Prescribing narcotics to drug seekers

[Djuna]

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?

[Rob72, ASN, RN]

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.

Wow. Where do you work? In KS/OK, we do not dispense if there is a pharmacy open (by law). Since CVS & Walgreens are 24*, now...

Probably the best solution I've ever seen was when a doc had us do a check on a suspected seeker, who had, in fact, been to all three local hospitals in the preceeding month for pain complaints multiple times(w/no validated injuries). The doc discharged him with a script for naloxone, tellng him to be sure to wait 'til he got home to take it and that the doc was sure it would help things immensely.

[edlove]

To mjmoom:

As nurses, we have more responsibilites than just simply giving pain meds to those who seek it. I wouldn't give alcohol to an alcoholic, nor would I continue to give narcotics to a narc addict. It's not only feeding the addiction, its ignoring the problem. As a provider of care, I have every right to adequatly assess and report if I suspect a pt is a drug seeker (whether it be for their own addiction or they are trying to get it to sell it). It is not me passing judgment, it is just me doing my job. I can't sleep at night knowing I just fed someone's addiction, or fear that I just allowed a seller to walk out the door with drugs he plans to sell, or even worse....have someone OD and we see them back in our ED a few hours later...dead

[psu_213, BSN, RN]

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.

We have 'to go' packs of certain narcs, which consist of 2 pills. We can only dispense them at night (i.e. when most pharmacies are not open, and people cannot get their scripts filled).

As for lack of power...any lack of power that I feel is over issues a lot bigger than giving drugs to addicts. Does it may me happy to do it? No. Do I wish that people would not be able to come to the ED to get the fix? Absolutely. I am going to lose sleep over it? Never (I have about 90 other things I lose sleep over, I don't need another one)

[Anna Flaxis, BSN, RN]

To mjmoom:

As nurses, we have more responsibilites than just simply giving pain meds to those who seek it. I wouldn't give alcohol to an alcoholic, nor would I continue to give narcotics to a narc addict. It's not only feeding the addiction, its ignoring the problem.

I would, in a heartbeat. A key difference between alcohol dependence and opiate dependence is that alcohol withdrawal can be life threatening, whereas opiate withdrawal, while extremely unpleasant, is rarely fatal. If the patient is not in the hospital for detox and has no intention of ETOH cessation after discharge, then it is arguable that it is kinder to the patient to give them a beer with dinner or a shot of whiskey at HS to prevent them from going into withdrawal while they are being treated for their cellulitis, heart failure, or some other health problem without complicating the picture (or killing them) with ETOH withdrawal. On the other hand, denying an opiate dependent person opiates does not typically present the same risk of death.

However, I don't think that denying the opiate dependent person opiates in the ED is going to make much of a dent in the overall problem. Unfortunately, if one doctor is firm and says "No", all the patient has to do is come back in a day or two and get a different doctor who says "Yes". This is intermittent reward, which actually strengthens behavior. Until there is a concentrated, consistent effort to address the issue, it's not going away. It's just like spitting in the wind. Even if a person WANTS to break their dependence on opiates, there is little available support to do so, because the emphasis on substance abuse in the U.S. is on criminalization and enforcement, not on treatment and rehab. Until we adopt a harm reduction model toward drug use and really provide resources to people who do want help, I'm not sure we'll ever see much change.

As someone else mentioned previously, prescribers can be scrutinized for over prescribing, and they can be scrutinized for under prescribing. Which end of the continuum a prescriber would rather lean toward is highly individual and multifactorial. I'm not sure where I would fall in that spectrum, because I have not walked in those shoes.

As an ED RN, I do have a dog in the fight. From my vantage point, it's not so important to me that the person who I believe to be drug seeking does or doesn't get what they want. I truly believe that in order to break any cycle of dependency, one has to be internally motivated. What matters most to me is the behavior of the drug seeking person, because it affects the care of other people in the ED. Demanding, manipulative behavior that distracts me from taking care of critically ill patients ****** me off. On the other hand, sitting in your room and waiting your turn, saying please and thank you, is not such a problem. You know and I know what the real deal is (it's the elephant in the room), and I know you're not going to quit until you're ready. Don't distract me from my really sick patients by being dramatic and self centered, and I won't get ****** off that you're there wasting my time in a transparent attempt to feed your dependency. If the doctor doesn't give you what you want, don't take it out on me. I don't have the authority to prescribe, it is not my decision, and your anger is misplaced if you think I have any control or power over this decision.

[Guest219794]

we are the problem. we create the need by giving narcs for trivial pain, or using narcs inappropriately to treat real pain (headaches). it's not just narcs, we essentially tell people, that for any problem, no matter how trivial or preventable, there is a drug to treat it.

some recent examples:

a childlike 17 year old who shares a pediatrician with her baby as a pcp comes in with a headache, 9/10. it's the kind of headache that allows you to watch tv, talk conversationally, text, and eat. we diagnosed her with a migraine. we prescribed narcotics. this is simply medically wrong on a couple fronts. however, she now is a migraine patient who has been taught that a- headaches are migraines. b- migraines get treated with narcotics. c the place to get narcotics is the er. i highly doubt that her pcp is going to giver narcotics for a headache. he is probably worried about minor things like her need to be fully functional to care for a baby, the likelihood of her becoming dependent, the fact that narcs are known o be a poor choice for treating headaches.

a patient with acute on chronic back pain comes in for her 8th visit in 4 months. her pcp has easy access to her hospital records, and based on his in depth understanding of his patient, has decided not to prescribe prn narcs for breakthrough pain complaints. he has decided that the risk/benefit ratio is not in favor of this treatment.

we have two providers on. provider a saw her the last time, and documented in his dictation his explanation on the need to follow he judgment of her pcp, and that the er is not the place to treat chronic pain. she was seen this time by provider b, who, as in past visits, gave her narcs. this is called variable re-enforcement. according to behavioral scientists, this is the most effective way to ensure that a particular behavior persists.

a 4 year old vomited 3 times after eating a reheated frozen pizza for lunch. he is , active, playful, and not vomiting. no doctor in the world would drug his own child or grandchild for this. i not only gave a dose of zofran, i sent a bunch home in the middle of the day, as state funded insurance does not cover zofran. this validates the parents choice to come to the hospital for this silliness. if we will medicate a 4 year old who puked up junk food, what won't we medicate?

the list is endless, but you get the idea.

as far as potential solutions: the onus is on the medical staff. a commitment to evidence based practice, and some agreed upon policies would be a start. for example, on a pt's 3rd visit in a year for chronic pain without objective findings, that doc, or the medical director, decides a plan of care. any deviation from that plan needs to be justified. it makes no sense for two providers in the same practice to give contradictory treatments. another thought is to recognize that narcs are potentially dangerous drugs, and act accordingly. not unreasonable to require a doc o check prior visits and the state's narc data base. no different than checking an allergy record before giving abx.

as it stands now, with no policies or consistency, providers take the path of least resistance. why stick their necks out in a system that won't support them?

[mwboswell]

a patient with acute on chronic back pain comes in for her 8th visit in 4 months. her pcp has easy access to her hospital records, and based on his in depth understanding of his patient, has decided not to prescribe prn narcs for breakthrough pain complaints. he has decided that the risk/benefit ratio is not in favor of this treatment.

we have two providers on. provider a saw her the last time, and documented in his dictation his explanation on the need to follow he judgment of her pcp, and that the er is not the place to treat chronic pain. she was seen this time by provider b, who, as in past visits, gave her narcs. this is called variable re-enforcement. according to behavioral scientists, this is the most effective way to ensure that a particular behavior persists.

i agree with your assessment that the patient is receiving the behavioral modification "intermittent positive reinforcement"....but what are they receiving? intermittent reduction in their pain?

i think we see it as them "scoring" something, but couldn't it be intermittently reinforcing becuase their pain is relieved?

[mwboswell]

Just a follow up as some of us have been mentioning the "variable/intermittent positive reinforcement" at play here. If we recognize that in the world of behavior modification that intermittent positive reinforcement is much, much, much more powerful of a behavioral tool than negative reinforcement; then why do parents still rely on negative reinforcement much more often than intermittent positive reinforcement? Probably off topic, but just interested to hear from you parents out there.

[Anna Flaxis, BSN, RN]

Let's not confuse the concepts of reward and punishment with positive and negative reinforcement.

In the pure form, positive reinforcement means that you're adding a stimulus (+) in order to reinforce a behavior. Negative reinforcement (-) denotes a lack of or a withdrawal of a stimulus, with the intent of decreasing the likelihood of a behavior occurring again. There is no value assigned (i.e. "good" and "bad").

An example, since I have a background in dog training, would be teaching a dog to sit. The dog sits, and a stimulus is added (i.e. praise, a treat). This is positive reinforcement. Or, if you tell the dog to sit and the dog doesn't sit, then nothing happens. No stimulus is applied to the "not-sitting" behavior. Only when the sitting behavior happens is a stimulus added to increase the likelihood of the behavior occurring again.

Negative reinforcement can also be the withdrawal of a stimulus. An example would be teaching a dog not to jump up when greeting people. As long as the dog has all four paws on the ground, the dog is getting attention. The second the dog jumps up, the person withdraws attention by folding his or her arms across their chest and turning away from the dog.

In reward and punishment, behaviors that we like are rewarded with things that the subject likes. In the case of a dog, this would be things like food, petting, playing with a ball, etc. Behaviors that we don't like are punished with things that the subject doesn't like. In the case of the dog, this might be scolding or jerking on a choke chain.

So, you can see how the concepts can overlap, but aren't synonymous.

The concepts of random reinforcement and intermittent reward are nearly indistinguishable in my mind, but maybe someone else will come up with some distinctions between the two.

The idea is that at first, when you want to teach a behavior, you reward it every time it occurs. Once the behavior is learned, reward becomes intermittent. This strengthens the behavior because the subject will work harder and harder for the reward. The behavior has always resulted in the reward before, so why isn't it working now? Maybe I need to try harder!

How this applies to the seeker in the ED is that one visit, the subject gets Percocet. Maybe the next two visits, they get ibuprofen. But then the next time, they get Percocet again. This just teaches them that if they keep trying, sometimes they will get what they want. If the subject never ever got Percocet in the ED and it was consistent, then they would eventually stop trying (also known as extinction); this is an example of negative reinforcement in its pure sense.

What parents typically rely on is reward and punishment, not positive/negative reinforcement.

[mwboswell]

Let's not confuse the concepts of reward and punishment with positive and negative reinforcement.

In the pure form, positive reinforcement means that you're adding a stimulus (+) in order to reinforce a behavior. Negative reinforcement (-) denotes a lack of or a withdrawal of a stimulus, with the intent of decreasing the likelihood of a behavior occurring again. There is no value assigned (i.e. "good" and "bad").

An example, since I have a background in dog training, would be teaching a dog to sit. The dog sits, and a stimulus is added (i.e. praise, a treat). This is positive reinforcement. Or, if you tell the dog to sit and the dog doesn't sit, then nothing happens. No stimulus is applied to the "not-sitting" behavior. Only when the sitting behavior happens is a stimulus added to increase the likelihood of the behavior occurring again.

Negative reinforcement can also be the withdrawal of a stimulus. An example would be teaching a dog not to jump up when greeting people. As long as the dog has all four paws on the ground, the dog is getting attention. The second the dog jumps up, the person withdraws attention by folding his or her arms across their chest and turning away from the dog.

In reward and punishment, behaviors that we like are rewarded with things that the subject likes. In the case of a dog, this would be things like food, petting, playing with a ball, etc. Behaviors that we don't like are punished with things that the subject doesn't like. In the case of the dog, this might be scolding or jerking on a choke chain.

So, you can see how the concepts can overlap, but aren't synonymous.

The concepts of random reinforcement and intermittent reward are nearly indistinguishable in my mind, but maybe someone else will come up with some distinctions between the two.

The idea is that at first, when you want to teach a behavior, you reward it every time it occurs. Once the behavior is learned, reward becomes intermittent. This strengthens the behavior because the subject will work harder and harder for the reward. The behavior has always resulted in the reward before, so why isn't it working now? Maybe I need to try harder!

How this applies to the seeker in the ED is that one visit, the subject gets Percocet. Maybe the next two visits, they get ibuprofen. But then the next time, they get Percocet again. This just teaches them that if they keep trying, sometimes they will get what they want. If the subject never ever got Percocet in the ED and it was consistent, then they would eventually stop trying (also known as extinction); this is an example of negative reinforcement in its pure sense.

What parents typically rely on is reward and punishment, not positive/negative reinforcement.

Agree to all of the above with the additional comments:

Positive reinforcement can come in the form of a reward. AND-

Behavior extinguishment can come in the form of punishment.

[AndyLyn]

Well, this won't be popular, but a lot of the problem comes with the assumption that "pain is what the patient says it is." That statement completely leaves out the practioners' leeway in negating so much of what is common sense. When a patient is texting, watching TV, and eating cheetos, why are we giving them narcs for a reported 10 out of 10 migraine? It doesn't make any sense.

[heron, ASN, RN]

Well, this won't be popular, but a lot of the problem comes with the assumption that "pain is what the patient says it is." That statement completely leaves out the practioners' leeway in negating so much of what is common sense. When a patient is texting, watching TV, and eating cheetos, why are we giving them narcs for a reported 10 out of 10 migraine? It doesn't make any sense.

What doesn't make sense is that so many can't tell the difference between chronic severe pain and short-term, recent onset acute pain.

Sorry about the snark, but it gets hard to see activity cited as disproof of reported pain in chronic pain patients.

I understand the point you are trying to make - that addicts lie about their pain. It's true, they do ... but a pt's activity level doesn't prove anything about that one way or the other.

[Guest219794]

I agree with your assessment that the patient is receiving the behavioral modification "intermittent positive reinforcement"....but what are they receiving? Intermittent reduction in their pain?

I think we see it as them "scoring" something, but couldn't it be intermittently reinforcing becuase their pain is relieved?

Absolutely.

Regardless of what causes the distress, it is relieved by the vicodin. Or Percocet.

But- as ER nurses, we complain that patients use the ER rather than their PCP. The example I cited is one reason why people do it. I am not judging whether or not narcotic use is in the best interest of this patient. Her PCP is. If she goes to her PCP, she she won't get narcs. If she comes to our ER, she has about a 75% chance of getting what releives her distress. Of course she bypasses her PCP.

BTW- This particular patient is allergic to Tramadol and Toradol.