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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.

In Part I and Part II of our Pain Management series, ER doc Brady Pregerson and Nurse Rebekah Child examined the challenge of accurately assessing a patient’s pain, as well as the perils and pitfalls of simply dispensing the dope any time a patient asks. In this article, they point you to signs and symptoms that may indicate your patient has more than physical pain on his mind.

How to Recognize a Seeker

Dr. Brady: What do I do when I have a patient who I think is feigning illness in an effort to get narcotics? It depends. First and foremost, I do my best to make sure I’m not missing something. If you let your guard down, you will eventually get burned. I also find it useful and relatively simple to check and see how often the patient comes to the hospital. If she’s here less than five or six times a year, I worry less than if she’s here every month. But you have to be careful with this test, as some patients with real disease, such as sickle cell disease, really do need our services that frequently. Plus, in urban areas, some patients just visit different EDs every month; checking their home address may give a clue to this one. Another thing I like to do is call the patient’s doctor, if she has one, to get more information.

Nurse Rebekah:

Top Ten Signs Your Patient May Be Seeking Narcotics Inappropriately

1. He knows which ER docs have a proclivity for dispensing narcotics and schedules visits around their work hours.

2. She remembers your password for the Pyxis—and prompts you when you forget it.

3. He knows the exact dose of medication that will kill the pain: “4 mg of Dilaudid IVP usually works for me.”

4. She’s allergic to Toradol and morphine.

5. He went into a clinical depression when many emergency rooms stopped stocking Demerol.

6. She can relate to Nurse Jackie.

7. He’s been to the ER 15 times in the last year for pain management and yet can’t make it to the pain clinic for his appointment.

8. She balks at the idea of narcotics being given subcutaneously.

9. His holiday wish list looks like a Pyxis report.

10. Her primary physician not only knows her name, but so does the doctor’s wife, his three kids, the pharmacist and the pharm tech at the local drugstore.

Yes, this list is somewhat tongue in cheek, and sometimes the hints may be more subtle than directly depicted above. But all kidding aside, remember that these drug seekers get very good at their pasttime of hoarding meds. Don’t disregard any suspicion as an overreaction because it may lead to more than you realize. These people, for their own safety and the safety of your license, must be dealt with and their addiction must be treated. Do not be afraid to report them.

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ER doc Brady Pregerson and Nurse Rebekah perform a raid and bust on that sketchy personality, the “Candyman.” Why does he exist? And what is he thinking?

In Part I of our Pain Management series, we looked at the challenge of gauging your patient’s pain. In this article, we examine the many consequences of taking a too-easy approach to a complex issue.

Dr. Brady: Treating pain and other symptoms such as nausea and anxiety is a core competency in many medical specialties. Sometimes it’s all we can do.

As doctors, nurses and PAs, we should take pride in easing the suffering of our patients. It’s morally superior to over-treat 100 drug-seekers than it is to withhold analgesia to a single patient who is truly suffering.

Some physicians have the philosophy that if they just assume all of their patients are telling the truth and treat them accordingly, everything will work out for the best. This is an attractive way to approach pain management and surely simplifies the job. It completely avoids the added task of being the narcotics police in addition to being the doctor, and your patients will love you. Also, you can often discharge patients more quickly this way, because instead of giving them a long explanation after telling them “No,” you can instead just say “Yes.” Perhaps this is the best approach.

Of course, there are downsides to being the “Candyman.” Will your nurses respect you for it? Will your DEA number be used to buy prescription drugs that are later sold to junior high school students for profit? Will your behavior encourage repeat visits from drug-seekers who back up the waiting room and put sick patients at higher risk of a bad outcome due to delays in care? After all, it has been frequently said, “If you feed the bears, the bears come back.”

Nurse Rebekah: Oh, and we have some bears! But we also have some legitimately ill patients. I remember taking care of a Japanese man who fell a good amount of feet off a ladder and broke eight ribs. He was tachycardic, hypertensive and breathing way too fast. Every time I would ask him if he was in pain, he would emphatically say, “No.” I didn’t believe him. There’s no way that you can break eight ribs and not be in pain. It’s physiologically impossible. For him, it was part of his culture to not admit weakness. For me, it was part of my culture to give him the good stuff! I finally convinced him to take a little morphine IV and, lo and behold, he calmed down, his heart rate came within normal limits and his furrowed brow looked like he had just received a good dose of Botox.

We used to give out Vicodin six-packs for patients to take home. And we actually had a doctor we referred to as the “Candyman.” These six-packs were a pain to get. They required two signatures, a copy of the scrip, an extra trip back to the Pyxis—they took up way too much time. No one liked to work with this doc in our quick care area because we all feared that we might lose our nursing licenses for “suspicious use of narcotics.” This problem was recently solved, though—the laws changed and we can’t give out those packs anymore! It has shaved a good half an hour off each shift, and we no longer live in fear of the next Pyxis audit.

Most people are pretty funny with narcotics. They say funny things, do funny things (sometimes it depends if you think cessation of respirations is funny…) and are usually quite happy to be taken out of their pain. I look like the good gal then! That almost makes up for any patient who is using narcotics “recreationally.”
So what’s the best approach when those hungry bears come knocking on your door? In Parts III and IV of our Pain Management series, Dr. Brady and Nurse Rebekah share how they discern a “seeker” personality and how best to deal with it.

ER Doc Brady Pregerson and Nurse Rebekah are ready to “go there” in the first of a four-part series on pain management.

Dr. Brady: The can of worms I’d like to open up is one that I think raises more hackles than almost any other patient care issue in medicine: the use of narcotics to treat pain.

We’re all well aware of the fact that mixed in with our usual patients is a smattering of those who are addicted to narcotics or, even worse, fill their prescriptions and then sell the drugs on the street.

Prescription drug abuse is becoming a bigger and bigger problem. But oligoanalgesia—the under-use or sometimes non-use of opiates to treat legitimate pain—is also a problem. And we doctors and nurses are caught in the middle of this dilemma.

As a physician, I read in a quarterly newsletter from the Medical Board of California about all of the physicians whose licenses have been revoked or placed on probation. This litany of doctors and their bad deeds is there in black and white as a warning to the rest of us not to stray from the path of Hippocrates.

Each month, a good part of those whose licenses are under restriction have ended up where they are through the inappropriate prescribing of narcotics. Inappropriate narcotic prescription can do more than feed an addiction; it can get you in trouble.

On the other hand, if I don’t treat a patient’s pain appropriately, not only does the patient suffer, but she’ll probably write a letter to my boss. If I mess up either way, there’s trouble.

This wouldn’t be such a big deal if I could accurately gauge pain all of the time, but I can’t. I rely mostly on what my patients say. That’s accurate if they’re telling the truth, but what if they’re lying? You can’t fake hypoxia, you can’t fake hypotension, you can’t fake hyperkalemia or rales or vomiting up blood, but it’s not that hard to fake pain. And as the Bard said, “There’s the rub.”

Nurse Rebekah: I love this hot topic. There is a continuum of people in real pain, people in fake pain, people in pain who refuse to acknowledge the pain, people in pain who acknowledge it too much…the list goes on and on. From my perspective, scaling the pain can prove to be the biggest obstacle.

I love when I’m asking a patient for his pain scale and the following scenario occurs:

Me: “On a scale of zero to ten, ten being the worst pain you’ve ever had in your life and zero being no pain, what would you rate your pain?”

Patient: “Twenty.”

This kills me! I gave you ten integers, eleven if you include zero, and you still go off the scale! You don’t get more pain points if you make up your own pain scale…you probably won’t even get a higher degree out of this faux original research because there are, like, a MILLION pain scales out there.

Or this one:

Me: “On a scale of zero to ten, ten being the worst pain you’ve ever had in your life and zero being no pain, what would you rate your pain?”

Patient: “Uh, I don’t really know…[pause]…lemme think…

[Insert "Jeopardy!" theme here.]

[Ten minutes go by.]

…uh, maybe a five and a half.”

Well, I’ve fallen asleep waiting for the patient to scale his abdominal pain, and his appendix has probably burst by now. I’m so glad he put that much thought into it.

Okay, there’s really no right or wrong answer here. Your pain can be whatever you want it to be (as long as you stay within the 0–10 range; otherwise I get irritated). I won’t yell at you if you lowball or highball your pain. IT IS YOUR PAIN. Embrace it, own it, rate it.

If you suspect that a patient seeking certain drugs is an addict, share this concern with the physician immediately. This is extremely important because oftentimes doctors can be unaware of these drug-seeking tendencies. Once they’re armed with knowledge about the drug seeking patient, MDs may choose to prescribe different medication or put limits on the prescription.

If you find that a patient has repeatedly been able to badger or manipulate his way past a certain doctor, speak with another doctor or a hospital supervisor about the patient. That person might have a better idea of whether the patient is exaggerating for drugs. If the behavior persists, the patient may need a psychiatric consult to evaluate the degree of dependency on the said drug.
 
Let’s say that even against your best judgment, even after you’ve expressed your concern, you are ordered to provide drugs for a drug seeking patient. It’s your responsibility to do so. Remember that ultimately it’s the doctor’s job to decide whether the patient should be treated.

Remember though, that seekers may get violent and angry when not given the drugs they seek. They may shout, scream and badger until the drugs are administered. Remain calm, get help if the patient becomes unruly, and do not give in to unreasonable demands.

Above all, keep an eye on the drug seeker once they are admitted. They may act as if the hospital is their personal hotel, sneaking out for smoke breaks or walking around as if they own the floor. The best thing you can do is tell the doctor who admitted the patient about the patient’s behavior.