Drug Seekers: Part 2 – Management

Continuing from yesterday, we now return for the conclusion of the Drug Seeker (DS) encounter emphasizing a practical approach to this pesky problem.

Doc: “Medicine that starts with a D huh? Is it Demerol by chance.”

DS (desperately trying to contain her excitement): “Yes, yes that’s the one. I think that one works well for my pain. You’re a great doctor by the way.”

Doc: “Oh, thank you. But before we get to your medicines I need to ask some important questions though.”

DS (suddenly retracted and cautious): “What kind of questions? I mean couldn’t we wait until after I get the medicine and feel better? I’m sure I’ll be able to answer better then.”

Doc: “Well, to be honest I am concerned that you might get a little cloudy as this medicine can cause some serious drowsiness and goofiness.”

DS (leaning forward and bargaining hard): “No, no doctor – I’ve had demerol plenty of times and it doesn’t really affect me so strongly.”

Commentary – Caught in the lie. Switching gears on a DS like this can bring out all of the inconsistencies in their story. In this case, based on actual patient encounters, she now pronounces the name of the medicine perfectly and contradicts her earlier report that she gets the medicine rarely. Also, the ratcheted anxiety about getting the medicine is a clear indicator of addictive tendencies that should be looked for closely.

Doc (calling her on the contradiction): “I’m sorry, I thought you had mentioned before that you don’t get demerol so often?”

DS (flustered now): “Well, I meant … well, that … I mean I’ve had it before enough times to know that it doesn’t affect my thinking and stuff like what you were saying.”

Doc: “Oh, I see. That’s understandable. But here’s the deal. You know this is the first time that we have met and I like to always give people the benefit of the doubt. Since this medicine works well for your pain, I want to give it to you so that you can feel better today, but … we will not make a habit of this.”

DS (cautious): “What do you mean exactly?”

Doc (firm but cool): “What I mean is that the ER is not the place for managing your pain when that pain comes from a chronic condition … a condition that you’ve had for a long time. Looking through your records on our computer system, I see that you have several different prescriptions from various ER providers for narcotic pain medicines and this is not good.”

DS (back to looking for sympathy): “But doctor, I need them for my pain. You don’t know how bad it is. (Tries to wipe crocodile tear from her eye with her shirt)

Doc: “My dear, I know that you must be in pain. I believe you. But coming here to get pain medicines is not a good way to manage that pain. I don’t want you to have to suffer so much that you have to come in here and wait hours to get something. You need to get in with a pain specialist, that’s what I’m saying. I’m saying that now because we all get busy and its tough to sometimes find the time or funds to make that appointment when you have a convenient option like the ER. I will work with you today but if you return for the same problem without making an effort then I want you to know that I won’t be as understanding next time.”

DS (processing): “Hmm, I understand. Thank you … I promise I will make an appointment right away. But it takes time you know to get in with these specialists.”

Doc: “Yes, I know. I will give you a prescription to last you a reasonable time until you can get in to see a specialist. And I want you to know that if God forbid anything else should happen, like you fall and break something, then of course this agreement doesn’t apply to something like that. What this applies to is your general pain problems. Your specialist will give you a note to keep in your purse with detailed instructions so that in the case you do need to come here for some reason that we will know what to do.

Commentary – This is a personal approach I take to DS behavior by setting limits and expectations. It has happened that such people did come back and I told them that they had violated our agreement and I didn’t take too much flak as they knew the agreement. This of course doesn’t prevent them from trying to hit up my colleagues or moonlighters, but at least it makes them consider coming in to get their fix.

Another interesting strategy that I’ve been seeing good results with is treating the “psych” component of DS behavior by using something like a low dose Haldol or Geodon, or even Inapsine with caution (QT prolongation so check EKG before and after). Amazing how cooperative these people become when the “psych” component is out of the way.

Lastly, I’d rather be burned by giving a “seeker” pain meds than to deprive someone genuine relief from their pain. We all know it can sometimes be tricky, especially when a known seeker comes in with an acute injury.

I’d love to hear your own personal strategies for dealing with this problem. I truly do have empathy for these patients because I believe that they have dug themselves into such a deep hole that they see no other way out.

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19 Responses to Drug Seekers: Part 2 – Management

  1. TUNDE says:

    I AGREE WITH YOUR APPROACH. ONE CAN’T BE CAREFUL ENOUGH THESE DAYS. EVEN THOUGHT SOMETIMES WE ARE CERTAIN THE PATIENT IS A DRUG SEEKER , ER HAS TO GIVE IN SO THEY CAN AVOID LAWSUITS. ISN’T THAT A TREAT? EVEN ADMINISTRATION ENCOURAGING DOCTORS TO DO SO, SO THE HOSPITAL WILL NOT BE INVOLVED IN ANY LEGAL CASES. HMMM,

    WHERE I WORKED A SMALL ER, PATIENT KNOW ABOUT THIS PRACTICE, AND THEY TELL YOU WHAT THEY WANT , AND IF THE DOCTOR TELLS THEM NO, THEY THREATEN HIM WITH LEGAL PROCEDURES. GUESS WHAT?… THEY ALWAYS GET IT.

    AS ADMINISTRATION SAY “COMPETITION IS VERY STRONG SO WE HAVE TO BE THE BEST”, EVEN IF THIS WILL INVOLVE GIVING OUT NARCOTICS LIKE CANDY. NO YOU DO NOT HAVE TO BE RICH TO BE A JUNKY, GO TO ER AND MEDICADE WILL PAY FOR YOUR HABIT….SAD BUT TRUE.

  2. Jennifer Edwards says:

    Drug seekers frustrate me. I believe they may be, in part, to blame for my having to wait over an hour for pain relief the two times I went to the E.R. — once for a kidney stone and once for a kidney infection. I’ve also learned that the E.R. treaters may not have been thrilled to see a patient like me —a reproductive age female with abdominal pain, and a history of depression.

    • ER Doc says:

      Thank you for your comment Jennifer and sorry that you had this terrible experience. It frustrates me in the same way when I discover someone totally legit having to wait hours in pain because of some loser who just wants to get their high. There must be a better way!

  3. ladyk73 says:

    I like your approach. I am a social worker (OMG-in two weeks I will have my MSW) and I have worked with MICA (mental illness, chemically addicted) Clients and as a discharge planner in a hospital. I think your approach works because you are giving the person a chance, and you treated them with respect.
    In my work with seriously addicted and mentally ill, they often had acute medical issues be overlooked because of their maladaptive ways of dealing with life. I also like your use of the geodon and such.
    I also like your approach because when a DS finally tries to get help for their drug use, or seek detox, they may come try to find you. (lets hope)
    When I worked with MICA clients, they were mostly schizophrenic crack addicts. And guess what? They were getting clean! and taking their meds!!!!

    • ER Doc says:

      Thank you LadyK for your wonderful comment and encouragement, it meant a lot coming from a social worker who often sees a side of patients that we on the medical end of things don’t see.

  4. l33t MD says:

    Well-written, thoughtful. Thank you.

    As a medical student, I have yet to experience true DS behaviour first hand, but from all the blog posts I’ve read about the subject I know it’s something I need to be prepared for in my future career. I’ve always had a hard time consolidating my attitudes towards addicts. On the one hand, I think they have made some really bad decisions and need to take responsibility themselves if they want to have a better life. On the other hand they’re /people/ and as deserving of my respect and help as any other patient. Your post made this last point so much clearer to me. Again, thank you.

    • ER Doc says:

      Hi MD and thank you for your comment. It made my day to know that I had done something to help a future doc to gain perspective. It is easy when you’re out in “the real world” to get jaded and it is for that reason, all joking aside, that I really do try my best to imagine everyone of my patients as if they were a family member. When you give people the benefit of the doubt and treat them like people, the most amazing things happen. Best of luck in your training and I hope the blog will continue to provide some insights for you.

  5. Warmsocks says:

    Your post, along with the numerous other ER posts about DS, makes me realize why it took so long to be seen when I went in for severe pain that turned out to (probably) be gallstones. After a long turn in the waiting room plus another hour in the exam room waiting for a doctor, my pain completely disappeared about five minutes before the doctor came in. I felt like an idiot for being there. It happened a second time, with equal lack of response at the ER. Since then I’ve had two other attacks that I sweated out at home – I spend an hour puking my guts out, then a couple miserable hours in so much pain I can barely move, and then suddenly the pain disappears. It was extremely frightening the first couple times it happened, but I don’t need to waste anyone’s time if it will get better on its own so now I just stay home. Both trips to the ER I didn’t want pain medicine; I wanted to know what was wrong.

    Vicodin makes my neck turn red and my throat swell so it’s difficult to breathe. It’s extremely unpleasant, and it takes over a month for all the swelling to go down. In hindsight, I shouldn’t have provided that information to the nurse. Apparently having a drug allergy that other people lie about means that I will never be taken seriously. There really should be another way.

    Anyhow, I enjoy your blog. Thanks for writing.

  6. This is the best that I have read this week. Great work. We are putting together a list of USEFUL websites, to be formed into a directory that addresses the needs of folks who are looking for information in this field. Please check out the site (it is still being developed) and please email us with any suggestions. http://usmle-usmle.org

  7. Edwin says:

    I have had awful experiences in my local ER in this regard. The first time I had a kidney stone I was in great pain but evidently didn’t whine enough. The doc told me if I had a stone I would be “rolling around on the floor.” So I got a urine test, an X-ray and CT scan, revealing a 9mm stone, and two hours later I got medication. I want to punch the doc in the face.

  8. Edwin says:

    I have had awful experiences in my local ER in this regard. The first time I had a kidney stone I was in great pain but evidently didn’t whine enough. The doc told me if I had a stone I would be “rolling around on the floor.” So I got a urine test, an X-ray and CT scan, revealing a 9mm stone, and two hours later I got medication. I wanted to punch the doc in the face I was so pissed. They still submit me to a series of tests first now even though I have had four in the past five years, all treated at the same ER.

  9. I realise this is an older entry, but it was posted to one of my boards. You see, just as there are networks of nurse and doctor blogs where long posts about eeevil drug-seekers abound, there are also networks of patient blogs.

    People with real, actual chronic pain who are treated by kind doctors. Who have taught themselves self-hypnosis. Who have run enough hot baths to flood the Sahara. Who have dipped themselves in enough parrafin to give Madame Tussaud a run for her money. Who on occasion simply cannot continue to writhe on the floor or the couch and so their spouses and/or parents pack them in the car and race to the ER for help.

    Once they get to the ER they may be able to be coherent enough to answer questions. Its because while most people in pain haven’t been there, we’ve been in so much pain we know tricks to dissociate from it for short periods of time to be helpful partners in our medical care. It takes all the energy you can muster, but then once you’re done you sink back into the pain.

    As of this Sunday I have passed 119 kidney stones. Most of those I’ve done at home without any help. That should give you an idea of how I’ve come to tolerate the pain over the years.

    I live with pain on a daily basis. I have Endometriosis (Yes, it’s been visually diagnosed via laparoscopy. Four times.) I have RA, with visible damage to my left hand. Pain is now a background noise to my life. Fortunately I have very good specialists who take care of me. Although I do underrequest pain meds from them. I don’t want to risk a good Doctor/patient relationship by asking for the proper meds to completely control my pain. I don’t want to be seen as a drug seeker. Because I read these posts and comments and feel the contempt radiate through my computer screen.

    Oh. And also, I don’t like narcotics. They make me sleepy, sick to my stomach and always leave a bounceback migraine in their wake. Some–Vicodin, I’m looking at YOU–also make me suicidally depressed when they leave my system after finishing their work. Opiod analgesics are the devil I have to deal with. I may ask for them. I may thank you for the prescription. But trust me when I say that I’m not taking them home to sit back and listen to Dark Side Of The Moon. I’m taking them so that the pain abates and I have peace.

    If anything good comes of the struggle that my life has turned into, I want it to be this. I want front-line caregivers (especially in emergent medicine) to understand that any personal victory you may feel at being cold to suspected drug seekers should be tempered with the realisation that the person you suspect may actually be someone whose life is a waking nightmare that you cannot fathom.

    • ER Doc says:

      Hi Katherine and thank you for your detailed comment. I tried to read it carefully but it seems that you are accusing me of having contempt towards people with real pain. I am very sorry that you feel this way in all honesty and I would request that you carefully review my posts on this subject. I am quite certain that I have written that I would much rather give pain medicine to the type of drug seeker who only seeks to get high than to miss one person in true and real pain. In fact, statistically speaking, a prescriber who is successful in treating people with true pain must also give drug-seekers narcs from time to time. The very history you present is indeed the exact type of history that I believe almost no physician would ignore or classify as drug-seeking. You have verifiable history, you have physical findings and you are knowledgeable about your condition. The ones I refer to are the ones who have a known illegal drug use, typically young and have little to no physical findings. They never have any relationship with any physician that can be verified. In short, they are very different from you. I sincerely hope that you will re-read the post and see how clearly it doesn’t apply to you and others like you who do suffer from pain. Just as a note, one of my very good friends suffers from fibromyalgia, so please do not lump me in the group that has ice running through their veins and just wants to mistreat people.

  10. […] Drug Seekers: Part 2: – Management […]

  11. ER Doc,

    You are undoubtedly correct. I think I did rush to judgement and apologise if my frustration with some of your commentors and their own blog entries on the subject was directed at you. It seems I’m guilty of the same sin I decry in others. Judge me on my own merits, not on the merits of a category in which you think I might or might not fit.

    I realise that after my own disasterous ER visit this past Sunday I’m still a bit raw. I only ever go to one ER. And this is an important point that I want to make to ER professionals. A point that I suspect many of you may already know.

    Chronic pain patients are often the caught-in-the-crossfire victims of a turf war between specialists and ER doctors. I blame the DEA. Nobody wants too much drug on their hands.

    I’ve been told flat out by one of my specialists that I need to go to the ER for breakthrough pain associated with that condition. To them, visiting the ER is part of my actual treatment plan. They give me a very limited amount of pain medication; if I need more I have to go to the ER. At the ER I ‘waste everyone’s time’ and have to undergo dangerous radiaton to make sure that this time isn’t the time that my horse has turned into a zebra.

    I’m self-conscious about it. I’m very careful to go to the same ER each time, tell them everything I’ve taken. I used to bring in the pill bottles for my pain meds (Tramadol and Hydrocodone 5) to show that I had plenty left–I hadn’t burned through them and come to the ER for my ‘fix’. An ER nurse told me herself to stop doing that because they were afraid that other patients would steal them if I was in a curtained area instead of a room.

    Yet there are still 2 nurses–and one doctor–who see me as a FF DS and treat me as such. I go there often enough that I know them all and know whose going to be the one to ‘accidentally’ bang a few inflamed joints, give me a painful intubation and a positional IV. It’s kind of like a sad little game we all play. Most of the time I accept that its because the shop is busy and I’m not bleeding out my eyes. But sometimes its hard. Its hard because no doctor can fix me, no doctor can properly treat me and on top of it all I’m made to feel lower than vermin.

    I’ve been reading these med blogs in an effort to walk a mile in the other guy’s shoes–to understand why ER professionals can sometimes be cruel in their patient care. After several hours I think I understand pretty well. Doesn’t help me, but I understand.

    Again, I’m sorry to have incorrectly assumed things about your character and I’m chuckling over the irony.

  12. Brandi shaulis says:

    I am a chronic pain patient who has dealt with this problem since 2007. I got smart and took my bottles, records and pain drs number to the Er. I have had no problems since. Before then, yes, I was labeled a drug seeker and got the usual lecture. For everyone who is frustrated, let the Er know your history and provide proof. It is amazing the difference in how you are treated.

  13. back injury says:

    Thanks for finally writing about >Drug Seekers: Part 2- Management | ER Drama:
    The Blog <Loved it!

  14. ConfusedPatient says:

    I am a non- ds have actual pain and can be seen by a pain management clinic monthly but having troubles dealing with an array of issues. My diagnosis is I am a 1% where I have a double Virtibae(forgive my spelling) but anyway I also have 4 bulging disc in my lower back L4,L5,L6,L7. I have had the Cortisone injections that is more painful then the pain I experience that is unbelievably painful due to all the disc that are on nerves. I developed these shortly after my 1 year marriage to my wife Katherine. My wife who is 12 years younger then I got involved with a girl who is a DS and evolves her whole life around it. Now my wife is the exact same person she her friend is. We have children together and she is a grate mother hands down. I have revolved to taking cocktails of Tylenol, Motrin, Aleve and several other things to relieve my pain because I don’t want to enable the habit. I take such high doses for the pain at this rate I will be dead from kidney failure or something serious in the next year. I tried going to my Pain Specialist who will prescribe me 10/325 percocet at 120 per month and he does random pill counts and drug screens to verify the narcotics are in my system. My wife doesn’t get that I need these for myself for a condition I have because she can’t get past the fact that she needs to get high that’s the most important thing. So here is my question in my situation what should I do?? I have played it out say she goes to rehab and gets out won’t the temptation and readiness be to easy for her to get a hold of my drugs that she will just continue going down this road her whole life and I am considering divorce because it appears to make the most since or kill myself with over the counter medicine. Any help with this would be grateful. Thanks

  15. Mary says:

    Sorry to necropost here, but I’m just out Googling around for some answers and hit this blog. I’m not a doctor, nor do I play one on TV (haha), but I am a concerned family member of what appears to me to be a drug seeker. She should get a “narco award.”

    This young woman was just in to the ER, her second visit to two different hospitals this month, complaining of abdominal pain. At the firest visit, they gave her an abdominal ultrasound looking for gallstones, with none found. The second time, different hospital, they gave her morphine and sent her home with a prescription for Tramadol. The thing is, she’s always going to the ER and they always giver her morphine and pills. The causes of her pain vary (falling and spraining her ankle is a routine claim), but not the end result – powerful pain meds.

    I am very familiar with pain pill addiction, as I was married to a man that let it destroy our life together. Later, I was a manager in an office and one of my employees had a problem with pain pills. I know the behavior. I also know that it can turn into a major problem.

    Since you are familiar with how these things work, would it be a bad idea for a concerned family member to report their suspicions to the ER? I know they can’t give me info, but I can certainly give them info. What they choose to do with it is their business.

    What do you think?

    Thanks!

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