The drug-seeking patient
This is not a subject that I have talked about much before except in passing. It is one of the difficulties in working in emergency medicine. It is the drug-seeking patient. These are often some of the most infuriating and resource draining patients. Since starting residency, I have developed a strategy for dealing with such patients which, while still a work in progress, I will share with you.
The central problem with pain control as a whole is that there is no objective direct measurement of pain. Pain can only be measured subjectively (usually by asking the patient to rate their pain on a scale of 1 to 10), or indirectly by measuring objective symptoms of pain (such as blood pressure or heart rate). As should be immediately apparent, this is a less than ideal methodology, but it is what we have to deal with. Now, dealing with pain is usually done by the administration of narcotics. Unfortunately, as with all interventions, nothing we do is absolutely benign, and there are untowards consequences with the inappropriate administration thereof. There are both short and long-term sequelae. The short term problems include narcotization, vomiting with the concomitant risk of aspiration, possibly death and even constipation. Long-term issues are narcotic tolerance, addiction, and habit reinforcement.
When a patient comes into the emergency department, the majority are not seeking narcotics, but it seems that about 10% of them fall into the category of patients with drug-seeking behavior. When I get the triage report, there are usually some clues that make me cautious. Clues include a chronic pain issue, multiple EC (emergency center) visits, and multiple allergies. The allergies are usually to the less potent pain control medications. Then, when I see a patient, they usually exhibit certain behavioral patterns that indicate to me that what they really want are drugs. I am not going to go into them in this forum since the last thing I want to do is give some drug-seeker advice on how to confuse the doctor they are trying to hoodwink.
Before I go any further, I should state there my strategy is inappropriate in a number of cases. Patients who are at the end of their life, or who have terminal diseases I generously give narcotics to. If you have stage IV lung cancer with mets all over the place, I will open up the spigot pretty damned wide, and give narcotics as long as the patient asks for them and is not about to lose their gag reflex. One also must keep in mind that strategies, protocols and guidelines are often times helpful, but you must be willing to abandon them when you think that they are not appropriate.
My goal with drug seekers is not to correct their behavior, and turn their life around. I can't do that at 2 am on a wendsay night. That is outside my scope of care. My goal is to first, do no harm, and second, keep them from using the emergency department as their source for drugs that the cops can't bust them for. So, what I usually do is basically make a deal with patients where I will give them what they want if they give me something in return. What I ask in return is their cooperation for further evaluation. This means that when a 40 year old female with a history of headaches comes in for the third time this month for the same headache with no objective signs of distress and multiple negative CT (cat) scans, I tell her that I want to do a lumbar puncture to fully evaluate her, and then hold off on giving her the meds until afterward. Lumbar punctures are usually fairly uncomfortable procedures, but are a good idea to help with your diagnosis. In fect, I think that EC physicians are generally reluctant to do them, and we do too few lumbar punctures, if anything, as a result. If a patient refuses the LP, then I basically tell them that if they wish to refuse treatment, then they should see their primary physician for chronic pain control.
So, what about the patients in whom there is no punitive testing that would be appropriate? What about the thirty-six year old male with back pain that has been going on for years, and decides to come in for his dilaudid shot? Well, what I do is I tell them that their home pain medication, by their own account, is not working, and that what , by their own account, will work is not available outpatient, then they need to be admitted to the hospital for pain control. This way, the problems they have are being addressed, and if they say they will not go into the hospital for a few days, then I tell them that there is nothing more that I can do for them in the EC, and recommend that they see their primary physician as soon as possible for follow-up.
Finally, there are the most desperate kind of medication seekers. They are the most abusive and demanding of patients. These are the ones who insult and threaten staff for not bowing and scraping to them. These are the ones who I have the least tolerance for. For them, I give them one offer, and and it is only given once. I will offer them a single shot of narcotics. One. But it will be given with the explicit understanding that this will be the last time. EVER. I explain to them that I will leave an entry in their permanent record (sometimes you have to address people as children when they have the coping skills of a child) and this entry will basically be the documentation that they were told that they were not to use the EC for narcotics, and that if they ever return, narcotics will be the one thing that they will not be given.
Sometimes patients get very upset when you tell them that their dope line is about to be cut off. They usually start threatening, and sometimes violent. This only puts more evidence in your pocket to use against them later. And let me say, that it feels really vindicating when a drug-seeker comes in and you look through their records and find a note explaining this. Then, you basically tell them that you are aware of what the previous emergency physician told them, and that you will toe the line. You tell them that you will be willing to conduct any appropriate testing, and that you will certainly try alternative pain control, but you are NOT under any circumstances going to give them dope.
These drug-seekers are a terrible drain on resources that everyone else has to pick up the tab on. You have to pay for them in the form of rising insurance premiums, higher healthcare costs as hospitals recoup the unreimbursed cost of treating them, and also in the form of consuming time, and longer wait times in the emergency department.
Unfortunately, it seems that the more you give in to drug-seeking behavior, the more you are reinforcing that very behavior by rewarding it. It's easy and simple to just give in to such behavior. The patient then stops bothering you and the nurse, and everyone gets along. The problem is that they have just learned that if they go to the emergency department with that complaint, then they get a shot. It's exactly like a rat and a feeder bar. Also, drug-seekers will go from EC to EC to EC. Because we cannot communicate readily with each other, the guy I see today may have just gotten his shot yesterday, but my records do not show a visit for several weeks. So, if it is more difficult at my EC to get the shot, they will follow the path of least resistance, and go to another EC where they are more compliant.
Anyway, that about sums up my strategy; Give them what they want, but at a price. Also, you would be suprised at how many people who are yelling and writhing about "the pain, doc!" suddenly decide that a couple of vicodin and a bus token will suffice when you tell them that a shot equals a weekend admission on a friday afternoon. It also cracks me up how people will come in with a legitimate complaint (dizziness) and, as you are walking away say "hey doc, can I get sumpin' for da pain?" After just completing a full review of systems, where you had asked them about anything else going on, and they said 'no'. They suddenly remember they have this thirty year old old football injury that is acting up, and want a shot for it.
No.
There are unfortunately some attendings who are pushovers when it comes to drug seekers. The most vivd example is a young woman who came into the EC rolling and thrashing around on the gurney, who was wailing about nausea and abdominal pain. After pausing just long enough to request her dope of choice, she continued her hysterical show. Sadly, the attending gave her what she wanted, and she drifted off into a near comatose state. She was fine for hours -much longer than the drug's undurance when the attending told me to go check on her. I gently shook her shoulder, and then this sound asleep patient suddenly woke up, looked around, and upon realizing that her scam had worked started it all over again. So, once again, the attending gave them what they wanted. The patient was signed out to the next shift. I was so embarrassed that I couldn't look the oncoming docs in the eye when telling them about it.
Repectfully Submitted,
-doc Russia