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.