Caring for Drug Seeking Patients? Well, It’s Complicated

Kim McAllister over at Emergiblog is questioning her role as an emergency nurse. The source of her discomfiture? Patients seeking narcotics, or those we label as “DSIs”, drug-seeking individuals:

Getting patients out of pain [she writes] is one of the most rewarding aspects of emergency nursing. It’s as close as you can get to instant gratification – you medicate, the patient gets relief.

That isn’t what I’m talking about.

I’m talking obvious, blatant, in-your-face drug seeking that is becoming more obvious, more blatant and more in-your-face every day.

But the narcotics still flow.

And it’s getting harder and harder to be a part of that.

She places the blame for the increase in narcotic seeking patients squarely on the Joint Commission, which mandates U.S. hospitals to implement pain management measures when treating patients, and Press-Ganey, a survey company which rates hospitals according to patient perceptions.* Both of these institutions have created an atmosphere where emergency room physicians feel obligated to order or prescribe narcotics for anyone regardless of dependency, first to satisfy government regulation and in the second, to assuage patient perceptions of good care.  (That the perception of good care is becoming more important than actual good care is a topic for another post.)

Kim McAllister’s frustration and sense of ethical distress is palpable. “I’m not helping anyone,” she writes. “I’m certainly not therapeutic in any way.” Emergency department nurses and physicians are not supposed to be an addict’s co-dependants, yet we’re often placed in the position of facilitating the addiction. We aren’t helping these patients by giving out more narcotics. How can I treat these patients ethically knowing that? It’s the moral equivilent of telling a Type II diabetic pound cake and Pepsi is an adequate breakfast.

As one old emergency nurse to another, I get it. But I have no words of wisdom for her. There aren’t any good answers, only judgement based on knowledge and experience. I can only humbly offer up for consideration what I’ve concluded. Your (and her) mileage my vary. For me, of course, it’s complicated. I have to ask myself, to start, who are the people who seek narcotics? If we eliminate those who want narcs to sell on the street, who need to be firmly escorted off the premises, and those who genuinely come to the ED in pain, we’re left with those with a drug dependency. Fine, you might say, send these loser addicts on their way. But notice how all three categories, and the last two especially, can overlap? What do you do with an acute bilary colic with an unwarranted fondness for Percocets? Tell her to suck it up, because she’s made her choices? More than a few times in my years as an emergency nurse I’ve seen physicians refusing to order pain control for large bone fractures because of a previous history of drug dependency. Is this ethical, or even wise? I’m not clear punishing drug addicts for their sins is part of the job description.

Only in the last few years I’ve to some sort of resolution, moving from where Kim is to a place of relatively less self-doubt. First, I recognize the truism that substance dependency is a disease, with its own etiology, pathology, and treatment. Very trite, yes, but something we all tend to forget in a culture that still views drug dependency as a moral failing, and a crime for the righteous to condemn and punish. Keeping this obvious fact firmly in mind allows the distance to see drug seeking as part of a medical condition, and focus on the patient, not the admittedly annoying behaviour. Secondly, I’ve come to realize we can’t fix addiction in the emergency department, during a two or three hour visit, in the same way we can suture a laceration or treat asthma. We never will, and beating ourselves up over this elementary fact is pointless. Addiction simply doesn’t work that way. It requires willingness on the part of the patient, and treatment modalities far beyond the capability of even the most experienced nurse or most sophisticated emergency department. Even getting the patient to recognize the need for treatment is a challenge in the ED: believe me, I’ve tried.

Hence, I am a pragmatist. Most drug seekers will come in with presenting complaints like lower back pain or migraine; these can be (willingly or no) given Toradol (and for those with a Toradol “allergy”,  naproxen) and sent on their way. As for the rest, does it really matter? Giving the known drug addict IV morphine for renal colic (real or supposed) or sending her home with a script for ten Statex until she sees the urologist is not going to make a whit of difference in the course of her addiction. Of course she might sell them; at the very least, it encourages bad behaviour and multiple repeat visits. But again, so what? Is it our obligation to make that judgement? I’ve heard, “Oops, he really had pancreatitis! Maybe he wasn’t faking the pain!” too many times to count, I’m afraid. And do we want to be in a place where we actively discourage people already marginalized from seeking of health care?

I have no firm answers, and in the case of drug seekers, the answers tend to be coloured by experience and personal values. Admittedly, beneath the crusty exterior, I’m the prototypical bleeding heart. I prefer in the end, everything else being equal, to accept a patient’s description of pain at face value. It seems too risky and less ethical to act otherwise. But like I said, it’s complicated.

__________

*In contrast, many emergency departments in Ontario, if not most, have sternly worded signs at traige that read, in effect, “Your narcotic prescription won’t be renewed here, so go ‘way.” We’re fortunate in Canada, as front-line nurses, not to have to deal with the Joint Commission, whose regulations often defy common sense and indeed occasionally border on insanity. Hospital survey companies like Press-Ganey do exist in Canada, but their influence on hospital policy and procedure are much less than in the U.S.

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  1. #1 by rww on Friday 29 October 2010 - 1407

    Part of the reason for the problem is that we are a society of wimps and where our parents might have asked for medication for unbearable pain we want the pain alleviated before we feel it.

    Although I like to think I have a pretty high pain tolerance.

  2. #2 by Raquel on Friday 29 October 2010 - 2120

    And the wimpishness is getting worse. One of the questions we ask upon an admission is “On a scale of one to ten, what is an acceptable level of pain for you?” It is amazing how many people answer “zero”. And these are presurgical patients! They demand that their surgery produce NO pain. This is not even possible! I see people daily coming in for surgery under general anesthesia for I & D’s of abscesses that we used to do in the ER with a shot of Lidocaine if they were lucky. A lot of this is to please the Press-Ganey Gods.

  3. #3 by jenjilks on Saturday 30 October 2010 - 2054

    It is complicated. To ensure that a patient has pain-relieving drugs, at the risk of extending a dependency, I laud you.

    I was so worried that my dad was in pain, but couldn’t convince his nurse.
    So what? He was palliative. He had a brain tumour. God forbid that we made a mistake and he had pain relief.

    Great post. You hearten me. I hope MANY nurses read this blog.

  4. #4 by GMF on Wednesday 17 November 2010 - 1241

    I think the only way to get people of the Narcotics is to take out the “feel good”, aspect of the drug. If you take out the euphoria of the medication why would you demand it?

    Sticky situation and there is no clear fix! I do think everyone should be given the benefit of the doubt.

    Are we so sure we have discovered all reasons as to why someone is in pain? I don’t know about you but I think it is pretty obvious that we are still in medical infancy; with many more discoveries to be made in pain and every other field!

  5. #5 by alan on Monday 11 April 2011 - 1011

    Not all patients seeking pain releif are drug seekers. I was sent home from a double fusion. Two rods six pedical screws and lots of bone removed through an 8 inch opening in my back. By the way with nothing. The pain got so bad the second day I was going into shock. Went to the hospital and they helped. Dont punish all for the addictive people. Narcotics can be handled by close observasion and counseling. My friends wife committed suicide to get out of pain is this what we want? we can make people comfortable and should. Some quality of life is important. I wish the people who are againts these drugs could go through the pain I deal with every day. there opinion would change very quickly, The real key here is you accept the good with the bad. At least the good wont be punished for the missue of others

  6. #6 by Jenna on Friday 27 July 2012 - 1129

    This is absolutely disguisting what society has come to. So here is the issue, doctors in the last five years were paid the big bucks to prescribe pain killers to anyone and there dog in pain. Then the country got addicted to them clearly as they will be habit forming to anyone taking them for an extended period of time PERIOD. Whether your a priest a judge or an ER doctor if you have pain and take narcotic pain killers for it for over 2weeks your body will build a tolerance. However that is not to say that you are qoute on qoute and “addict” or should be treated as such this is unreal behaviour. The doctors guess what they created this issue to begin with, and now they are going the complete opposite end of the spectrum denying patients who truly need pain control the help they desperately need truly only further aggrevating the problem. People with pain are commiting suicide, and suffering greatly loosing there jobs and quality of life because the fear that someone might be drug seeking as they call it. The bottom line is NO ONE should be judged like that EVER if they have a provable medical reason for thier pain that is known to cause pain. My fiance has lis frank fractures on both his feet and metal plates and screws in them, also a torn rotator cuff in his shoulder that needs surgery desperately. He actually had an ER Nurse say to him (at Triage none the less) and i qoute” how do we know your not just taking the pills downtown and selling them” he didnt even know what this meant…lol he was astounded. This is how we treat our sick now? This is absolutely not ethical in anyway shape or form. The drug addicts as they call them, have options they can get all kinds of help. They can get on methadone programs the same day as im learning in my research of this matter. Methadone is the STRONGEST opiate on the market and can actually kill the person it is intended for and or anyone else that might get there hands on it. This is sold on the street as well. So lets all get this straight the “drug addict” can go get the strongest opiate known to man next to Herion at the drop of a hat but because of them which btw I dont condem them in anyway as the docs created them to begin with(of course with the help of the addict), but a patient with provable medical causes for pain cannot be properly treated to have some quality of life. This outrages me. We have gone from one end of the spectrum to the other….We over prescribed created a serious problem and now we are not treating pain period! This has to be stopped. This is the way i see it if a person is complaining of pain and has no known cause for it i can understand err ing as they say on the side of caution. However if a person has a known medical reason for there pain and discomfort we cant just NOT treat there pain because there may be a slight chance we may give an addict one dose of there drug of choice. Accidently giving a “Drug Seeker” a dose of there addiction is not going to make one ounce of difference in the long term to there addiction. Besides drug addicts are not patiently waiting 10hrs to get into ER rooms with no medical problem and blood full of drugs to get a possible one dose of medication they will go to the street long before that. If this does happen then they will have no real deabilitating thing that is known to cause pain and send them on there way. We need to TREAT pain period all humans should have the right to pain control if they have a proven medical ailment. This is ethically and morally wrong the way the entire system is gone the opposite way leaving the health care system in complete dissaray. I intend to bring some serious light on this situation, I would love to hear your storys and your opinions.

    • #7 by Anonymous on Monday 26 November 2012 - 0734

      Work in the ER as a nurse for ONE day and you will clearly see why this article has been written.

  7. #8 by Gary Shelley on Wednesday 06 November 2013 - 1517

    I think it is complicated and this author has written a good article on some of the issues. I would also like to thank the author for thinking of us pancreatitis patients. I live in S. Ontario,and I was flat out turned our away for my vague stomach complaints (classic drug seeking, I guess) on 2 or 3 occasions, no pain meds, no tests, and no help. After a rather severe attack I went again to the local hospital, a doctor ordered blood tests and discovered I had pancreatitis and still do. It’s a small city 1 hospital and they know me and treat me better these days, plus I have adequate pain meds now, so I don’t go to ED because of inadequate medication anymore. I know when I have to go, like a dog to the vet. Today, chances are if I went to the hospital, the nurse would look me dead in the face and say: “YOU! Did you eat or drink something you should NOT be having, you know you have a prescribed diet……….you know the drill, I’ll get an IV started…….”

  8. #9 by Gary Shelley on Wednesday 06 November 2013 - 1533

    Nothing more sickening than to be having bad pancreatitis pain and you’re listening to some one decree 10 out of 10 pain for some small thing. All chatty and smiles till the nurse walks in and asks how they are doing, and for the record I have never said 10 out of 10 pain because I don’t think I can comprehend it. I usually think “I got dicked over because there are so many like you!”. So here to me if a nurse asks is what I would consider 10 out of 10 pain: alone in the forest I squat down to go to the bathroom, my package hangs into a “trap” that snaps shut,now when I get to the end of the chain, I realize I have to use my own pocket knife to free myself. Maybe an 11.

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