apparently caused us to throw clinical objective assessments pretty much out the window. Or...at least caused us to be afraid to act in accordance with our clinical assessment.

Try not to let this issue become a battle between physicians and nurses. As the physician of record in these situations, ER docs are in a 'damned if you do, damned if you don't' position. Any action by them can and will be perceived in different ways by both patients and nurses, and any action they choose CAN be reprimanded or even litigated, if the wrong person disagrees with the physician's evaluation of what is appropriate. By the time you factor in the State Board of Medicine, the hospital administration (and "patient satisfaction" scores....which can and DO affect physicians' livelihoods), the patient's view of what is appropriate, the DEA....and other entities....there are a number of mechanisms to punish physicians for prescribing....or NOT prescribing....for perceived over-treating or perceived under-treating. Speaking of my own experiences only (and not about you personally! :) ), I have come across a number of nurses out there who enjoy seeing themselves as the heroic patient advocate juxtaposed against a physician who is somehow less honorable or less concerned for the patient or for 'doing the right thing'. I guess I am just saying most all of us (physicians and nurses alike) want to do what is right for patients, and it would go a long way if we each could put ourselves in each others' shoes. Prescribing (or refusing to prescribe) narcotics is a huge responsibility and liability. I know it seems like 'wonton prescribing of narcotics'....but you probably wouldn't view it that way if you were the physician who had been professionally reprimanded for under-treating the pain of a patient whom you *sincerely* felt was malingering.

This is not the answer to the problem, but it may help you: Envision yourself as you truly are ~ you are there to do what you can for a particular person at a particular time. It sounds simple, but it is good to remember that the patient is the one with a problem, and you are there to try to make some sort of an impact for the better. You can do that whether your clinical assessment supports their complaint of 10/10 pain or not. You can also do that whether or not narcotics end up being prescribed. Perhaps you can be a listening ear. Sometimes you will get to be the person who diffuses the situation (or behavior) just by committing yourself to remaining neutral. If all else fails, you can empathize (privately ) that this patient needs your care today if for no other reason than it can't possibly be the life they dreamed of living....traveling from ER to ER in pursuit of narcotics. We can discuss pain contracts or refusing to prescribe narcotics or changing our policies or reporting malingerers to the police.....or any other 'solution' you can think of, until the end of time. But....I can all but promise you the only thing that is going to have a positive impact on YOUR life, your professional practice, and your perception of all of this, is that which comes from within. You just have to take yourself out of the personal realm of this, I mean this in the *most sincere* way. This is a societal problem, not a problem with your particular doctors, nurses, hospital, town or patients. Do not let yourself get burned out on others' problems.

Best wishes ~

Djuna · Feb 8, 2011

JKL33, thank you for your post. I appreciate the dispassionate outside view. I admit, I am angry. I am an overseas RN and in my country this phenomena is not as widespread. I thought I could facilitate change but I am obviously wrong.

Your post has made me rethink things a bit.

Again, thank you.