They pretend to have chest pain or whatever pain. They range from being annoying to threatening. Many of them are strong young guys. They demand dilaudid/benadryl IV Q4. Really a big hassle, especially for night float. I do not want to give them pain meds easily. However, pain is subjective, isn't it?
How to deal with drug addicts in hospital?
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B52 ftw
I simply tell them that I am more than happy treat their pain with pain medication that is appropriate for their condition. For chest pain, unless it's trauma, sickle cell, or PE, I simply tell them that I don't give dilaudid for chest pain and that it's not appropriate, regardless of what any other doctor does.
Just make sure that it's not pain-relief seeking behavior that you're confusing with med seeking behavior.
Just make sure that it's not pain-relief seeking behavior that you're confusing with med seeking behavior.
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I also go by 'The Candyman' when I'm on. Pain is subjective, but the drug seekers are usually obvious to everyone. Still, it's pretty much not possible to prove. I try to give the absolute minimum possible to make them happy. No more, no less. You have to pick your battles, and, to me, this is one that's hardly ever worth fighting.
If you truly want perspective, talk to anyone in EM and they will tell you how they are forced to kneel to the almighty 'Press Ganey', even if it means acceding to the drug seekers.
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For the people who say that dilaudid is the only thing that works for their pain (and I don't have any evidence that they're otherwise seeking which would allow me to kick them out), I have the nurse put their dilaudid in 100ml of saline and infuse over 15-20 min. The pain relief profile of dilaudid push and dilaudid slow drip is about the same, but you don't get the euphoric effect. Once the drip has had a chance to work (at about the 30 min mark the pain relief is the same), if they still complain or say it didn't work and demand another dose with benadryl then I call BS and show them the door.
Plus it helps to be slow on the benadryl admin. If they don't get the histamine rx or any other objective signs then they want it for another purpose.
Plus it helps to be slow on the benadryl admin. If they don't get the histamine rx or any other objective signs then they want it for another purpose.
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My usual way of dealing with these pains/patients is to rule out any underlying pathology that may have lead to these kind of pains... Then when all the significant underlying etiologies are ruled out, tell them, there is no reason to have such kind of a pain and kick them out of the hospital and document in the chart in details of their "drug seeking behavior"... so that the next time around, every body is catious enough.
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Saying no to drug addicts is important for our profession and it is too bad we don't get more training in it. One thing that helps me remember to hold my ground with them is to think about it this way: If the DEA decides my controlled substance prescribing habits are questionable, or say that someone ODs and they find a pill bottle with my name on it in an addict's possession, my license is on the line. Is it worth jeopardizing my license and career to kowtow to an addict? NO.
If you honestly believe a patient might pose a threat to you or other staff, don't be afraid to use restraints. You may want to call security ahead of time to let them know that the patient is a high risk to become combative and ask them to come on the unit so they can respond quickly if the patient
becomes agitated.
When talking to the patient, be very mindful of keeping your tone even, non-confrontational and avoid sounding condescending or disrespectful. That can help de-escalate things with a volatile patient. If they sense you're looking down on them, that can enrage them.
I will sometimes say things like "I can't do that, but what I can offer you is X". Sometimes they're just testing you and will let it drop when they see that you've set firm boundaries about what you will and won't do.
You might also want to try to observe a patient when they don't know you're on the unit to see them (if you're able to do that) and document that when they have their guard down they don't show any objective signs of being in intense pain.
If you honestly believe a patient might pose a threat to you or other staff, don't be afraid to use restraints. You may want to call security ahead of time to let them know that the patient is a high risk to become combative and ask them to come on the unit so they can respond quickly if the patient
becomes agitated.
When talking to the patient, be very mindful of keeping your tone even, non-confrontational and avoid sounding condescending or disrespectful. That can help de-escalate things with a volatile patient. If they sense you're looking down on them, that can enrage them.
I will sometimes say things like "I can't do that, but what I can offer you is X". Sometimes they're just testing you and will let it drop when they see that you've set firm boundaries about what you will and won't do.
You might also want to try to observe a patient when they don't know you're on the unit to see them (if you're able to do that) and document that when they have their guard down they don't show any objective signs of being in intense pain.
The only thing I'd like to also add is to please make sure you don't confuse seeking behavior with true pain, before you start dismissing them. These are harder to tell apart than it seems
1. If someone is asking for dilaudid over morphine, I can tell you from experience that dilaudid is a much cleaner feeling drug than morphine. After having both, I would want dilaudid any day over an equivalent of morphine.
2. If someone is saying that they're not receiving enough pain relief, make sure you'r enot underdosing. Morphine starts at 0.05-0.1mg/kg. That means your big fat guy is gonna have a starting dose of 8-10mg of morphine per slug, or 1-1.5mg dilaudid. 2mg morphine pushes are for cardiac pain and 5 year olds.
3. Account for drug tolerance. Someone on regular oxy's isn't gonna even feel 4-5mg of morphine. Someone on methadone?
Once you've accounted for that, then check how many Rx's they're filling, check their doctor shopping, call their bluff if they don't belief pca or dilaudid drip does anything, etc. And there is no reason you need IV benadryl. Give em PO benadryl ATC so they don't get that histamine release.
1. If someone is asking for dilaudid over morphine, I can tell you from experience that dilaudid is a much cleaner feeling drug than morphine. After having both, I would want dilaudid any day over an equivalent of morphine.
2. If someone is saying that they're not receiving enough pain relief, make sure you'r enot underdosing. Morphine starts at 0.05-0.1mg/kg. That means your big fat guy is gonna have a starting dose of 8-10mg of morphine per slug, or 1-1.5mg dilaudid. 2mg morphine pushes are for cardiac pain and 5 year olds.
3. Account for drug tolerance. Someone on regular oxy's isn't gonna even feel 4-5mg of morphine. Someone on methadone?
Once you've accounted for that, then check how many Rx's they're filling, check their doctor shopping, call their bluff if they don't belief pca or dilaudid drip does anything, etc. And there is no reason you need IV benadryl. Give em PO benadryl ATC so they don't get that histamine release.
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Your state medical board will publish either a monthly or quarterly account of their disciplinary actions. Having been looking through them in 3 states now, the docs that are getting disciplined (not losing their license but requiring monitoring and CME) are doing things flagrantly wrong. Most of the disciplinary actions are for doctors consistently prescribing narcotics without a recorded physical exam or records indicating an on-going need for narcotics. The rest are almost always for prescribing narcotics to someone with whom the doctor is involved in a sexual relationship. Most of the suspensions or revocation of licenses are from repeated failures to comply with board-ordered remediation from prior offenses. There are a ton of reasons not to give narcotics to people you are suspecting of abusing them, but losing your license is a pretty weak one.
Also, gather all the information you'll need to decide about giving narcotics and then stand by your decision. If someone is trying to get narcs out of you for secondary gain, they're not doing their job unless they make you feel like a horrible person for not giving them narcs. So make sure you have the info you need prior to letting them know they're not getting narcs because all kinds of reasons and excuses are going to come up. One of more of them might actually be legitimate (although manufactured) reasons to prescribe narcs and it can be really tough to tell if the patient is lying if you don't have a good baseline knowledge of the situation.
Finally, if it's drug-seeker that knows they're going to be stuck with the same provider or group of providers they may try the long play. Some of the most frequent abusers are actually extremely polite when you refuse narcs because they know you or your staff will remember the verbally abusive jackass and the well will be poisoned for future encounters.
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Or for plenty of adults who have had a laparotomy. Starting with weight-based dosing of 8-10mg of morphine for your bariatric patients is a good way to find out where the nurses keep the Narcan. I prefer to titrate to effect.
Except most of my surgical patients are NPO...
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If you have concerns about addictive behavior, IV benadryl is one of the most euphoric substances available (right up there with demerol). In those cases I'd give it IM.
That is true about NPO patients, I agree with Arcan that if I suspect abuse, Benadryl goes in as an IM shot.
8-10mg morphine requires narcan in your bariatric patients? really? The only time I've had apneic patients was a freak case of a regular adult with appendicitis needing it after 4mg morphine (hadn't diagnosed the appy yet, thought it was just bad gastro at the time), and post-op patients who got dosed q15min with mult. doses of fentanyl and dilaudid. Recent post-op pain is generally a different beast, not one that I deal with in my specialty. I deal generally with acute pain, and find any excuse not to treat chronic pain with IV meds.
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On the pain service I had several consults. Some from drug seekers, some were legitimate. We could usually figure it out, but sometimes it took some digging.
Everyone in the hospital had deemed one lady as a drug seeker and crazy, possibly assuming the identity of her recently deceased sister who died of painful cancer. She had supposedly been kicked out of her nursing home for abusive behavior. She was a very thin woman who had this story of having a football sized tumor inside of her abdomen, and tumors all over her body and in her hips (Wasn't able to palpate that on physical exam). This was supposed to be an extremely rare and slow growing cancer that no one else had ever heard of (though it was in the medical books). Her nursing home said they knew nothing about this cancer. She knew the answers to everything, it all seemed too convenient. She wanted super high doses of pain medications, especially Dilaudid, and this was high even in comparison to other patients that were coming to our chronic pain clinic. She had been all over the city to multiple different chronic pain doctors at different times.
We quickly obtained some records of a PET scan from another major hospital and found out that she did have a massive tumor as well as innumerable metastases throughout her body. Our consult recommendation was pretty much to give her whatever she wanted and please get her into hospice care.
But for others the recommendations were "Patient is not a good candidate for opioid therapy". Or even "continuing opioid therapy may be dangerous to the patient, please take measures to decrease opioid use."
Hydromorphone is a very good drug. It is also a very old drug, and relatively inexpensive, though not as inexpensive as morphine. Morphine can have severe side effects in comparison, so it is no wonder people prefer hydromorphone.
Everyone in the hospital had deemed one lady as a drug seeker and crazy, possibly assuming the identity of her recently deceased sister who died of painful cancer. She had supposedly been kicked out of her nursing home for abusive behavior. She was a very thin woman who had this story of having a football sized tumor inside of her abdomen, and tumors all over her body and in her hips (Wasn't able to palpate that on physical exam). This was supposed to be an extremely rare and slow growing cancer that no one else had ever heard of (though it was in the medical books). Her nursing home said they knew nothing about this cancer. She knew the answers to everything, it all seemed too convenient. She wanted super high doses of pain medications, especially Dilaudid, and this was high even in comparison to other patients that were coming to our chronic pain clinic. She had been all over the city to multiple different chronic pain doctors at different times.
We quickly obtained some records of a PET scan from another major hospital and found out that she did have a massive tumor as well as innumerable metastases throughout her body. Our consult recommendation was pretty much to give her whatever she wanted and please get her into hospice care.
But for others the recommendations were "Patient is not a good candidate for opioid therapy". Or even "continuing opioid therapy may be dangerous to the patient, please take measures to decrease opioid use."
Hydromorphone is a very good drug. It is also a very old drug, and relatively inexpensive, though not as inexpensive as morphine. Morphine can have severe side effects in comparison, so it is no wonder people prefer hydromorphone.
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I never use morphine as a first-line drug, and I honestly don't remember the last time I prescribed it as anything other than a pre-filled order set on a specialty rotation. I use fentanyl, and it is the very rare patient that needs more than a 30mcg demand dose on a PCA. I would certainly not start with three times that much.
I've only had someone go apneic after getting Versed. He'd been getting blasted with fentanyl all day, needed a chest tube, was still pretty ornery, so we gave 2mg of Versed. He was young and pretty big, and he just stopped breathing completely. The Narcan arrived first, and it was enough to reverse him. The benzo probably potentiated the narcotic to a much greater degree than I was expecting.
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There is a difference between acute dosing (once or just a couple of doses), and the repeated doses that post op patients get. The 8-10 mg is good for the first, while 2 mg q2 hrs prn is a nice starting point for the second (with hold parameters, and adjusted for age/weight). That is a whole different topic, though.
As for the seekers I adopt a few different strategies.
For the person who is a known substance abuser who has an identifiable reason for severe pain (trauma patients with real injuries, infected folks who get a big debridement), I discuss with them at the first possible moment that they are going to have pain and it is going to be difficult to control due to their abuse. I let them know that I will be trying a variety of methods to control their pain and they need to be patient since it may take some time until I find a good combination. I tell them the deal is that as long as they are cooperative with anything I try on them, that I will continue adjusting things until they get good control. Then I use a combination of meds. Usually this works out pretty well and they end up on stuff that isn't that much more than someone else in their condition (and is almost always po only)
For the ones that don't admit to using but are obvious about things (asking for IV benadryl despite taking po, asking for IV phenergan but not showing any signs of nausea, claiming 10/10 acute pain with no change in vitals and sitting there chilling when they don't know they are being observed, refusing to even try alternate medications, listing multiple "allergies" to pain meds) I base it on what I am seeing them for. If I think they are exaggerating pain they actually have, I will give them po meds (again I like a combo) and let them know that there is no medical reason to give them IV stuff. Often times this will help you get them out of the hospital, but all it takes is one person to give in to extend their stay. If there is no good reason for them to have pain, and they are being jerks, I will document very well and discharge them.
For the ones that I am not sure of (asking for certain meds because they know it has worked for them before-but willing to try other stuff first if I say so, claiming much more pain that would typically be seen with their injury/illness-but looking like it is legit even when you hide and observe, those with a chronic pain history that isn't something readily verified on imaging/records I have that I am seeing for something acute) I may start with some heavy hitting meds, but I still try to build a nice po regimen for them. A lot of times I may be satisfying a skilled seeker, but I know that not everyone has the same responses to pain (I for one require what could be considered huge doses of pain meds post op). At least that seeker will be pleasant, cooperative, and nondisruptive on future visits.
As for the seekers I adopt a few different strategies.
For the person who is a known substance abuser who has an identifiable reason for severe pain (trauma patients with real injuries, infected folks who get a big debridement), I discuss with them at the first possible moment that they are going to have pain and it is going to be difficult to control due to their abuse. I let them know that I will be trying a variety of methods to control their pain and they need to be patient since it may take some time until I find a good combination. I tell them the deal is that as long as they are cooperative with anything I try on them, that I will continue adjusting things until they get good control. Then I use a combination of meds. Usually this works out pretty well and they end up on stuff that isn't that much more than someone else in their condition (and is almost always po only)
For the ones that don't admit to using but are obvious about things (asking for IV benadryl despite taking po, asking for IV phenergan but not showing any signs of nausea, claiming 10/10 acute pain with no change in vitals and sitting there chilling when they don't know they are being observed, refusing to even try alternate medications, listing multiple "allergies" to pain meds) I base it on what I am seeing them for. If I think they are exaggerating pain they actually have, I will give them po meds (again I like a combo) and let them know that there is no medical reason to give them IV stuff. Often times this will help you get them out of the hospital, but all it takes is one person to give in to extend their stay. If there is no good reason for them to have pain, and they are being jerks, I will document very well and discharge them.
For the ones that I am not sure of (asking for certain meds because they know it has worked for them before-but willing to try other stuff first if I say so, claiming much more pain that would typically be seen with their injury/illness-but looking like it is legit even when you hide and observe, those with a chronic pain history that isn't something readily verified on imaging/records I have that I am seeing for something acute) I may start with some heavy hitting meds, but I still try to build a nice po regimen for them. A lot of times I may be satisfying a skilled seeker, but I know that not everyone has the same responses to pain (I for one require what could be considered huge doses of pain meds post op). At least that seeker will be pleasant, cooperative, and nondisruptive on future visits.
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