Drug Seekers: Part 1 – Origins

pill-bottleOne of my attendings in residency taught me a great lesson which I faithfully try to apply to all my patients – well with the exception of really aggravating drunks that piss on the floor, people who choose to vomit on the floor even though the trash bin in 3 feet away and parents who let their kids kick me in the groin when I’m trying to evaluate them. So, ok maybe I don’t apply it as faithfully as I should, but you get the idea. One group that really challenges our reservoir of compassion and empathy though are drug seekers. For those readers who are unfamiliar with what a drug seeker is, an explanation is in order.

Everyone gets pain from time to time. Some unlucky people though have to suffer with pain on a daily basis. These two groups of people are legit, and it provides me great immediate gratification in my work to help relieve their pain when they come to me. Yet there is another group of people out there which totally obscures the pain picture and makes this task very challenging. This pathetic group of losers has lovingly been dubbed “drug seekers” by virtually all ER’s around this great nation.

Drug Seekers are people who typically fake pain in order to get pain medications that provide a euphoric feeling (in other words, they get high with them). Such drugs are usually narcotics that act like heroin, benzodiazepines that mimic alcohol in many ways and then some other really crazy FUBAR stuff that I won’t get into now.  Here is a typical drug seeker encounter:

Doctor walks into patient room to see drug seeker (DS) sitting calmly on the stretcher.  More often then not, they are munching on some chips and drinking a soda (in other words, they look totally healthy without the slightest indication of any sort of suffering). He introduces himself and asks the patient what brings them into the ER today.

DS (the drama begins): “Oh Doctor, I have been having a horrible _____ (fill in the blank – headache, stomach ache, back pain, etc. – for extra points can use more than one area of pain to complicate the picture) for the past 2 days!”

Doc: “I’m sorry to hear that DS. Have you ever had pain like this before?”

DS (ratcheting up the drama): “Yes doctor, it happens a few times a year. My doctor has put me through all the tests before – a CT, an MRI, blood tests and even a specialist saw me, but they can’t seem to pinpoint the problem.”

Commentary – As Whitecoat has mentioned on his blog, there appears to be a Drug Seeker handbook or Standard Operating Procedure (The DSSOP) out there. They often give the line about getting tested or evaluated, but strangely it is usually in another city/state and in almost 100% of cases they report “normal” findings. Of course they never have any written documentation of these evaluations and asking them what doctor they treated is useless as they never remember of give some generic name like Dr. Smith. Truly fascinating.

Doc: “I can imagine that it must be very frustrating to not get any answers, even from a specialist.”

DS (thinking she’s got this doc in the bag): “Oh yes doctor, soooo frustrating. It just seems that no one understands what I’m going through, but I can see that you do. I can’t even begin to tell you how comforting that is.”

Doc: “So how have you been able to control the pain in the past?”

DS (nearly salivating now): “Well, in the beginning I used to get by on Tylenol. I even tried aspirin and ibuprofen, but I had some reactions and my doctor explained to me that I am allergic to NSAID’s. So the only thing that worked after that were medicines like Vicodin or Percocet … except when it flares up and I need to come in like now.”

Doc: “Yes, it seems that you really have had a tough time. When you do get these ‘flares’, what seems to help then?”

DS (faking an inability to accurately remember): “Oh, its a medicine that starts with a D … deme … dama …. Oh, I can’t remember exactly. Do you know which one I’m referring to?”

Commentary – From an underground version of the DSSOP: “It is imperative to demonstrate that you have tried over-the-counter medicines and that they have not helped, and even better, to say that you are allergic to them. That way they won’t try to prescribe you any crap like Naprosyn or that Toradol BS they try to inject you with in the ER. Then you need to feign unfamiliarity with what you really want so that a naive sucker (the doc) will imagine that you get this medicine so rarely that you can’t even remember the name.”  Those of you in the ER will agree that it is amazing how textbook this act is pulled off. Worthy of an Emmy, or a “Narky” as I like to call this award.

Check back tomorrow for the exciting conclusion and to read about my personal approach to dealing with these fine, veteran actors.

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32 Responses to Drug Seekers: Part 1 – Origins

  1. TUNDE says:



  2. maha says:

    A couple of shifts ago, I had a DS who was having ‘generalized pain’. I’ve personally never had him as a patient, but some of the senior staff knew about him and they warned me. He had all the same lines for me and the doc. Because we were swamped that day, the doc didn’t get to him ‘quickly enough’ and he started to pull all this crap about how he’s an RN from the UK and how I’m a shitty nurse because I’m not advocating for him. When I snuck up on him a couple of times, he was watching a movie on his laptop looking VERY comfortable. Eventually security threw him out when he refused to leave despite getting 16mg of morphine. Ass.

  3. Erica says:

    Another page from the DSSOP: “seizures” sometimes help round out the picture when we pesky ER people aren’t buying the pain angle. But do it right: bite your tongue, piss yourself, and for god’s sake don’t answer questions in the middle of your presentation.

    Took care of a young lady on repeated occasions who had the most bizarre seizure presentation: what appeared to be standard tonic-clonic activity, paired with the inability to speak. Except she found the strength to say two words: “fentanyl” and “valium.” Weird.

  4. Jim says:

    I’m sure Doctors everywhere get their fair share of drug seekers, and I’d guess they piss you off from time to time. But do you have to treat everyone that comes in with pain like a drug seeker? I guess in a way they are drug seekers, they’re seeking drugs to relieve their real @#%#ing pain!

    • ER Doc says:

      Hi Jim – thanks for your comment. In reality, the majority of patients that most of my colleagues and I see are treated with benefit of the doubt. We do not automatically think of every person in pain as someone with an alterior motive. Certainly though, in some hospitals, particulary inner city hospitals, they get such a heavy amount of people who truly are just blowing smoke in many cases that a lot of these doctors can get jaded. I didn’t want to get that way which is why I left that environment. In any case, I’m sorry if you have been treated in an unsympathetic manner.

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  7. Bekah says:

    THese kind of people make my life hell on earth. I have RA and LUpus and before it was known exactly what it was, even though the ER doc student was trying her best to get to the root of the problem, I had visible pain in the form of swollen joints, bloody eyes, severe inability to walk right, and pain that caused screaming. I still had one of the ER doctors treating me like a drug seeker because the diagnosis was not yet presented. ONce the RA/Lupus was assumed, thankfully the story changed. I was in so much pain that I was about ready to kill myself for relief. There are times when serious legitimate pain is a sign of a horrible disease and that should be taken into top priority. Instead, I waited thrithing and crying in pain so horrible I wanted to die until someone helped me out of the ability to recognize the symptoms were real…It scares me to think that PAIN is not a medical emergency when it comes on suddenly and you are near seizing from it. Priority should be first and foremost.If you can study the eyes of the patient you can tell if they are lying or not!..

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  12. Karin says:

    My sister is a drug seeker. She has always had some sort of dependency issue, but it was made much worse when she got approved for disability. While now at days she leaves the illegal drugs alone, she has a medical card for all the free drugs she can get, its just a matter of finding the right doctor and telling the right story. She will go from hospital to hospital until she gets what she wants. Somehow she has gotten someone to give her a morphine patch which she loves and at the end of its cycle she will actually chew on it to make sure all the meds are out of it, but the problem is that I know for a fact most of our family is allergic to morphine it makes them hallucinate and now she seems to be losing her mind thinking she is infested with bugs. She has said it was scabies, fleas, crickets, bedbugs, and now its an undiscovered bug. She has given herself chemical burns from bleach, and has since been covering herself in lysol and germ x. I am convinced its the morphine patch. She is also on several other meds on of which is xanex. But what can I do? Is there a way for me to report her as a drug seeker? Its a horrible fear that one day she will die from an overdose.

    • ERDOCTN says:

      Sorry to hear about your sister. Yes, there are ways to report these patients as well as the physicians who prescribe them without any evidence that theyre needed. You can also report her to Medicaid.

      Morphine seldomly will cause people to think they have bugs under their skin. That sounds more like crack-cocaine withdrawal.

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  15. Peter S says:

    I am an ED Physician and my wife in addition to Lupus, had a problem with recurrent SBO. As we travel often, on 4 of her 15 admissions, she was not in our home town when she required treatment. Her story was much like your fictional drug seeker, and I think those out of town Doctors were schooled by your professor who outlined the patient above. It amazes me how even after getting a CT which demonstrated a 20 cm segment of small bowel with wall thickened to the point where the lumen was obliterated and several feet of small bowel proximal to the transition point distended well beyond 3.5 cm, ED’s would still use the number of milligrams of drug rather than the result to determine dose. I would offer the number of my home ED and urge them to call so they could determine that we were legit-no luck. It was amazing how once an ED decides the patient is drug seeking, no amount of evidence to the contrary (such as a CT or lab work or abnormal VS) will let them change their mind to consider that perhaps some people really do have pain. It is better to give 100 “drug seekers” a small amount of narcotic than to allow one person in severe pain be left untreated because they might be “drug seeking”. Finally my wife had a segment of her small bowel resected. The diagnosis-NSAID enteropathy. Yes NSAID’s-the drug of choice of “drug seekers.

  16. Karin says:

    Giving a drug seeker drugs if even a small amount is bad, one Dr. gives a small amount and another one gives a small amount and so on and so on eventually they have a large amount. My sister died from this in June, and her death ended up killing my mother in August. My advice to anyone that travels often as with your situation would be to keep copies of the CT as well as anything else that would be helpful with them so dr’s wouldn’t think they are a drug seeker and will give them the proper meds that they need.

  17. John says:

    It’s a sad state when you “Jaded” doctors can’t differentiate between patients with legitimate pain and drug seekers. I suffer from chronic back pain and it is a rarity in the medical profession when I haven’t been treated otherwise. You doctors need to be re-trained, show some real compassion, abide by the oath you have taken and stop using the DEA as an excuse.

  18. Jessica says:

    I have to say that it is because of people who do that stupid shit; is the reason that people like me don’t get the pain treatment that they need!! I have ankylosing spondylitis and a lot of other problems, I pretty much have to over dose on tylenol and other nsaids to get releaf from the pain I have. I’m not even support to take nsaids because of stomach problems, but I do any ways!! Some times I think I would be better of dead….
    I really hate going in to my doctor’s office and being treated like some pill head or something. What I would give to be able to give my pain to a doctor, and see if it screws up their life too. I use to be very out going,
    lots, of energy and thought I had a future; but now all I can think about is when it’s going to end. I don’t even feel like I should live another day, but the only thing that gets me through most of the time is that I have kids that

  19. D-rock82 says:

    I have had my own personal expierence and been labled as a drug seeker at my local ER. Last year (2011) I got really sick and at 2am landend myself in the ER. They x-rayed me gave me fluids and narc’ed me up to where I didnt know my name hardly. After being discharged early on a saturday morning. I went home and passed out. Woke up the next day with the exact same pain and nausea. I had my roommate go have my prescriptions filled. I was prescribed Norco. After I took that I became more sick, I suffered for most of the day and after I tried to get up to go throw up I collasped. My roomamte called 911 and I was taken to the same ER I had been at just hours before. The PA came in and they hooked me back up and gave me more fluids and a CT scan. The PA asked what I am able to take for pain since I seemed to have a reaction to Norco. I advised her of what I was given the day before, which was something I didnt know existed called Dilaudid. SHe looks at me and says HMMMMM… I will be right back. while waiting they gave me some meds for nausea and It made me very sleepy. I was half asleep and in pain in my abdomin. they tried to get me to give them a urin sample and I couldnt so the nurse threatened to cathyirize me. At that point I could care less. The PA came back in and said she had ordered me some Toradol for pain. I shook my head in agreement. Shortly after the nurse gave me the injection i begain to itch and my skin felt like it was burning. I called the nurse and she gave me some benadryl in my IV… I never want that stuff again. It made me crazy!! After that The PA re entered the room and gave me this discust look. she said my electrolytes were low, and the scan didnt show anything to warrant my pain. she then asked how my pain was, and I advised her it really hadnt changed. She became very angry and pulled up the computer and turned it toward me, she then staeted you have been here twice in 48 hours and the only thing that works for you is Dilaudid? I said that thats what the doc from ealriier gave me and it seemed to help. but I cant take the Norco as It made me sicker. She ran through this long story of how only cancer patients get Dilaudid and that she was “NOT” giving it to me. I told her I didnt care what she gave me i just want the pain gone ( i was a lil aggitated and angry at this point) . a few minutes later the nurse came in took out my IV and the security gaurd escorted me out. I could hardly walk I was in so much pain. I set in my roommates car and litterally cryed it hurt so bad. HE then decided he would drive 40 miles to the other hospital to have me seen. As soon as I walked in they took me straight back and hooked me back up. basically they repeated the same tests (gave me moprhine) and 2 hours later I was on the operating room table as I had 12inches of my terminal illium removed and was diagnosed with Chrons disease. The sad thing is a few times a year now I have “flair ups” and take a remecade infusion every 8 weeks to keep these at bay. sometimes they are really bad and I end up going to the the ER. because I am labeled at my local ER as a “DRUG SEEKER” my GI doctor has to call them and let them know its ok to treat me with normal narcotics. Its very embarressing when I have to go because they look at me funny and treat me differently. then after hey speak to my doctor they rarely leave my side. how do I get them to not have that label on me. and 40 miles is to far to drive when Im in pain and my GI isnt open or avalible.

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  25. Bob Stuckrath says:

    This drug abusing assumption results in patient abuse. I went to an ER with a dislocated thumb. Suffered 2 hours waiting. Given nothing whatsoever for pain. The PA tried very hard to relocate my thumb with no numbing, nothing. The ER is the worst place to go for medical assistance. It’s a legal torture chamber. I hate being treated like trash.

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