Tuesday, April 6, 2010

Just Say No: Drug-Seekers in the ED

One of the daily frustrations of working in the ED is dealing with drug-seeking patients. Presentations of these patients will vary, but with some time and experience most providers will generally be able to differentiate the "seekers" from patients presenting with legitimate pain. Regardless, it is important to always provide care appropriate to the patients immediate needs and to facilitate appropriate follow-up care. When these patients continue to repeatedly visit the ED for on-going chronic pain control, it is appropriate to just say "No."

The EMTALA definition of an "emergency" in the prudent layperson standard specifies "acute" complaints (which includes pain). When a complaint is not "acute," then the prudent layperson definition (and therefore EMTALA itself) does not apply to that patient encounter. However, it is still important to perform a history and examination sufficient to reasonably exclude any potentially serious problems.

In my experience, the "seekers" will generally present with a limited number of complaints. Most often, there and on-going complaints of back or other musculo-skeletal pain, toothaches, headaches, etc. A few may present with a myriad of minor complaints and then address their medication-seeking with an "oh-bye-the-way" type of request. Unlike most patients with actual acute pain, these patients tend to either be fairly nonchalant with their 10/10 pain, or overly dramatic. The vital sign abnormalities generally associated with acute pain (i.e. mild tachycardia, elevated BP, etc.) are often absent. Medication allergies are typically extensive and usually include all analgesics that the patient doesn't want. Toradol is almost always listed. Historical inaccuracies with these patients are common. Some may weave a story based on a thread of truth, while others will outright lie. Several could easily qualify for an Oscar-winning performance. One recent example that comes to mind was a patient that came to my ED for pain complaints stemming from being "injured by an IED in a Humvee in Iraq in July of 2002." Having been in Baghdad myself and knowing that the US didn't invade Iraq until March of 2003, I was able to get a handle on this one pretty quickly and had him bounced from the ED PDQ.

In less blatent cases, it is important to deal with the apparent acute need for pain management and reasonably attempt to facilitate appropriate follow-up care. Observing my own persoanl "three-strikes" rule, I will order appropriate analagesia for the complaint, and refer the patient back to the primary care provider (or refer to a primary care practice if the patient has no PCP) for continued outpatient management of the pain. I will give a short-term prescription for analgesics, generally a 4-5 days supply and tell the patient that the emergency department will not be able to provide ongoing care for his/her pain control needs. All of this is documented in the patient's record and spelled out in the discharge instructions that the patient signs.

On a second visit, I will do the same thing. Administer analgesia, refer again, but provide only a 2-day prescription for analgesics. Again, the encounter is documented and spelled out in the discharge instructions, with the statement that additional prescriptions for controlled medication will not be issued from the ED.

On a third visit, I will adminsiter only a single dose of oral analgesic medication and provide no prescription. I will tell the patient in no uncertain terms that there will be no prescriptions issued for his/her chronic pain on this or any subsequent visit to the ED and remind him/her of my prior referrals and instructions.

On subsequent visits for the same complaint, I will perform the H&P, document that the patient has no acute issues or emergency medical conditions, and will offer or provide only an oral dose or a non-controlled analgesic and discharge the patient without a prescription. If the "give them what they want" mentality hospital administrators disagree with my approach, I would invite them to head back to school to become qualified and licensed to do what I do. Otherwise, they can feel free to stay behind their desks.

With limited resources, the emergency department cannot be "all things to all people." EMPs cannot assume the role of both the acute and chronic care provider for the community, much less the prescription drug supplier. Trying to do so results in a disservice to all of our acute patients.

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