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Tips for dealing with drug seeking without becoming bitter?

Discussion in 'Emergency Medicine' started by buffywannabe, Oct 29, 2014.

  1. buffywannabe

    buffywannabe 7+ Year Member

    May 15, 2009
    So I get it, it's part of the job. And it doesn't bother me so much when we aren't super busy, I'll go and tell the pt why I am not going to give them a ton of narcotics. However when the waiting room is packed and the nursing staff is calling again and again about THE PAIN you have few options, give pain medication to make them shut up because really you are busy or go again and again to the same person and tell them you aren't giving narcotics and then document and document and document. I just feel like this shouldn't frustrate me as much as it does. Maybe I just need my vacation that is coming up. I hope I feel better when I come back. Any tips?
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  3. Hercules

    Hercules Son of Zeus 10+ Year Member

    Jul 25, 2000
    Mobile, AL
    Set clear limits from the initial encounter and don't bend. Either agree to dope them up or refuse then move on and don't let it occupy any more of your attention. You don't have to go back in the room if you have told the patient they can't have any more narcotics.
    EM4life, gman33 and Promethean like this.
  4. Arcan57

    Arcan57 Junior Member 10+ Year Member

    Nov 21, 2003
    I don't engage emotionally. A good drug seeker should make you feel crappy about not giving them narcs. That's their job. I deal with it by having no emotional skin in the game. Derive no satisfaction from them feeling better and feel no discomfort at their lack of improvement. Be extra vigilant for unexpected pathology because the lack of rapport limits spontaneous expressions of useful medical history. Move on to the next patient that you have a chance to help.
    WilcoWorld likes this.
  5. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Jun 6, 2002
    It works great when you're in a state with a narcotic database. I print it out (or show them on my iPad) their prescription history and say "sorry, the state monitors our prescribing patterns and I'm not risking my license to write you a controlled substance. I will give you a referral to a pain management specialist."
    fancymylotus and TheERdr like this.
  6. Birdstrike

    Birdstrike 7+ Year Member

    Dec 19, 2010
    This is how I would approach it. Stop thinking in terms of "drug seeker." Think along this algorithm:

    Acute pain or chronic?

    If "acute" and you're treating it seriously enough to work it up with some way, then treat the pain, rule out the emergency and you're done. Easy, this is what you're trained to do. Unless there's some contraindication or ongoing signs of medication/substance abuse, prescribe minimal medications necessary to bridge a patient to see the follow up MD for their acute condition. That is, prescribe what you deem appropriate. It's not an a la carte menu. Done. No negotiations.

    If deemed "chronic," and that means you're willing to stake your career on there being nothing acute whatsoever, to the extent you're going to blow it off, no tests indicated, "out the door," then there's not really any obligation to treat non-emergencies in the ED. "My dog age my Vicodin Rx" is not an emergency. That's a prescribing agreement violation with most prescribers and not filled as an outpatient either. Remember, many inappropriate medication requests have already been turned down by outpatient PCPs and Pain doctors who determined that there's some red flag. These patients when told "No" will not walk away happy, out of the PCP office, Pain MD office, spine surgeon's office or your "office." Accept that. (If admin via Press Ganey is demanding inappropriate prescribing then that's a whole other thread.) Some people do have a blanket "when in doubt everyone gets 'X' number of pills" just to get them out the door (ie, 6 or some small #) to avoid the Press Ganey beat down, but I can't say I'm condoning that.

    Try to get away from thinking in terms of "drug seeker," mainly because it can be medico legal pitfall, in the sense that often people can have chronic pain, and can be "seeking" pain relief because they've got a concurrent emergency. I've seen lots of life/limb threat emergencies that were hidden behind "chronic" pain.

    Make a decision. Prescribe or don't. Know your reason why. No negotiations. No hard feelings. Don't ever argue for even one second. My way or the highway. Next case.

    That being said, if you truly feel a patient is having an acute exacerbation of chronic pain, and there's no evidence of medication abuse/diversion, don't beat yourself up over the fact that you treated their pain. Also remember, there is more than one medication class to use for pain. Opiates are only one.
    Last edited: Oct 30, 2014
    fancymylotus and Blue Goose like this.
  7. gman33

    gman33 Moderator Emeritus 10+ Year Member

    Aug 18, 2007
    One of my attendings gave me some good advice.

    Develop a standard approach for these patients, just like you would for any other chief complaint.
    Look for red flags. Medical red flags. If there is something worrisome, work the patient up as appropriate.
    I err on the side of working up these patients when in doubt.
    Unfortunately these people still get sick and it's so easy to blow them off.

    If they have no acute pathology, they get shown the door.
    I will offer them some non-narcotic pain medication and d/c papers.
    If nursing informs me that the patient is requesting different meds or to see me, I tell them the plan has been discussed already and the patient is d/c.
    If they won't leave, I call security to escort them out.

    Does it always play out this easy? No, but that is what I strive for.
  8. TysonCook

    TysonCook Senior Member Physician Faculty 10+ Year Member

    Aug 19, 2002
    Carolinas Medical Center
    Agree with gman. Also, you need to get comfortable with "No". Once you can say no, without restraint, when necessary, your job gets a heck of a lot easier.

    Don't get me wrong, it isn't a flippant "No" and walk away, it's a "No, and here is why". Don't be afraid to BRIEFLY justify your "no", and don't be afraid to walk out. Ultimately this is an area that we, as physicians are not good at going, but need to become comfortable with. Yes, "customer satisfaction" is a slight issue, but when "No" is done properly, I don't believe it factors greatly into PG.

    It also applies to the, "I need test X", "my doctor told me to come here for Y" , or "I need admitted for Z", etc.

    Get comfortable with "No"...
  9. TimesNewRoman

    TimesNewRoman 2+ Year Member

    May 14, 2013
    This was something that I just couldn't do last year as an intern. I had such a hard time telling people no. I would just get run over by these folks. I would end up getting into 10 minute talks with patients that would end with "I'll have my attending come talk to you." It's amazing how much can change in a year.

    I feel so much more comfortable. "I'm sorry, we have a policy against prescribing narcotics for chronic pain." "well, the last doctor did." "I can't change what has happened in the past, but I can tell you my boss tells me I can't prescribe narcotics for chronic pain. I can give you a shot of toradol and rx for ibuprofen. Sorry, I hope you feel better. Anything else I can do for you?" walk out...

    Or sicklers who say "I always get itchy when my x/y/z narcotic, the only thing that helps is IV benadryl!" - "sorry, I don't write IV benadryl." "but......" "sorry, I just don't write IV benadryl, I'd happily give you some zofran or oral benadryl. Anything else I can do for you? Would you like a blanket or sandwich?"
  10. EctopicFetus

    EctopicFetus Keeping it funky enough 10+ Year Member

    May 3, 2004
    Reality is that with experience this is much easier. Honestly, they dont frustrate me. I typically enjoy catching them in a lie because it defuses them. They are usually off to aa different spot.

    On the rare occasion when it isnt the case my system has a "pain protocol". This allows me to simply say you are on pain management. That means x,y,z. They know (or some pretend they dont) and I simply say thats all we can do. I honestly cant remember the last time these patients got under my skin.
  11. GeneralVeers

    GeneralVeers Globus Hystericus Physician 10+ Year Member

    Mar 19, 2005
    Las Vegas
    It also helps to set boundaries with the nurses too. When I know i have a narc seeker who will ask again and again for meds, I tell nursing immediately the plan, and that I will not be giving any narcotics. In almost all cases that stops them from repeatedly asking me for pain meds, and they actually appreciate it as it makes their jobs easier.
  12. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    1) Remember the patient is the one with the disease. It's not your issue, it's theirs.
    2) Decide up front whether you think they're a drug seeker or not, and then treat accordingly (state database helps immensely)
    3) If you've decided they are, then tell them up front what they're getting or not getting. Most of the true drug-seekers will either walk right out here, or sneak out in a few minutes. If there are conditions on whether or not you'll treat them with narcotics, tell them what they are. "I'll give you narcotics if there is a stone in your ureter or something else that I think needs narcotics, otherwise non-narcotics only."
    4) Tell the nurse what the narcotic plan is. "I don't think they're a drug-seeker, titrate to hypoxia" or "I've told this patient he is not going to get narcotics; if he asks you can remind him of that."
    WilcoWorld likes this.
  13. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    I would caution against the approach of blaming it on a policy or on your boss. Instead, I would say "I am not going to give you narcotics because I think it's the wrong idea/it's bad for you/it's dangerous/it's not good medicine." It empowers you. If they ask to speak to my boss, I tell them I have none. If they want to complain to someone I work with, like hospital administration or nursing staff, they're welcome to do so but they can be assured that my chart will make it very clear I think they have a narcotic issue.
  14. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner Moderator Physician Faculty 10+ Year Member

    Aug 2, 2006
    49 of 50 states have them at this point. Suck it, Missouri. In fact, Washington State now has basically a consensus amongst hospitals that describes conditions they will and will not prescribe meds for. Of note, their database is automatically uploaded to the chart when the patient registers.
    hydroxyurea likes this.
  15. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 24, 2002
    In Pennsylvania, the PMP is available to law enforcement only. Physicians and pharmacists do NOT have access.
  16. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner Moderator Physician Faculty 10+ Year Member

    Aug 2, 2006
    They will soon.
  17. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 24, 2002
    Haha - you know more about the state than I do! Last I'd heard, 1180 wasn't going to pass. I'm quite happy that it did.

    Better late than never!
  18. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Jun 6, 2002
    I love it when they call the house supervisor because I won't give them pain medications. They quickly find out the house supervisor is a nurse that doesn't have prescriptive authority.
  19. Pons Asinorum

    Pons Asinorum Physician Moderator Emeritus 7+ Year Member

    Jul 30, 2010
    North Carolina
    That part seems amazing...
  20. EMbeastmode


    Mar 18, 2014
    I always state that I'm, "not comfortable prescribing that medication in this situation", and patients generally respect that (not always, but generally).
  21. diphenyl

    diphenyl Dancing doctor 7+ Year Member

    Jul 31, 2008
    One of my personal favorites to do is I will treat the "pain" however, I never order IV push. Put it in a little bag of saline and run it in over and hour. No rush for them. Amazing how that separates the turkeys from the legitimate. Nurses hate doing it so I often just grab the bag and spike it myself in front of the RN after they pull up the med so they don't have to deal with the liability of making their own drip.
  22. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    It also helps to remember "don't feed the trolls." I had a guy in the other day who clearly had a narcotic problem- 36 scripts from 26 providers in the last year, including one script for a single Norco 5. Yes, one pill, that he actually filled 2 weeks prior. However, he also had epididymitis confirmed on exam and US. So I gave him a few Norco. Sure enough, he was back 5 days later with his usual chronic complaints with no objective findings. Of course, my partner gave him nada and he stormed out. I had tried to work out a long-term narcotic plan with him (he was to call his doc the next day and either have his doc be his only prescriber or have his doc refer him to pain management) but he was obviously interested in only one thing. He also asked "how do I get off the drug-seeker blacklist?" It's not that hard buddy- just don't fill any narcotic scripts for a year.

    Moral of the story: The less you give the less likely you are to see a drug-seeker twice.
  23. chet

    chet 7+ Year Member

    Oct 2, 2008
    EMbeastmode. . . thats a great name.
  24. MSmentor018

    MSmentor018 Hooah! Physician Faculty SDN Advisor 10+ Year Member

    Jul 9, 2007
    it's always hot!
    haldol, it's like using the jedi mind trick.

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