A small number of patients account for an inordinate amount of ER visits. Some say that drug seeking behavior is part of the cause:
Drug-seeking behavior is at the core of the problem, says Neven. Forget the stereotype of homeless people or drunks who just need a place to sleep it off, he says. Many have chronic pain, have been struggling with it for years, and are being prescribed drugs to deal with it. Sometimes they are not getting the result they want and insist on the quick fix the drug provides when delivered by IV or injection, rather than the hard work of physical therapy every day for six months.Others have figured out that selling painkillers can be a lucrative and relatively safe way to get quick cash. In fact, the non-medical use of prescription drugs is the second-most common form of drug abuse in America, responsible for about 40 percent of drug abuse nationwide. In addition, ER care is by its very nature episodic and uncoordinated, with patients who are supposedly seeking acute care being seen by different doctors and nurses. All of that makes it easier for drug seekers. And because patients cannot be turned away, says Neven, “the fact that we have to see them, have to talk to them “” that has created the beast.”
(via a reader tip)
Related posts:
- Glenn Beck and the drug-seeking patient
- Drug seeking in primary care
- Drug-seekers, again
- How hospitals should deal with disruptive physician behavior
- Drug seeking, without finesse
- The skill of drug seeking
- No shame for drug handouts
{ 14 comments }
I don’t see why this article would surprise anyone. Living with severe pain is one of the most overwhelming human experiences there is, and the avoidance of pain is one of the most powerful drives any human being has. Pain is the thing that keeps you from burning your hand on a hot frying pan, from trying to run on a broken ankle, or from literally working yourself to death. It is the number one reason people see their doctor.
All human motivation, reduced to its basic fundamentals, consists of the pursuit of pleasure and the avoidance of pain, which are two states that are diametrically opposed to each other. Why then, is it so difficult for people who allegedly have some training in medicine to understand just how desperate for relief having to live in severe pain every moment of your life can make you? Why do you persist in demonizing people in desperate need of relief from their suffering as “drug seekers?” Isn’t “relieving suffering” what you signed on to do?
What this article is talking about is basically blacklisting patients who, very often through no fault of their own, are not getting proper treatment for their pain. Getting labelled a “frequent flyer” or “drug seeker” can effectively block you from ever getting treated for your pain, and may amount to a lifetime, non-judicial sentence of torture the only escape from which is suicide. To stigmatize a patient in this way for no other reason then they want an alternative to sticking a gun in their mouths is the grossest and vilest form of slander imaginable. Patients like this are invariably treated with derision and contempt, which only adds to the enormous physical and psychological suffering they have already experienced. I have yet so meet a sinlge person with chronic pain who has not been abused by the medical profession.
This kind of behavior on the part of doctors is disgraceful and barbaric, and without a doubt I think a lot of people who choose to become doctors would be better off in professions where being a ruthless, bigoted, arrogant son-of-a-bitch is an asset, like running a death camp somewhere. Then you can be as cruel as you like to people and it is actually part of the job requirements. Unfortunately for you and even more unfortunately for your patients, that just isn’t the case with medicine though far too many doctors seem to think being abusive is part of what they’re being paid for.
If you’re unwilling to treat severe pain and have no compassion for those who suffer from it, you’re in the wrong profession. If the DEA arresting 50 doctors a year for drug-dealing has got you so terrified you refuse to treat people with pain, either stop dealing drugs or take a look in the mirror and face up to your own moral cowardice rather than trying to project your inadequacies onto your patients, whose struggles and ordeals with trying to overcome a life-destroying condition you know nothing about.
Redhawk:
You don’t work in an ER do you? I bet you have never been assaulted or stalked by an addict.
Relieving pain is a compassionate and part of my job. Giving addicts their “high” is not.
Apparently, Redhawk has not worked in the ER and has no idea of what ER docs and nurses are talking about.
…either stop dealing drugs or take a look in the mirror …
A physician in Hyannis recently did this. He announced that he would no longer prescribe controlled substances, referring his patients to other physicians who he felt were better qualified than he to treat chronic pain.
He was crucified in the press.
Damned if you do, damned if you don’t.
The anger and passion in Redhawk’s comment are a sigificant reason why physicians have difficulty with chronic pain. The depth of emotions(which are real, but different from pain) is quite distracting and frustrating. I think all physicians need to have ther personal strenght to deal with this level of anger and emotion in a compassionate way. However, it may not include prescribing narcotics if the judgement of the compassionate practioner is that the narcotics are harming the patient. And some patients are harmed by them.But that’s a difficult discussion to have in the face of abusive, angry patients.
Agree with the above. I probably sort through 5 cases of “seekers” in the ER for every one case of true pain. These “seekers” have a problem that is destroying and controlling their lives much like alcoholics. I don’t prescribe alcohol to the alcoholic so why whould I prescribe narcotics to the narcie?
In addition I meet many people that have come to the realization that they have become addicted to vicoden who always blame the doctors they saw as “getting them hooked”
Relieving pain is one of the most satisfying thing that I can do as a doctor. On the other hand, enabling the addict perpetuates self harm and is not my duty.
First of all, thank you Redhawk for a terrific posting.
A couple of anecdotes are in order here.
Many years ago I had a carpool arrangement with my father, a cardiologist. (I had a physics postdoc position at the time.) Every day we’d ride in to work together and I’d drop him off at his office across from the hospital. Then in the evening I’d go to the hospital and wait for him to finish his evening rounds. I either waited in the ER or in the doctor’s lounge right next door. Sometimes the wait was for only a few minutes, other times it was several hours.
The net result was I ended up spending literally hundreds of hours in and around the ER watching what went on without participating. I saw plenty of drug-seeking behavior there, but I also saw quite a few instances of callousness and even outright cruelty on the part of doctors towards some very sick and desperate people.
Some years later I started having serious abdominal pain. After one episode in the fast lane of I-10 where it was all I could do to get my head out from between my knees and keep driving, I went in for some tests. The verdict: Gallstones. A cholecystectomy was needed in very short order, followed by a five week hospital stay – fairly serious stuff.
At one point during the stay my GP stopped by. He glanced at my chart, frowned, and left the room. A few minutes later he was back and announced “I’ve called your surgeon and he has agreed to increase your pain meds.” I was a bit puzzled by this because while I was far from comfortable I was hardly screaming in agony. It was only after the larger dose kicked in that I realized I had been in considerable pain all along and I had just gotten used to it. I asked my GP about it later and his response was “your surgeon is a nice guy but he has never been sick a day in his life and he just doesn’t understand pain”.
So what’s the bottom line? The bottom line is that pain is unfortunately a subjective thing both for doctors and patients, and any time something is this subjective there are going to be mistakes and misrepresentations.
But the one thing that has no place in any of this is the arrogance I see in far too many postings by physicians. Remember that when “4 out of 5 people asking for pain meds are just after the drugs” it also means that 1 out of 5 do need the meds, and like it or not you’re going to make mistakes sometimes.
It would certainly be nice if pain could be placed on an objective footing. Someone really needs to invent the dolorimeter I recall seeing in one of the original Star Trek episodes. If such a device existed I’ms a bunch of people would end up cut off from their drug supply, but I also suspect a bunch of doctors would be aghast at what they’d done.
“The anger and passion in Redhawk’s comment are a sigificant reason why physicians have difficulty with chronic pain. The depth of emotions(which are real, but different from pain) is quite distracting and frustrating. I think all physicians need to have ther personal strenght to deal with this level of anger and emotion in a compassionate way.”
Adopting such a smarmy, condescending attitude would elicit anger in anyone, chronic pain or not. If you’re like this with your patients, it’s little wonder a lot them get pissed at you.
It is significant that you didn’t address a single point I made in my post or the issue of medical blacklisting, which is blatantly unethical. Instead, you chose to psychopathologize me as if my “anger and passion” can only be the result of some shared fundamental character flaw common to people in chronic pain, rather than a reaction to the abuse most people with pain are subjected to by the medical profession. How charming.
This is a perfect illustration of how doctors dehumanize patients, where any overt expressions of pain behavior are labelled as malingering, factitious disorder or drug seeking, and even the mildest expressions of anger or disagreement are seen as evidence of a personality disorder or a rage disorder. Alternately, if you don’t show pain or are too passive, you will be told you can’t possibly be in as much pain as you claim to be in. You will rarely be treated as a human being having a predictable human response to an extremely stressful situation.
I’m not exactly sure what “harm” you are talking about with narcotics. Taking as directed, they are the safest and most effective treatment for most kinds of pain, and there is no evidence of organ toxicity from narcotics. As for addiction, the rate of true addiction to narcotics in pain patients treated with them is less than 1 to 3 percent. The NSAIDs and other drugs doctors hand out like candy are far more dangerous, and many drugs like Paxil or benzos far more addictive in terms of trying to get off them.
You seem unaware that having to endure severe pain and its attendant stress on a near continuous basis for yearscan be pretty damned harmful as well, and many people end up totally disabled for life due to the destructive effects of untreated pain. So I suspect the “harm” you are seeking to minimize is not your patient’s, but your own.
“Agree with the above. I probably sort through 5 cases of “seekers” in the ER for every one case of true pain.”
Really? Considering the rate of addiction among cp patients is actually rather low, I’m curious where you’re getting all these “seekers” from? Do you have some sort of infallible technique for discerning people who are seeking drugs for pain from those who are seeking them to get high, or do you just have a biased attitude towards people in pain?
The reason I ask this is that it is a common complaint among people with cp that they are falsely labelled as addicts and denied pain treatment, and I cannot begin to describe the sheer psychological stress this causes to a lot of patients, who see it as a betrayal of the trust they put in their doctors. Most doctors have a tremendous amount of bias and hostility towards people with pain, and I supect that this bias manifests itself with false accusations of drug seeking as well as in the false perception most legitimate pain patients are drug seekers.
Beyong that, it is a very self-serving rationalization for a doctor who is afraid to prescribe pain meds to imagine that he is actually doing his patients a favor by not indulging their alleged addictions, rather than having to face his own moral cowardice.
This is complete nonsense of course, as pain is far more destructive than any addiction, and a lot of the damage drug addicts experience is caused by the constant cycle of use and withdrawal they experience due to inconsistent supplies, so you’re not doing a junkie any favors by forcing him to go through withdrawl or having to rob someone to pay for his fix that night.
In the UK and Switzerland they are beginning to treat heroin addicts with maintenance doses of heroin, and the result has been a dramatic improvement in health and functionality among hard core addicts and a decrease of criminal and anti-social behavior.
Seems like aggressive treatment with opiates is the best option for both those in pain and those who are addicted.
To leave hundreds of chronic pain patients suffering from severe, intractable pain in order to avoid giving a junkie a free, clean high is destructive both to people in pain as well as the junkie. It is morally indefensible.
“But the one thing that has no place in any of this is the arrogance I see in far too many postings by physicians. Remember that when “4 out of 5 people asking for pain meds are just after the drugs” it also means that 1 out of 5 do need the meds, and like it or not you’re going to make mistakes sometimes.”
Thanks for an excellent and inciteful post, Anon.
I have been the contact person for a few chronic pain support groups for over 13 years. In this role I have heard literally hundreds of stories from people in chronic pain, in addition to those I have read on the internet and elsewhere. I have never spoken to a single person with chronic pain who doesn’t have a horror story about abuse from the medical profession, with ER docs being the worst offenders. I wouldn’t send a dog I didn’t like for pain treatment in a typical ER.
The most common forms of abuse are rude, arrogant behavior from doctors and their staff, acccusations of drug seeking or addiction, manhandling during physical exams and minimizing or outright dismissal of pain problems or being told the pain is all in your head, and of course, simple denial of effective pain treatment.
These are just some of the milder abuses I’ve heard. The more criminal ones involve women being pressured into having sex or risk losing their pain meds, doctors screaming in their patient’s faces or groping them during exams, and doctors lying and using scare tactics to get desperate patients to have unnnecessary or highly questionable surgeries.
When patients react to all of this abuse with anger and distrust, they are then labelled as “difficult patients” or as having “personality disorders” and it is not uncommon for patients to have their medical care sabotaged by being blacklisted to where no doctor will treat them
And of course there are the ubiquitous “script doctors” who charge $500 to $1,000 a month retainers in exchange for prescribing anything a legitimate patient or a junkie could want. These are the guys the DEA is after, but every doctor is terrified he could be next on the DEA’s hit list so they avoid prescribing pain meds like the plague.
Although there are plenty of good doctors out there who treat their patients with dignity and respect, and lots of people can and do receive adequate and compassionate pain treatment, it is also true that there is a tremendous amount of abuse and exploitation out there as well, and you can readily see the kinds of hostility, ignorance and arrogance directly underlying a lot of that abuse right here on these medical boards and blogs.
Redhawk knows what he is talking about. Labeling patients about anything is being extremely contemptuous toward them. Unfortunately, it often happens unfairly, too, to people who are not “seeking” narcotics. Blacklisting patients for any condition is wrong and unethical but it is done every single day by doctors and hospitals.
It’s a amazing.
I have recently found out that when I went for a stress test a few years ago, that I was labeled a drug addict by the “nurse” administering the thallim stress test.
I am confused as the best way to rectify this.
Twice at two hospitals I have been refused treatment and labeled a methadone addict thanks to a long gone pain management specialist.
First he put me on this then the same pain doctor removed me from the methadone do to reactions, and put me on morphine sulphate.
After he kicked me to the curb my regular doc put me back on it and will not take me back off. I am assuming this is do to the label. Yet he knows me twenty years. His answer seek another pain management specialist.
How in the name of god can some professional administering a stress test label me and I not find out for several years.
For starters all files should be signed by both the patient and attending person to avoid this type of conflict.
I mean I had a hard time for years until I finally asked them why I was treated like shit. Then he told me.
Redhawk is right and you folks give yourselves away when you jump on him.
Pain severly affects ones emotional state. Perpetual stress 24/7. logic dictates that it will have a major effect over time.
Any you folks expect him to be nice when the feelings are not reciprocal.
LOL
Redhawk said,
“This is a perfect illustration of how doctors dehumanize patients…”
That’s funny and ironic, because that sentence is a perfect illustration of the way unintelligent people generalize when confronted with a situation they either cannot grasp or lack the perspective to view fully.
There are people with real pain. And there are people who use drugs for gratification, as well as a spectrum in between. You stand at one end, and you’re unwilling to admit the other even exists.
I generally know when people are honest and when they’re faking. But I tend to treat the fakers, because maybe the end result is a good thing. Drug abuse seldom stagnates–it spirals out of control. So maybe I’m helping that person weed himself out of the gene pool. I’m thrilled about that.
That said, here are some things to remember:
1. Someone with 10-out-of-10 pain, does not have a heart rate of 75 (without being on a beta blocker, or other reason for adrenergic inhibition)
2. Someone with 10-out-of-10 pain does not become visibly more comfortable when he or she thinks no one is watching.
3. Someone with 10-out-of-10 pain is generally not interested in milking a food tray out of his fast-track visit.
Someday, we’ll be able to use fMRI’s to determine accurately who’s lying, and prosecute them with extreme prejudice, like the felony it is. Cheers!
Things to remember:
Levels of pain cannot always be measured by behavior.
Unless you are culturally competent you will always make a mistake about whose being honest and whose faking.
There a numerous types of cultures including the cultures of gender, child abuse survivors, domestic violence victims, etc.
Facts based on bias must be considered erroneous. It is easy to make facts fit ill conceived presumptions. Once a doctor believes a patient is drug seeking they stop investigating any other illness. My hyperthropic cardiomyopathy was undiagnosed because they believed I was a drug addict
1. Undiagnosed heart disease can cause a decreased heart rate. I suffered from severe pain due to autoimmune pancreatitis. My heart rate was 58 bpm. I was beginning to have an adrenal crisis, but that was ignored because they believed I was a drug addict. I was so weak from dehydration that I could barely take my clothes off. They told me they were going to cut them off. When I finally did take my clothes off that was their proof that I was looking for drugs.
2. Patients become more comfortable when doctors that are disbelieving, condescending, and abusive are no longer interrogating them.
3. There are people that eat because of the stress of their pain or they are hungry. Statements like “milking a food tray” are definitely evidence of bias. Something very basic like addressing someone’s hunger is what civilized society’s and people encourage.
4. Medical tests like fMRIs are only useful if those who are interpreting them are free of bias and are also competent. I had an pituitary tumor it was ignored. My pituitary ruptured and I had blood in my spinal fluid they said it was a migraine and sent me home. MRI showed an empty Sella, CT showed an empty Sella the abnormality was ignored. I almost died due to an adrenal crisis, before I was taken seriously. I was sent home from the ER with life threatening complications (adrenal crisis) and collapsed in my PCP’s waiting room with a blood sugar of 34. At that time, I wasn’t taking any pain medication. It is worse now that I am.
Women in childbirth are taught not to cry out in pain “lose control”. This “training” carries over to other painful disorders.
When I was a child my aunt would punish me by beating me with a switch, belt, and one time a broom. My aunt would yell shut up every time I cried out in pain. The beating would not stop until I stopped crying. That meant every time she hit me and I cried out the beating would continue. She stop hitting me after I stopped crying. Then I had to prove I wasn’t going to cry anymore by enduring several more hits without crying.
Is it any wonder why a patient like me would not cry out although I am in tremendous pain. I controlled my pain by sheer will power and I am blessed that I am still alive.
It is basic human instinct to maintain silence and control when in the presence of danger. In an ER, where doctors and nurses abuse patients that take medication for chronic pain, danger exists. I have been abused and treated like an addict although I wasn’t taking pain medication.
My illnesses are ignored because I take pain medication. I have been sent home with a blood pressure of 235/107, no treatment was provided.
My medical illnesses, adrenal insufficiency, require me to go to the ER when I am ill to prevent an adrenal crisis. More often than not I have been denied care, viewed with suspicion and interrogated. These incidents happened when I wasn’t taking pain medication.
Statistics show that 4 out 5 patients are not addicts and to state otherwise is a “fallacy of distraction”. Characterizing those who disagree with you as unintelligent is another fallacy of distraction; when all else fails attack the person.
These actions show a considerable lack of critical thinking.
What makes you all knowing. I was accused of being a drug addict. I was referred for a steroid injection. Based on my race it was automatically assumed that I was a drug addict. Whether it was conscious or unconscious racism, I was denied medical care because of bias. Although they issued a written apology, I have never forgotten the humiliation of having my body checked for needle marks and being interrogated like a criminal.
Drug addiction is a disease.There are worse addictions. Diversion of Viagra and the passing of AIDS, Syphilis, and drug resistant venereal infections to innocent partners. Child molesters and pornographers arrested while having Viagra in their possession, but no one complains about the abuse and diversion of this drug.
Just because you are doctors, while we choose different professions does not make you all knowing and powerful.
You remind of the doctor who became angry when my mother said she wanted to live as long as possible. She refused to agree that her life was no longer worth living. He believed she should just die.This man should never be allowed to practice medicine nor should you.
Too many innocent lives are lost because of doctors like you. I have met doctors like you. Bias and prejudice ruled their decisions while my medical illness was allowed to fester and now I will die an early death. Find another profession.
Oath of Maimonides
The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
May I never see in the patient anything but a fellow creature in pain.
Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.
Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.
Pain is inevitable, suffering is optional.
Veritas
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