article: being "fooled" by drug-seekers

doctorFred said:

an IO line without analgesia.

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Actually, quite well tolerated - about as painful as large-bore IV attempts. I'd have no qualms about using this for semi-urgent access in a conscious patient who was a difficult IV stick and in whom the risk of a central line did not outweigh the benefits.

J. Davidoff, R. Fowler and D. Gordon et al., Clinical evaluation of a novel intraosseous device for adults, JEMS 30 (2005), pp. S19–S22.

L. Gillum and J. Kovar, Powered intraosseous access in the prehospital setting, JEMS 30 (2005), pp. S23–S25.

doctorFred said:

forget about specific conditions and specific medications. as a physician, which offense is worse:
a) enabling 9 drug seekers out of 10
b) mistakenly denying the final 1 out of 10 opiates because you think they're trying to pull a fast one

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I think part of the problem is that it's not really our job as emergency physicians to try and sort this out one way or the other. If you are in pain chronically, the ED isn't a reasonable place to get your medications. We are not trained in the treatment chronic pain and you can very likely get better care from someone who specializes in pain. So in this situation I do the best I can even though I'm likely going to deny someone in legitimate pain at some point.

Complaining that we undertreat real chronic pain is like complaining that the cardiologist didn't address your diarrhea/concern for IBD.

Stitch said:

I think part of the problem is that it's not really our job as emergency physicians to try and sort this out one way or the other. If you are in pain chronically, the ED isn't a reasonable place to get your medications. We are not trained in the treatment chronic pain and you can very likely get better care from someone who specializes in pain. So in this situation I do the best I can even though I'm likely going to deny someone in legitimate pain at some point.

Complaining that we undertreat real chronic pain is like complaining that the cardiologist didn't address your diarrhea/concern for IBD.

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I think there are some reasonable steps you can take to stratify the risk. I have a series of steps I go through:

1. Look up visit history. Is there a history of multiple ED visits for the same complaing, or for multiple minor complaints? This history in a young person under 40 is especially concerning.

2. Look them up on the Nevada DEA website to see what prescriptions they've had written in the past 30 days. If they have more than one or two prescriptions for controlled substances or from multiple providers it's concerning.

3. I test them to see how truthful they are about their past visits, the length of their pain episode and what doctors they've seen.

GeneralVeers said:

I think there are some reasonable steps you can take to stratify the risk. I have a series of steps I go through:

1. Look up visit history. Is there a history of multiple ED visits for the same complaing, or for multiple minor complaints? This history in a young person under 40 is especially concerning.

2. Look them up on the Nevada DEA website to see what prescriptions they've had written in the past 30 days. If they have more than one or two prescriptions for controlled substances or from multiple providers it's concerning.

3. I test them to see how truthful they are about their past visits, the length of their pain episode and what doctors they've seen.

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Not all states have the DEA data base tho. I've rotated in a state that has the data base, and I've also rotated in a state that does not. I can tell you that it makes a world of difference!!! My attending would print out the page and show it to the drug seekers and show them to the door.

december07 said:

Not all states have the DEA data base tho. I've rotated in a state that has the data base, and I've also rotated in a state that does not. I can tell you that it makes a world of difference!!! My attending would print out the page and show it to the drug seekers and show them to the door.

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I can already envision the lawsuit by family claiming the ER physician "should have known" the victim was addicted to narcotics from the state database, and never should have written the Rx the victim overdosed upon. Just one more time-consuming addition to the standard of care requiring us to babysit the patient population bent on deceiving us for narcotics.

Fred,
In another thread you compared opiates for drug-seekers to the legal system. I think that is setting up a false analogy. Imprisoning someone for many years versus allowing someone with chronic pain to go untreated for one day is not the same situation. Plus, a significant percentage of chronic pain patients that frequently visit the ED are diverting drugs. With the epidemic of prescription drug abuse in high schools and among young adults, putting more opiates out on the street has a real societal cost.

Also, let's not pretend that in the long term a shot of demerol or dilaudid changes the course of their disease. If you have chronic pain every day, does the 4 hours of relief (+/- euphoria) that an IV bolus gives make that much of a difference? Intermittent dilaudid boluses does not a pain regimen make, anymore then going to the ED for insulin only when your diabetes makes you feel terrible is a glycemic control regimen.

This is obviously a controversial issue, and one that I am only four years into learning, but here are my thoughts...

I used to worry about the plague of "drug seekers" and occasionally still do. This came to a climax when I encountered a 45 yo woman who had an odd appearing red knee which she said was swollen and painful after falling down the stairs. She kept asking me to do something quickly and so in my haste I didn't dry my hands from the sink and began to examine her....what do you know, the redness was dribbling down her leg....curious it was. Interestingly, she still refused to admit that she had colored her knee.

In the light of that worry, I used to dole out opiates with intense caution and kept trying to asses who was in pain and who wasn't. I looked for objective evidence of injury or illness, vital sign abnormalities (BTW, when I had a kidney stone and experienced the worst pain of my life my EMS vitals: BP 123/67 & HR 62...life changing moment for me), etc, until, one of my most respected teachers asked me a simple question...

which way am I willing to error after making all reasonable attempts to assess a patient's pain....in favor of giving pain medications to someone who may not be in true pain? or in favor of not giving someone pain medications who may truly be in pain?

It is a really simple question, and assumes that you have done your reasonable best to assess the medical need (Hx, Px, Chart review, state logs if available), but when you are left wondering, that is when this question comes up. The painted knee is easy, the cancer mets is easy, the abdominal pain without objective evidence is difficult.

In the end, for me, the decision was that I did not want anyone in pain to go untreated on my shift. It is a simple rule that I have, and one that i stand by...if someone has an obvious history of misuse or is blatantly lying they will get no where with me, but anyone whom I cannot disprove, will be trusted at their word. This works for me, as it fits with my medical ethic; I understand this is unique, and it will evolve as my career does, but for now it lies here.

In the spirit of pain relief, EMRAP had a great piece earlier this year by an EM physician in California, whose hospital has essentially eliminated the stupid 1-10 scale and changed it to the most important question: "Would you like some pain meidcation?" its a great piece in my opinion and worth listening to for every EM doc I think.

Cheers,
TL

doctorFred said:

it sounds like you're arguing a quantitative difference, not a qualitative one. while the analogy isn't 1:1, i was merely using it to illustrate a question - in other words, .."at which point is it ok for bad things to happen to good people?"



i wasn't talking about changing the course of a disease, and we may not be necessarily talking about chronic conditions. a patient could tell you their tooth started hurting for the first time today and they're in agony. in which case, those extra hours of relief that get them to a dentist may not make a huge difference to you, but it sure does to them.

and again, the technical details of the scenario aren't really what i'm interested in as much as the question itself.

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Well, at some point bad things will happen to good people, everyone has to decide at what point you draw the line. Not to mention that I don't know if giving a narcotic seeker their narcotics is actually a good idea. It's a simplistic idea that you're just relieving pain or giving a high depending on if they're seeking or in genuine pain. Narcotics aren't A v. B.

Forget the fact that drug addiction is a horrific disease that I wouldn't wish on anyone. In some cases giving narcotics are inappropriate or ineffective treatments (a lot of chronic pain syndromes), create new pain (rebound headaches), creates addictions, or is really just nonsuperior to other treatments you have on hand (odontalgia).

Hell today I had a patient who was screaming around in pain demanding more and more and more narcotics. Eventual admitting diagnosis? Drug-induced bowel obstruction from guess what, narcotics + poor bowel regimen + underlying disease. You know what I did? I made her condition worse by acquiescing and giving her what she wanted.

Yes, there are some diseases where narcotics are fantastic medicines. But to ever say that "oh I'd rather give 99 seekers narcotics than miss 1 real pain" is not really understanding the role of narcotics as pain medicine.



PS (and as a side note, have a headache story from my last shift). Had a post-LP h/a + pseudotumor v. migraine pt yesterday (yes, had at least 2 headaches at once, poor girl), plus maybe neck strain. The percocets prescribed didn't touch the pain and she came in seeking dilaudid that someone told her about. I explained that narcotics aren't particularly good medicaitons for headaches and can make things worse in the long run. She didn't believe me until I promised I'd throw the kitchen sink at her. Compazine + toradol dropped the pain a good 20%, the valium dropped it 20% more when it kicked in (neck became non-stiff), caffeine + fluids took care of most of the rest (the slow pharmacy/busy day actually put some space between all the treatments). she was 90% better when she went home and didn't even need a blood patch Hopefully I won't see her tonight for a blood patch...

BTW, despite that diatribe above, there are a lot of times when I suspect someone is a seeker and I will still have no problem giving opiates because I can't tell and it's a reasonable medication for that situation.

doctorFred said:

just wanted to say that this has been so thoroughly debunked by every reputable pain specialist i've ever spoken to.

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IV pushes have been debunked by pain specialists I've spoken with, sure. But not narcotics as a whole. To say that giving someone a medication multiple times that has the potential for addiction doesn't create addictions, then what does? Is someone just magically an addict who knows exactly what medication they want to be addicted to and seeks it out without ever having received it? No, they've received it multiple times in the past already and have in addition whatever other factors go into creating it.

doctorFred said:

it sounds like you're arguing a quantitative difference, not a qualitative one. while the analogy isn't 1:1, i was merely using it to illustrate a question - in other words, .."at which point is it ok for bad things to happen to good people?"

and again, the technical details of the scenario aren't really what i'm interested in as much as the question itself.

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The question itself has no answer unless context is provided. Bad things happen to good people all the time, and unless there are conditions (defining "good people" and "bad things") the question is trying to solve for multiple variables with a single equation.


I will order opioids on most patients with acute painful conditions. People who have a long history of ED visits for the same condition typically will not receive opiates. I typically will not give narcotic scripts to patients with chronic pain, for a variety of reasons.

There are tons of studies showing that it isn't frequent fliers that are clogging up our emergency departments, but boarding patients. However, the chronic pain patient who presents with an acute exacerbation of pain in the thoracoabdominal region and requires multiple doses of IV pain medication before they are willing to leave the ED suck up resources. Our ED fills to capacity between 7pm and 2am almost every night, and there are some very sick patients waiting for a bed that is being used up by a patient that is inappropriately using the ED. Giving them narcs (or even having to order a lipase for the 10th time that month) takes up time and resources that are needed elsewhere. Not giving them narcs encourages them to seek other venues for their care.

I personally think there is no role for IVP pain medications except in an extreme, acutely painful situation, like a long bone fracture, kidney stone, or appy.

IM or slow IV drip should work just as well without the euphoria, and possibly fewer adverse reactions.

I've always subscribed to the concept that we as Emergency Physicians do not necessarily create addicts nor break / cure addiction in the ED. I am convinced, however, that our prescribing behaviors, and to some extent our analgesic administration practices in the ED, contribute to recidivism and behaviors by patients that utilize our services inappropriately.

doctorFred said:

this, i totally agree with. i was never advocating push narcs for every head/abdominal complaint.

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Well, the general tenor of your posts is that you DO advocate narc for every head/abdominal complaint. Are you an EM resident, or in another area? You passionately defend narc-ing up everyone, state that addiction doesn't occur, and oppose what others say. What you post definitely has a clinic sense to it, and not necessarily sub-tentorial (ie, some psych clinic setup).

If you are an EM resident, I want to know where, because I want to know who are the administrators and attendings that support you clogging the ED with seekers, and where, when one person sees you, that person puts out the call that "he's on", and that you will soon see an influx asking for you.

I'm just saying that objective findings get stuff. If there's nothing there, there's nothing there. Although I loathe the history and politics of Ronald Reagan, he was the one who said "trust, but verify".

Apollyon said:

Well, the general tenor of your posts is that you DO advocate narc for every head/abdominal complaint. Are you an EM resident, or in another area? You passionately defend narc-ing up everyone, state that addiction doesn't occur, and oppose what others say. What you post definitely has a clinic sense to it, and not necessarily sub-tentorial (ie, some psych clinic setup).

If you are an EM resident, I want to know where, because I want to know who are the administrators and attendings that support you clogging the ED with seekers, and where, when one person sees you, that person puts out the call that "he's on", and that you will soon see an influx asking for you.

I'm just saying that objective findings get stuff. If there's nothing there, there's nothing there. Although I loathe the history and politics of Ronald Reagan, he was the one who said "trust, but verify".

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I practice alongside many very respected physicians and we all provide IVP narcotics for painful conditions. No hesitation. It is very unusual to have a drip form narcotic in our ED. We uniformly understand that this opens us to abusive situations, but again, openly, and proudly prefer to ensure that pain does not go untreated in our ED.

I think we should change the pain scale to this one.

We've probably all been fooled at one time or another. We simply don't know when. Patients are getting more creative as they watch television shows and gain new ideas. Some are also sharing their secrets online. As a result, we all need to get more sophisticated if we really want to catch people who are trying to trick us.

doctorFred said:

you are clueless. i don't advocate "narc-ing up everyone". i have said multiple times that i would never dispense narcotics to repeat visitors and known drug-seekers. i was asking a philosophical question about where people lean when they're on the fence. it's pretty obvious you fall off the fence entirely. and yes, i am an EM resident.

again, i don't even know where to start. you've misconstrued my position entirely.

ah, that explains it.

you're right. pain and depression don't exist at all. you've cracked the case! now, run, and share your findings with the world!

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Just give it up, dude. When you start insulting me, I see that your argument is much less substantial and failing. I "fall off the fence"? I misconstrued your position entirely? You make an absurd extension that "pain and depression" don't exist at all? So, by extension, are you saying that fibromyalgia (pain and depression) deserves the piles of Lortab and Vicodin that primary care docs dole out? If you are so up on the literature, you would know that opiates are not appropriate for fibromyalgia pain, and that is subjective pain without an objective way to quantify. See how people around here feel about fibromyalgia.

You say you don't support giving seekers what they are seeking, but your more verbose posting says the opposite. So don't start insulting. You've cracked no case at all, but you have garnered support from someone who, right now, has drug-seeking patients furiously searching the internet, trying to find the ED where they can go, say "I hurt and I need pain medicine", and get it - bolused! You may not know, so I shall tell you - patients, who know more about the meds than you do (which is like someone who says they know more about guns because they've been shot), know that Dilaudid, Demerol, Phenergan, and Benadryl don't work when they're given slowly - they have to be pushed rapidly.

Stitch said:

I think we should change the pain scale to this one.

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This comment sums it up nicely:

I really, really hate that chart (their chart, not yours). Everytime they ask me to rate my pain I want to scream, "It's a 12!!!" but then I think they'll think I'm trying to score the good drugs (which I totally am but they don't need to know that and also I'm a giant wuss so any pain is like a 40 on the richter scale). I also think everyone who sees me think I totally look like a druggie but I forget that I no longer wear the goth makeup because I'm a GRANDMOTHER now (poor planning having a kid while I was in college) and I look old and no one expects old, respectable people to be trying to score the good drugs and so I can scream its a 12 and no one will think anything of it...and yeah I hate those charts. I'm glad your boyfriend doesn't have ebola because that is freaking contagious.

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ThymeLess said:

In the end, for me, the decision was that I did not want anyone in pain to go untreated on my shift. It is a simple rule that I have, and one that i stand by...if someone has an obvious history of misuse or is blatantly lying they will get no where with me, but anyone whom I cannot disprove, will be trusted at their word.

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This is my practice as well. The one caveat is Demerol. I simply wont give it. If it's requested I say, "Demerol is not available when I'm working."

doctorFred said:

i'm sorry that you felt it was a personal attack. it wasn't. it was a question that i guess i should have phrased more succinctly and reiterated.

i'm a little shocked at the personal attacks that i've received in response.
i don't believe in "narc-ing up" everyone. i don't believe in dilaudid for fibromyalgia. the reactionary nature of those claims leads me to suggest that this is, indeed, a very touchy subject.

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Reread your 2nd post in this thread, the one in response to McNinja...

All done?

While you may not have meant your comments as a personal attack, they are inflammatory and not in keeping with the "I'm just curious" position you're taking now. If you're going to pull a trolljob, have the courage to deal with the fallout. If that was an honest attempt to elicit the community's views on analgesia, then it was full of fail. Hopefully you have more social skills in real-life, otherwise your seniors are going to hand you your a--.

doctorFred said:

he turned my question, unprovoked, into a personal attack, effectively accusing me of being a drug pusher that will have addicts excitedly monitoring the ER schedule to see when i'm working.

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Ramp up your reading and comprehension skills. That statement was not directed at you. Now you trying to turn what I said at you back at me is failing. Now you appear paranoid.

http://www.craigslist.org/about/best/sfo/301345524.html

Advice from an ER doctor to drug seekers
Date: 2007-03-27, 9:56AM PDT

OK, I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don't have your vicodin, me because I've seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we'll both be happier because you get out of the ER quicker.

The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.

The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn't require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the 'worst headache of your life' you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I'm not willing to lay my license and my families future on the line for your ass. I also don't want to miss the poor bastard who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your 'typical pain that is totally the same as I usually get' and we will both be much happier.

The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I've seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting by you might not be lying. (See below.)

The fourth rule is never ever ever lie to me about who you are or your history. If you come to the ER and give us a fake name so we can't get your old records I will assume you are a worse douchetard than you really are. More importantly though it will really really piss me the fuck off. Pissing off the guy who writes the rx you want does not work to your advantage.

The fifth rule is don't assume I am an idiot. I went to medical school. That is certainly no guarantee that I am a rocket scientist I know (hell, I went to school with a few people who were a couple of french fries short of a happy meal.) However, I also got an ER residency spot which means I was in the top quarter or so of my class. This means it is a fair guess I am a reasonably smart guy. So if I read your triage note and 1) you list allergies to every non-narcotic pain medicine ever made, 2) you have a history of migraines, fibromyalgia, and lumbar disk disease, and 3) your doctor is on vacation, only has clinic on alternate Tuesdays, or is dead, I am smart enough to read that as: you are scamming for some vicodin. That in and of itself won't necessarily mean you don't get any pain medicine. Hell, the fucktards who list and allergy to tylenol but who can take vicodin (which contains tylenol) are at least good for a few laughs at the nurses station. However, if you give that history everyone in the ER from me to the guy who mops the floor will know you are a lying douchetard who is scamming for vicodin. (See rule # 4 about lying.)

The sixth and final rule is wait your fucking turn. If the nurse triages you to the waiting room but brings patients who arrived after you back to be treated first, that is because this is an EMERGENCY room and they are sicker than you are. You getting a fix of vicodin is not more important than the 6 year old with a severe asthma attack. Telling the nurse at triage that now your migraine is giving you chest pain since you have been sitting a half hour in the waiting area to try to force her into taking you back sooner is a recipe for making all of us hate you. Even if you end up coming back immediately, I will make it my mission that night to torment you. You will not get the pain medicine you want under any circumstances. And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.

So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don't really give a shit if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says 'I am a drug seeker' and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don't want that. I don't want that. So lets keep this simple, easy, and we'll all be much happier.

Sincerely,
Your friendly neighborhood ER doctor

(OK, so I put one quote at the first, out of order...)

doctorFred said:

here's your original post, word for word:

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Apollyon said:

You've cracked no case at all, but you have garnered support from someone who, right now, has drug-seeking patients furiously searching the internet, trying to find the ED where they can go, say "I hurt and I need pain medicine", and get it - bolused!

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doctorFred said:

he turned my question, unprovoked, into a personal attack, effectively accusing me of being a drug pusher that will have addicts excitedly monitoring the ER schedule to see when i'm working.

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Apollyon said:

Ramp up your reading and comprehension skills. That statement was not directed at you.

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Hey guys. Let's chalk this up to not being able to really gauge someone's tone on the internet. We're all attendings and residents in this discussion. There was a little bit of playing devil's advocate to spur discussion and some back arguments that came off a little harsher than I think they were intended.

The whole thing goes to show that this is a very controversial subject and that it hits nerves with most of us on at least some level.

So let's dial the whole thing back a notch and proceed knowing that differences of opinion are ok on this one.

doctorFred said:

interestingly, the president of ACEP opposes drug database to run background checks on people seeking opiates, claiming that the minutes spent doing so are a waste of time and that the money to create such a database could be used better elsewhere. she argues that ER docs are not the "pain police."

i agree with some of what she says but i think a database would be pretty useful.

http://www.usatoday.com/news/opinion/editorials/2010-06-21-editorial21_ST1_N.htm

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One thing to remember is that at the administrative and ACEP level of things they view volume, even bogus volume, as power. Nationally the feeling is that if the number of annual ED visits increases by a few million the politicians will have to give us more money. The local administrative attitude is that an insured bogus dilaudid seeking visit pays as much as a legit visit so bring 'em on.

Keep that in mind when you read the papers about how the uninsured aren't clogging the EDs, it's the insured patients. That's because no one wants the politicians and public to lash back and cut funding.