Med Seekers

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Kris1

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I was curious to find out if medication seeking (specifically narcotics of course) is as big a problem as non-EMers say that it is. Also, do EM docs typically find creative ways of minimizing this so that it is not such a drain of their time or resources?

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part of our job is treating pain, and trying to weed out seekers from non is near impossible. im not going to go in suspicious of everyone, and potentially undertreat real pain to feel like i "won" by holding out on a seeker. if i think they have pain, or they say they have pain i give em meds. not all pain needs narcs, lots of people even decline them.

we do have a group of high use individuals that we monitor and have on a sort of pain protocol.

if it is someone i see has been here multiple times for the same recently, or that gives a funny vibe i just flat out tell them "you get 15 percocet, then you have to see your doctor. if you return without seeing them for this pain, you will not get more narcotics, and i am documenting this discussion on your chart". then i do so. i dont know that it affects anything, but when the next guy pulls up my old chart and see's that they have some grounds for perhaps not giving a narc. and most of my patients are cool with that. but really, i have more important things to think and worry about at work than did that guy dupe me for 10 percs
 
I was curious to find out if medication seeking (specifically narcotics of course) is as big a problem as non-EMers say that it is. Also, do EM docs typically find creative ways of minimizing this so that it is not such a drain of their time or resources?

Yes. Drug seeking is a big problem. Especially if you define problem as being a pain in my a** and making my shift less pleasant.

Yes, we find creative ways. Mine is saying "No. Have a nice day". The challenge is to do so in a way to lessen the impact on your Press-Ganeys. I decided to make this my pet project. I think I'm getting better at it.

Take care,
Jeff
 
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If you come into my department with severe symptoms, you are most likely going to get an expensive work-up. If you become a frequent flyer, we will soon pick up on the behavior and the narcotic supply will then dry up. You just end up telling them that you can give them a couple of percocet in the ER for their tooth pain and offer a dental block (for the same tooth that has been bothering them for 2 month and has now triggered the 3rd ER visit), but that they need to find a PCP or a dentist to manage their chronic tooth pain, rather than continue to come to the ER for the equivalent of a 500$ bandaid. Those are easy patients. Frustrating? Yes. Easy. Usually. Just try not to hate them for working the system. You can look someone in the eyes and with love in your heart, deny them narcotics, and explain that you don't think that it is in their best interest. Where it gets emotional, and draining is when you become antagonistic and react to their emotional demands by becoming angry. It isn't worth it.
 
If you have non-verifiable pain, that is chronic in nature with no physical exam findings I will probably not give you narcotics.

If you come in for "chest pain" I will not give you narcotics, rather I will give you nitro until your pressure bottoms out. You only get narcotics for chest pain if you get admitted.
 
If you have non-verifiable pain, that is chronic in nature with no physical exam findings I will probably not give you narcotics.

If you come in for "chest pain" I will not give you narcotics, rather I will give you nitro until your pressure bottoms out. You only get narcotics for chest pain if you get admitted.

If you are working up chest pain and do not give morphine, you do not meet the standard of care. After all, it is "MONA B". I mean, you bitch and complain all the time about the patients you see, and I will not tell you how to practice your medicine, but, if you give NTG "until your pressure bottoms out", and withhold the morphine, instead of giving them at the same time, it will bite you in the ass eventually - someone will sue you and win for extending their infarct because you inadequately treated their pain, which was coming from an objective (not subjective) source.

But, hey, that's you. You do it your way.
 
If you are working up chest pain and do not give morphine, you do not meet the standard of care. After all, it is "MONA B". I mean, you bitch and complain all the time about the patients you see, and I will not tell you how to practice your medicine, but, if you give NTG "until your pressure bottoms out", and withhold the morphine, instead of giving them at the same time, it will bite you in the ass eventually - someone will sue you and win for extending their infarct because you inadequately treated their pain, which was coming from an objective (not subjective) source.

But, hey, that's you. You do it your way.
Apparently you haven't read the article that showed an association of morphine use in patients with acute MI with increase mortality. Although there is no cause-effect relationship established yet, the mere mention of increased mortality with morphine use makes morphine not considered a "standard of care" anymore.

If you give NTG and it doesn't relieve the pain, and you still think it's cardiac, then you'd better have them on a drip and have cardiology see the patient.
 
I always like this approach:
Example person has 5 visits in the last month for the exact same abdominal pain. Has been w/u extensively ie labs, ultrasounds, and CT. PT still has not sought help from their PMD. I tell them I'll run labs to r/o a life threatening condition, treat whatever pain they have with non narcotic pain medication, and then refer them back to their PMD.
Usually when I up front telling them that they will not be recieving narcotics, the malingering decreases exponentially. they may be pissed but whatever.
I have heard that some ED's used criteria for who they send out eval forms to. If a patient has no PMD, has more than 6 ER visits in the past year, or has a strong psych Hx, they are NOT sent a survey. These institutions obviously have a "high" approval rating. Why 'cus adminitstration seeks the opinion of sane people.
I fin it interesting that at my institution the night docs in particular have the lowest "scores". Yet we are lectured by administrators who never work night shifts on the occasion they do come down from their ivory towers to actually see a patient.
I personally have had enough of this pres ganey crap. I practice medicine based on science not approval rating.
 
Apparently you haven't read the article that showed an association of morphine use in patients with acute MI with increase mortality. Although there is no cause-effect relationship established yet, the mere mention of increased mortality with morphine use makes morphine not considered a "standard of care" anymore.

If you give NTG and it doesn't relieve the pain, and you still think it's cardiac, then you'd better have them on a drip and have cardiology see the patient.

No, actually I am intimately associated with that article, as Matt Roe told me about it the month before it was published. As he said, patients become snowed, and state pain is relieved, but ischemia continues. That is why I limit the use to 7.5mg total only (2.5mg x 3 total doses, as ours comes 5mg/mL). The NTG comes first and heavy, but I do not withhold the morphine. I, too, will pound the patient with NTG (3 SL then the drip), but I do NOT wait to give them the morphine.

And, as I say, you practice your way. But when someone suffers an infarct and has a bloodthirsty scumbag lawyer come after you, and you say it's not the standard of care anymore, you will lose, because they will produce experts that will say that too much morphine is the problem, but not giving any is also a problem.

edit: I really do not mean to come out as sounding so combative. One thing I know is that you are whip-smart and good at your job.
 
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One of the primary docs I worked with has been trying to write Rx for ultracet (ultram plus acetaminophen) since it sounds like percocet and has had some success with the less than educated addict.

Anyone try this out there?
 
My understanding is that for someone with ongoing pain the standard of care is to titrate NTG to relief of pain or low blood pressure, as NTG dilates the coronaries and reduces ischemia. The logic for not giving morphine seems well-founded, as you're theoretically giving less than adequate doses of NTG. As I said, if your story is bad enough, and your pain is refractory to high doses of NTG then you're probably getting admitted, and you can have morphine.
 
No, actually I am intimately associated with that article, as Matt Roe told me about it the month before it was published. As he said, patients become snowed, and state pain is relieved, but ischemia continues. That is why I limit the use to 7.5mg total only (2.5mg x 3 total doses, as ours comes 5mg/mL). The NTG comes first and heavy, but I do not withhold the morphine. I, too, will pound the patient with NTG (3 SL then the drip), but I do NOT wait to give them the morphine.

And, as I say, you practice your way. But when someone suffers an infarct and has a bloodthirsty scumbag lawyer come after you, and you say it's not the standard of care anymore, you will lose, because they will produce experts that will say that too much morphine is the problem, but not giving any is also a problem.

edit: I really do not mean to come out as sounding so combative. One thing I know is that you are whip-smart and good at your job.
Unfortunately, a blood thirsty lawyer will come after you no matter what care you provide. Even if the patient's unfortunate outcome had nothing to do with your treatment, you can still be sued. My state has a pretty good tort reform law. Limited to $300,000 for non-economic damages, must show clear proof of negligence or intent to harm, and expert witnesses must be from the same specialty.

Dolobid. Pronounce it "duh-LOB-id".

I had never heard of this until one of our PA's mentioned it last night during a shift. Sounds like Dilaudid when pronounced a certain way. I like it!
 
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I avoid morphine for my chest pain patients and use fentanyl instead. Not a hard and fast rule for me, though.

I obviously give nitro as well. I give them both at roughly the same time because my interest is in getting them pain free. I don't find response to NTG to be clinically useful. Sort of like a rapid strep test. I'm not going to do anything differently because of it.

Take care,
Jeff
 
One of the primary docs I worked with has been trying to write Rx for ultracet (ultram plus acetaminophen) since it sounds like percocet and has had some success with the less than educated addict.

Anyone try this out there?

It usually only works once (if that).
 
Dolobid. Pronounce it "duh-LOB-id".

for one month straight i sent all my drug seekers home on dolobid, the conversations generally went something like this:

me: so i'm sending you home with a script for a really strong pain reliever
ds: which one?
me: dolobid
ds: dilaudid?
me: yes, dolobid, the really strong pain reliever... do you think it will work for your pain?
ds: i sure hope so (surely thinking i have a lisp or speech impediment, or am just dumb and/or naive)
me: ok, just make sure to take it as prescribed
ds: ::grins::

it's especially great when both you and the patient feel like we've won
 
this is true, but i'm not really quite sure what to do instead

There are basically two camps, and we have both in my group.

The first group of doctors says it's easier not to fight with the drug-seekers and just give them the narcotics they want. This group is becoming bigger with more emphasis on Press-Ganey scores.

The second group actively tries to discourage drug-seeking behavior, at the risk of pissing them off and getting poor scores.
 
I'd just like to drop in from anesthesia to reiterate the obvious: OH MY GOD is this Press-Ganey stuff you guys have to deal with just mind-bogglingly absofrigginglutely ludicrous.

I mean..... really. Patient satisfaction scores? In the ED?

Here's hoping your powers that be can do something about this, because it's just unfathomable to me that your reimbursements are tied to the satisfaction of a patient population that is in general unlikely to be satisfied regardless of the quality of care they have received.

Keep fighting the good fight.
 
I'd just like to drop in from anesthesia to reiterate the obvious: OH MY GOD is this Press-Ganey stuff you guys have to deal with just mind-bogglingly absofrigginglutely ludicrous.

I mean..... really. Patient satisfaction scores? In the ED?

Here's hoping your powers that be can do something about this, because it's just unfathomable to me that your reimbursements are tied to the satisfaction of a patient population that is in general unlikely to be satisfied regardless of the quality of care they have received.

Keep fighting the good fight.

what he said
 
my ER (small community hospital) has a good approach...

- any fishy stories or repeat customers, one of the receptionists calls the local pharmacies for the narcotic print outs... if there is a pattern, the patient is given contact info to detox programs, and NO narcs.

otherwise, all the other patients gets 4 pills of narcotic/benzo and that is it...

any repeat flyers get less and less narcotics, until ALL they get offered is Ibuprofen and flexeril...

the ER docs have seen a nice, steady decline in narc-seekers.
 
I'd just like to drop in from anesthesia to reiterate the obvious: OH MY GOD is this Press-Ganey stuff you guys have to deal with just mind-bogglingly absofrigginglutely ludicrous.

I mean..... really. Patient satisfaction scores? In the ED?

Here's hoping your powers that be can do something about this, because it's just unfathomable to me that your reimbursements are tied to the satisfaction of a patient population that is in general unlikely to be satisfied regardless of the quality of care they have received.

Keep fighting the good fight.

what he said

Thanks for the support guys. Every specialty has thier particular soul crushing annoyances. This is one of ours.

It does spill over though. Just last week I had a seeker who I discharged after I discovered she had >65 visits in 5 years just in my hospital chain (1/3 of local hospitals). She came back later and got admitted. She's managed to talk some GYN into doing yet another exploratory laparoscopy to try to fix her Dilaudid addiction. So one of your colleagues will get to meet her. Ug.
 
Enough with this customer satisfaction cr@p. so one guy goes home unhappy, we have plenty of other guys to fill the beds, there's no where else to go. People need to realized that these people aren't customers, they're patients and that sometimes means in order to care for them we can't tell them what they want to hear.
 
To borrow this annotation from homeboy Dr Mccoy:
Da** it Jim I'm a Doctor not a cruise director!
 
I don't care much for the Press-Ganey's. I treat people according to their need. If you're really sick, you will get every intervention, test, pain medication necessary. If you're a soul-crushing malingerer you will get the boot.

They can fire me for my low Press-Ganey score. I can always go back to Texas and make more money than I make now.
 
OUr state has an automated perscription system where we can sign up for an get access to all controlled scripts that have been filled on a patient.
So, often if I think a pt is a seeker I will print it out before I see the patient and then ask them when the last time they got a script filled was. If they lie to me, I have the proof right there. I love it when they say they got 20 2 months ago and it turns out it was 60 1 month ago....they claim they got their time confused and I tell them that they may get their time confused but would not confuse 20 for 60.

Also great when I had one that told me that the T-3 don't work for her and I told her that she has a lot of scripts written..she said that her doctor fills them for her at her pharmacy but I then told her that she has them filled from different pharmacies...she tried to tell me because another pharmacy is colser to her home so sometimes the doctor just calls it in for her.
 
this is true, but i'm not really quite sure what to do instead

Invoke Nancy Reagan:

"Just say no".

For the Press Ganey's, I try to say no with a smile.

As my notes say, "I politely but firmly declined their request for narcotics".

And just to be clear, I try to err on the side of treating and don't assume everyone is a drug seeker. EMRs, though, are pretty good at reviewing a repeat offender's track record. This also gets recorded: "I reviewed the patients Electronic Medical Record, taking particular note of their multiple ED visits, each requesting narcotic analgesia and their lack of PCP follow up".


Take care,
Jeff
 
Back to the original point I actually find that it is pretty rare for someone to come in and basically ask for an rx for pain medicine.

It happens but I probably see 20 chest pain, abdominal pain, vag bleed, lacs for every person who is clearly just seeking pain medicine.

Agree that the biggest thing is not to get angry. As soon as I sense that this dynamic is coming into play I usually say something like, "I will examine you and try to figure out what we can do for you today but you will not be getting IV pain medicine and I will not be writing you a prescription for pain medicine." Alot of people getting pretty interested in leaving after that.
 
my favorite answer when you confront a seeker as to why they fill different meds at different pharmacies .. "times are tight, and I have to watch every penny, so I compare each pharmacy and then get the vicodin wherever it is cheapest"....
 
Back to the original point I actually find that it is pretty rare for someone to come in and basically ask for an rx for pain medicine.

It happens but I probably see 20 chest pain, abdominal pain, vag bleed, lacs for every person who is clearly just seeking pain medicine.
I don't. Every shift I see at least one "chronic back pain" or one "headache" that has been to the ED at least a dozen times for the same thing.
 
I don't. Every shift I see at least one "chronic back pain" or one "headache" that has been to the ED at least a dozen times for the same thing.

Amen to that. At one of the three facilities I work at, it seems that every other patients has one of the following that "needs" a Dilaudid:

- Tooth pain
- Chronic back pain
- Chronic abdominal pain
- Borderline personality disorder
 
I don't. Every shift I see at least one "chronic back pain" or one "headache" that has been to the ED at least a dozen times for the same thing.

Well, with chronic headache, you've at least got a diagnosis of medication overuse headaches in which the treatment is to stop pain meds for 2 weeks. lol, try telling them the percocet is actually causing their headaches.
 
Once the majority of the population are out-of-work drug addicted people, maybe things will change?

Disability benefits + Oxycontin = A world gone mad
 
well... i think there is a reason why dilaudid has become so popular.... it is THE most profitable medication on the street right now when you compare the cost at the pharmacy and what the street pays...
 
I was curious to find out if medication seeking (specifically narcotics of course) is as big a problem as non-EMers say that it is. Also, do EM docs typically find creative ways of minimizing this so that it is not such a drain of their time or resources?

At the free clinic where I work we are not stopping with writing scripts for narcs because the area where we have the clinic is a known drug seeking area, when I am working the local ED I tend to stick to only giving narcs for serious cases. We do have a list of people who we know are med seekers who we end up seeing on a weekly bases if a Union doc has issued them the narcs while the normal docs were off.

With some of the patients I give them Percogesic, which them not knowing what meds really are, they think they are getting a narc and that seems to take care of it, those whom I have given that to have not come back asking for more narcs at our ED.

Dustin
EMT-B(+)
 
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