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When should nurses give drug seekers the benefit of the doubt?

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“Just say no” was a great anti-drug campaign, but it’s not a very helpful response when dealing with drug-seeking patients. As a healthcare provider, you’re torn between your duty to treat your patient and your duty to prevent further harm. So what do you do?

ER doc Brady Pregerson and Nurse Rebekah Child discussed pain scales, the “candyman conundrum” and ways to ID a seeker in Parts I, II and III of our Pain Management series. Now they tell you what you really want to know: how to deal with a seeker.

How to Deal with Seekers

Dr. Brady: Sometimes, if a patient has a chronic painful condition, I tell him that I can only send him home with two or three days’ worth of pain medication because the medicine is a “controlled” substance. Ideally, a single doctor, preferably the patient’s family doctor, should be the one “controlling” the situation.

If the patient has something that sounds acute or might be serious, like appendicitis, I often tell him that I’m going to give him one more pill before he leaves and that he needs to return in eight hours to be rechecked if he’s not better.

However, more and more, I find myself doing my best to give even patients with suspicious stories the benefit of the doubt. I really do want to help people with their pain. That’s part of my job. Actually it’s a big part of my job. Being a good doctor or nurse means making the right diagnosis and protecting our patients from harm. But compassion requires that we all also do our best to relieve our patients’ suffering and help them however we can in their times of need.

Nurse Rebekah: I find that empathy and limit-setting are foolproof. I mean, after all, I truly feel bad for the poor soul who is compelled by any addiction to come to a hospital to beg, borrow or steal narcotics. That’s not a productive, healthy or fulfilling way to live.

I think that if you are just up front and honest with them at least you go home feeling good about yourself. For example, I have said something like the following multiple times:

“We believe you are in pain and we want to help you. However, there is a limit to how much pain medicine we can comfortably give you. We want you to be safe. Continued pain medication use is best managed by the experts (and we are NOT the experts on this) so we would like you to see a pain referral doctor and here is their number.”

Also, I try to be up front about the fact that we will probably not be able to get rid of their pain completely (i.e. 0/10): “We will try to make it tolerable for you to get through the rest of the day. You have to help us help you and we both need to be reasonable.”

If necessary, I remind myself of these strategies to get through the shift. I’ve lost my cool on a couple of occasions, but find that if the doc and I go into the room together and set some boundaries, the rest of the visit is tolerable.

We’ve all seen numerous celebrities who have met an untimely death due to one addiction or another. So as a good mentor once told me, “You get along a lot better with patients when you can temporarily suspend your judgments.” Besides, the world is not black and white; it’s full of gray areas. I hope I never relegate people, behaviors or situations into “worthy” or “unworthy” categories.

The beauty of working ED is that the likelihood that a patient will be with me for an entire 12-hour shift is slim to none. God bless the floor nurses, because that thought has helped me survive numerous patient encounters!

Here’s my request to you: Utilize your pain scales appropriately, don’t sell narcotics to junior high school kids and be glad that you aren’t the one begging for pain medications to satisfy your addiction. My addiction is shoes, so here’s hoping that shoes don’t become illegal in the near future, or there soon may be a Nordstrom employee writing about me!

The bottom line? Give patients the benefit of doubt while setting appropriate limits. It’s the right thing to do—and your patients will appreciate you, too.

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Brady Pregerson, MD

Brady Pregerson, MD, a returned Peace Corps volunteer and winner of the 1995 Wise Preventive Medicine Scholarship, completed his medical school at the University of California, San Diego, and his residency at Los Angeles County General Hospital. He has authored three medical pocket books for nurses and doctors, as well as the educational web sites erpocketbooks.com and gotsafety.org. Dr. Pregerson currently works as an emergency physician in Southern California. He writes, "Although the ED environment may be quite different from working on the hospital floor or in an office setting, I am hopeful that you can take these tips and apply them to your own specific work situation." You can buy his books on lessons from the ER, including Don't Try This At Home: Lessons from the Emergency Department and Think Twice: More Lessons from the ER, at amazon.com.
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