I work in a rural area. I don't see a lot of illicit drugs, but prescription drug abuse is rampant.
For patients with multiple visits for pain complaints, I tend to give Toradol and/or Ultram - I have no problems saying no to narcs. For migraines, I give Compazine and Benadryl, +/- Toradol. If that doesn't work, I will give one round of Dilaudid IM prior to discharge, unless they have numerous visits or claim allergies to multiple non-narcotic meds. In those cases, I will not give narcotics. For non-emergent back pain (i.e., almost all back pain), I give toradol IM, Flexeril, and discharge with prescription for Ultram and Flexeril. For dental pain, I will not give narcotics unless there is an objective finding such as facial swelling. Cavities don't count as an objective finding, as all of my patients have those.
I frequently find myself saying:
- "Is there a non-narcotic pain medication I can offer you today?"
- "This is your 25th visit to the ER this year, so I think this is a chronic, not acute, pain issue. You would be better served by a chronic pain specialist. I'm more of an acute pain specialist."
- "This pattern of medication allergies is often seen in patients with prescription drug abuse issues. I understand that you may not be one of those patients, but as a matter of policy, I don't give narcotics in cases like this."
- Patients who bring in a copy of their MRI report from 6 months ago as proof of disk disease requiring narcotics in fact require management by a chronic pain specialist and prompt discharge by me.
- I like the idea of treating patients with a Dilaudid drip.
- In residency, I found myself giving multiple rounds of narcotic pain meds for things like back pain or migraine. Now that I'm out on my own, I often give one (or occasionally two) round of meds - often non-narcotic - and promptly discharge the patient.
- For patients with no prior visits, a non-concerning allergy profile, and those with OBJECTIVE painful complaints, I have no problem doling out the narcs - both in the ED and via prescription. I'll consider narcs for a swollen sprained ankle, a laceration, an abscess, or a corneal abrasion.
- I find lectures by pain management experts such as Jim Ducharme interesting, if somewhat self-righteous, but would take them a lot better if they were accompanied by an admission that prescription drug abuse - and abuse of our overcrowded EDs - is RAMPANT.
Fortunately, my compensation is not tied to Press-Gainey scores. If it were, I would definitely want some way to exclude drug seekers from the mix. I work in a group in which everyone does what they want, and several of my collegues are loose with the Demerol, so the seekers keep coming despite my efforts to stem the tide.
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