Not all pain patients in the ER are drug seekers

in Physician | 18 responses

by Melissa Velez-Avrach

About eight years ago, I was in an accident that left me with chronic lower back pain and muscle spasms.

Then, about a year and half ago, I was in a car accident. Bad combo for the pain. I’ve been to chiropractors, orthopedic spine specialists, had MRIs, the works and am following my doctor’s recommendations, doing yoga, deep breathing and physical therapy when needed. It has all helped me very much.

I am happy to say that I live with some form of tolerable pain on an almost daily basis but do not need to be on daily pain medication. This is okay by me because I do not do well with pain med side effects at all. I’d rather deal with more pain than normal than deal with the side effects.

The only exception to my med-free rhythm is that about a handful of times a year I have attacks, pain that I can’t tolerate. The pain becomes so intense that I can’t function and then, I become stuck in a certain position. If I try to move out of that position, I experience such terrible pain that I have screamed and cried myself hoarse. This is the point where I end up in the ER.

Of the times that I have been in the ER, no one has ever doubted that I have been in pain nor did it ever cross my mind that one of the healthcare providers who was helping me would doubt my pain. That is until I ended up in the ER during my vacation. I could tell that the doctor was really surprised that I still had 11 of the original 15 oxycodone/APAP that were prescribed to me after last year’s trip to the ER. In fact, 2 of those had been taken earlier that day in an attempt to forgo the Florida ER. I was on vacation; I did not want to be in the hospital, but no amount of yoga, swimming, water yoga and deep breathing could help me this time.

I was really struck by the whole experience and by how surprised he looked when he saw the bottle. I thought maybe I was imagining things so I told the whole story to a friend (she is an ER nurse) and asked her what she thought. Did I read him wrong? Turns out, according to her, I had probably read him correctly. Before seeing that bottle, he might have thought I was a seeker, that I couldn’t go without a fix on my vacation. She works in a very busy hospital and has daily experiences with seekers. She and I had a long discussion and we both feel that unfortunately, people who are in real pain sometimes look like seekers and the seekers themselves are in pain because of their addiction.

I can’t believe I had not even heard of the term seekers before. And I had thought the worse problem was dealing with the muscle spasms and the medication side effects.

Melissa Velez-Avrach blogs at In Other Words, the MedPage Today staff blog.

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Comments

A.N. Mousse
I was just thinking about this question. I read a lot of med blogs and the vitriol that ED providers (and other doctors) spew about patients seeking relief from pain is pervasive in those blogs (not unjustifiably, it would seem). I wonder if had the writer here not been able to prove that she wasn’t a drug seeker if her pain would have been addressed. From the comments in other postings, I guess not.
It seems guilty until proven innocent beyond a shadow of any doubt is how it’s handled. Of course, there was a woman in Boston who was labeled a drug seeker and summarily and repeatedly dismissed from the ED (the last time by security) who turned out to have had metastatic cancer. But, I guess in the vigilante justice meted out by ED providers, collateral suffering such as hers is justified so long as all the drug seekers are denied access. I’ve often wondered do any of you ever apologize to the patients you sneer at when it turns out their pain is real?
Also, since I am now afraid of the ED (from reading all the comments from the ED docs) maybe you could write a little piece about when it is appropriate to go the ED with pain as a symptom – and what proof is required to ensure we are taken seriously. But, maybe you don’t want to give out those secrets, lest the drug seekers use them to their advantage.

apurvab
The greater question is why people are repeatedly going to the ED for the treatment of chronic pain (doesn’t really touch upon the OP’s experience, as his situation is a bit unusual, but does reflect the vast majority of visits that are specifically for seeking pain medication). To ask an ER doctor, who’s training is exclusively in managing in life-or-death conditions (or at least triaging them) to start treating something so complex and in many cases incurable, is a setup for failure – i.e., you can’t treat chronic pain in the emergency room setting. The “treatment” of chronic pain is not just medication – its a comprehensive treatment that involves non-narcotic medication, psychological counselling and sometimes interventional modalities. Having a good relationship with a PCP or or specialist who understand the management of chronic (and often acute-on-chronic) pain is critical. My experience has been that most encounters for pain medication in the ER are due to a combination of apathy from both patients and their providers about the proper management of this real but complex medical condition.

A.N. Mousse
I understand that chronic pain is a condition best addressed through primary and sometimes specialized care and is not necessarily an emergent situation – however, pain as a symptom, pain so excruciating a person can’t function normally – certainly seems like it would be an emergency to the sufferer – particularly if one is a way from home as the writer was, or on a weekend or at night when a PCP is not available.
A few years ago I went to the doctor (my PCP) because I had had a cold or flu that left me with a cough that wouldn’t go away. I developed horrible pain every time I coughed, which was often. After several weeks of this I went to see my PCP. He gave me a prescription for 10 pills of a strong narcotic. I took 2 of them and hated them, kept the rest till their expiry date and then disposed of them.
I went to the doctor because I thought the pain was a symptom of something worthy of a physician’s attention. I didn’t go to the doctor seeking pain meds. In fact it seemed dismissive to me to have the pain treated, but not even discuss the cause. A few minutes’ (and really only a few minutes) explanation about the pain, its cause and its likely duration, plus a recommendation to take pain meds (maybe try OTC pain relievers first to see if they worked) seems appropriate. I left that visit feeling as if I’d wasted both my time and the doctor’s. So, really, I’m puzzled, when should I see my doctor? Because, it seems mostly, that they don’t really want to see patients.

http://minochahealth.typepad.com/ doc
My perspective as a physician about “drug seekers” changed after myself suffering severe pain requiring significant amount of pain medicines. As the saying goes, “Only the wearer knows where the shoe pinches.”

David bandy
Good for you Doc, sorry you were put in this position to realize what allot of us deal with, I had to recently switch PCP because I am now on medicade instead of private insurance..first visit to mt new PCP was a disaster, she has labeled me a drug seeker even though I suffer from Pulmonary Fibrosis and 3 compresed disk in my back, the pain in my chest and ribs is overwhelming and also causes additional pressure on my back..This all came about because i asked her nurse about Norco pain meds..my stomach is very sensative to asprin..My pilmonoligist had suggested perecet but it has really bad side effects for me in the bathroom..you know what I am refering to. I settled myself down and called the office of my prevoius PCP..Doc’s secretary said my new Docs response was predictable as she does not know what I have been dealing with for years..I have continued working even when my PCP begged me to file for SSDI, so much for trying to do the right thing..now I am at a point were as the pain is so very bad and I have a New Doc that will do nothing to help me. I wrote my new Doc a letter as better to do this..sometimes words can get out of control or misunderstand when the chronic pain takes over your life. I have always been totaly open with my Docs…all I am asking for is some type of quality of life with a terminal disease.

Jman
In addition, most of the visits to the ER are for an acute exacerbation of chronic pain. That is something that needs to be part of a long term treatment plan for chronic pain, as it is expected that exacerbations will happen. Unfortunately, without a complete knowledge of a patient’s history and medication profile, it’s quite hard for an ER physician to adequately treat such pain that may be refractory to standard modalities.
http://www.medicalbilldog.com Dennis (Investigator/Negotiator) at Medical BillDog
As the commenter identified as Doc says, until you’ve felt the pinch, you have no idea how much the shoes hurt. Even with the straightforward 0-to-10 pain scale, where 0 is freedom from pain and 10 is the worst pain you can imagine, actually communicating pain is nearly impossible. I’ve been dealing for three years with pain from degenerative disc disease, and I never feel comfortable that my doctors undertand what I’ve told them. Wanting to be precise, early on I developed my own pain scale explication.
Above a 3, I can’t stop thinking about the pain. It’s there with me all the time, an undercurrent to every thought, whining along like a UHF carrier wave.
At 5, I dread getting out of chairs, climbing the stairs, or rolling into the passenger side of the SUV. At a level 6, rolling over in bed or shifting my self in a chair causes annoying involuntary groans. I try to censor myself, but the augh, just slips out.
A 7 is my working threshhold. Above that, I can’t type, can’t spell, can’t think to construct anything more complex than a grocery list. Frankly, at an 8, grocery lists tend to be scattershot at best because all I’m really thinking is how much I want to lie down with an ice pack.
At 9, rational thought is displaced almost entirely. I stretch out on the ice pack and don’t talk. I am more likely to take one pill too many at a 9.
At 10, I pass out.
You can understand my confusion, then, when I see another patient in a surgical center who is clearly unable to stand without crying out who claims her pain level is 3 but jumps to four when she stands. More ludicrous still is the young woman I met in a hospital who complained of her horrid headache which, she claimed, on a scale of 0-to-10, to have reached a 44.
No wonder, as Dr. Jay M. Baruch claims in “Why Must Pain Patients Be Deserving of Treatment,” that clinical workers come to think of all of us as either junkies or wimps. Understandable, I suppose. Explicable, at any rate.Ultimately, though, I have to wonder of every physician who refuses to prescribe narcotics for the “gent” who looks “like he slept in his clothes.” Explicable, but not excusable.
I am sick of doctors looking askance at me any time I say a pain med isn’t strong enough. I am mad as hell at nurses who think they’ve identified a junky when they see someone shaking or wearing shabby clothes. Pain causes the shakes, too. And homeless people feel the same pain as you and I.
Don’t I understand the breadth and depth of the drug diversion problem in this country? Am I saying none of the clientele in the emergency room are seeking drugs for illicit uses? Certainly not, but I have news for you nurses and doctors who think you’re also brilliant narcotics cops: all those surefire methods you’ve come up with for determining which of us are diverting the drugs–they aren’t surefire. I sat with a young woman in a mental hospital last year and listened to her explanation of how she would go about making a few extra bucks for her boyfriend and herself once she got out.
“I feel a very severe case of cramps coming on again,” she said. “I’ll have my boyfriend drive me to the doc-in-a-box, and we’ll have an argument in the parking lot. Then I’ll go in, crying, and ask to see someone for my cramps. They’ve seen me before. When the doctor comes in, I’ll squeeze out a few more tears and bat my eyelashes. Then I’ll say, ‘The last doctor gave me some of that hypercodone.’”
Why did she think this would work. Because it had already worked several times. Later that night, she and her boyfriend would sell the pills for $5 a pop.
And why will she get away with this again and again? Because she’s pretty. Because she wears low-cut shirts with a flimsy bra. Because she targets places that have all-male physicians.
Later, in the same exam room, the same doctor will prescribe advil for some poor bastard who’s suffering excruciating pain from a migraine. Why? Because he’s come from a hard day’s yard work, covered with pollen and marinating in his own sweat.
The system is broke. Reading someone else’s pain is difficult, partly because no two people respond the same way to what appears to be the same pains. What you’re reading as success at not getting caught might just be relief at the thought of–well, relief.
As I write this, my pain level is approaching seven, even though I’m leaning on an ice pack. I’m wearing two Fentanyl patches, delivering a total of 62.5 mcg/hr to my system. They’re not quite enough to keep the pain under control, so I’ll go to bed shortly.When I wake up in the morning, I’ll pop a 10 mg mydrocodone to try to bring down the pain level again. I had another epidural corticosteroid injection ten days ago, so If I’m lucky, the pain level will only be 5 when I wake. Sound like drug-seeking behavior? It does to some.
http://crasspollination.blogspot.com Nurse K
If your pain management plan is to go to the ER with “flares”/muscle spasms, then seek another pain management doctor.
Hugh Hill
In our ED, we have recently instituted a chronic pain treatment policy — in the interests of all our patients, we don’t treat it. But if you come with a primary care or pain management physician’s phone number that I can call, I can tide you over. This leaves those who cannot get their own physician temporarily without access, but it seems to be the necessary balance we have had to reach with these addicting drugs.

http://www.medicalbilldog.com Dennis (Investigator/Negotiator) at Medical BillDog
So, you admit that your policy is part of the problem. The homeless and indigent who suffer chronic pain are automatically labeled as hard cases. They’re screwed. “Sorry that you can’t afford a primary or a pain specialist. We can’t give you anything. Suck it up. Come back when the pain has sufficiently ruined your health.” Necessary balance? That’s not balance, it’s oligoanalgesia. I don’t think elitism ever wore an uglier face. Instead of treating the problem, you’re blaming a societal ill–illegal distribution of meds–for your refusal to help a patient in pain. Worse, you’re teaching the poor not to come to the ED with their pains. So much for that fifth vital sign.
Okay, I’ll cede that this is not a simple do or do-not situation. The Hippocratic oath says, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” So, by refusing to give an ailing patient drugs, you’re hoping to prevent illegal sale of drugs. The problem here is that you’re relying on ugly stereotypes to determine who really needs the drugs. I have a pain management specialist, so you’ll give me drugs to “tide me over” but you won’t give them to the homeless guy who has no other options? That’s idiotic. If I have a pain management specialist, it’s easier for me to get extra drugs to sell. Your algorithm is all wrong. All of those hardened professionals on your staff who think they can spot a “seeker” a mile off, are wrong as often as they’re right. So, for every single seeker you prevent getting high or selling a pocket full of hydrocodone, you cause a half-dozen people to bear excrutiating pain and deteriorating health. Congratulation. You must feel so proud to have prevented a teeny bit of crime.
Now, I personally have never sold prescription drugs to anyone, but knowing how screwed up the EDs are, I work like crazy to avoid hitting a weekend or holiday without an adequate stockpile. If I ever do, though, I’ll remember to wear a splash of cologne and a suit and tie to the hospital. Help me out, here, Hugh. Should I be sure to let the pain show, look like I’m trying to put on a brave front, or just maintain a neutral expression? Lord knows I wouldn’t want to end up black-balled by your socially-conscious system.

http://paynehertz.blogspot.com Payne Hertz
Whether she realizes it or not, through no fault of her own the author of this piece qualifies as a “frequent-flyer” and thus is likely a drug-seeker in the minds of most ER doctors. You can argue that frequent visits to the ER are a poor way to get chronic pain treated, but this presumes that patients have viable alternatives and can reasonably be expected to know what they are, neither of which is backed by real world experience.
In the real world, most primary care doctors do not have the knowledge or inclination to treat pain aggressively. If they prescribe pain meds, it will usually be for just 30 pills to last you a month. Usually, they will refer you to multiple specialists, most of whom will be no more willing to treat the pain than the PCP was. Once you’ve been to the orthopedist, neurologist, physiatrist, psychiatrist and maybe got a surgical eval or two, congratulations, you are now officially a doctor-shopper. If you asked for pain meds at every visit and it was noted in your record, you are also now officially a drug-seeker. See how this works?
It gets worse.
Now that you have these labels, no one will touch you with a ten-foot pole. What do you do now? Maybe you go to the ER in desperation and if you’re lucky, you will leave with a script for 15 Lortab, or 2.5 days worth of meds. That’s $2,000 for 15 Lortab. Do that more than the official limit of 3 times, and you are a drug-seeker.
And you though drug-seeking was a scam.
In the real world, it is remarkably easy to earn the “drug-seeker” label. What’s worse, is that every patient who is falsely labeled a drug-seeker is then added to the weight of “evidence” of drug-seeking so that the next pain patient is more likely to be so stigmatized, and on it goes. It is a vicious cycle of bigotry where the bigotry becomes the evidence needed to validate itself.
Any honest, professional physician should be able to recognize that there is no objective way to determine if someone is seeking drugs for illcit purposes or not. Studies have shown that even a history of drug and alcohol abuse is not a reliable predictor or who will or will not go on to abuse their meds, let alone such nonsensical criteria as the clothes someone is wearing.
Yet there is no shortage of “how to spot a drug-seeker” guides out there, some of them published by medical societies. Most of the criteria these guides establish are based on medical folklore, stereotypes and sophistry and the personal prejudices of the doctors who wrote them. They rarely if ever have any basis whatsoever in science or even common sense. Many of them betray a stunning ignorance of the mechanisms of pain and how human beings react to it. Sadly, many doctors embrace these criteria, apply them to their patients and deny pain treatment based on nonsense. The result is an epidemic of undertreated pain coupled with an extremely exaggerated view of the drug-seeker problem by most physicians which has become self-reinforcing.

Dr. J
I agree with you that acute pan is much under treated in most emergency departments. If someone presents themselves to hospital with a severely painful problem it is a great feeling as a doctor to get that pain under control. That being said it is important to identify patients with an addiction problem because that too represents a problem that needs appropriate treatment.
Here’s my preferred recipe for acute pain: Morphine 0.1mg/kg IV and Gravol 1mg/kg IV, then Morphine 0.05mg/kg IV every 5 minutes until the pain is controlled according to the patient.
Ah, I love walking by the stretcher of that guy who was screaming with a kidney stone 20 minutes ago who now gives me a groggy thumbs up.
What about addicts? Well sometimes I get fooled and I don’t get too bothered by that. I do however ask patients about drug abuse and I look for track marks. It’s surprising how many tell me they’re using 7 points of heroin a day when I ask them directly. Why do I ask about opiate addiction, in order to ostracize these patients? Not at all. If you come to the hospital requesting narcotics because you are in opiate withdrawal that is a big problem, and I have no interest in making your problems worse. What I will offer to you is a safe and comfortable medical detox from opiates and to put you in touch with an addictions care program.

LisaMarie
ER Doc: “Chronic pain is not an emergency. Don’t clog up the ER”
Chronic Illness Specialist: “It’s not a good idea to use narcotics because of the risk of addiction. They just mask the symptoms. We need to bring Chronic Disease under control.”
Never mind that despite multiple medications, procedures, major surgery and other interventions, we have not succeeded in bringing Chronic Illness under control since my early twenties (33 now). And if I go from specialist to specialist looking for someone who will treat my pain adequately, guess what I am? A seeker!!!
Sigh.
http://www.eleventhhourllc.com LauraNP
As a Psychiatric Nurse Practitioner in an ER, I find it interesting that you brought in your bottle and made sure the doctor counted how many pills you had left. That behavior by itself speaks volumes about you, as long as they really were the right pills in the right bottle. The bottom line, whether you are a user or not, I’m going to have to check everything on you before I order an opiate because if you already have methadone or other opiates in your system, the next one I order may kill you accidentally. So you are going to have to “man up” and handle the pain until I am absolutely sure I can hand you an opiate without death as an outcome. People want examples…the person on methadone maintenance at a community clinic who comes to the ER and does not mention he/she takes methadone. The person who already took 10 oxycodones at home without relief but said they only took two. And on and on it goes. I have empathy, but I also have to keep you alive. Until I have all the accurate information, you will have to wait…just like everybody else. P.S. addicts have real pain sometimes too, and addicts come in all shapes and sizes. There are no stereotypical “looks” to an addict.
Hugh Hill
The passionate response of “Dennis (Investigator/Negotiator) at Medical BillDog” and LisaMarie’s more modulated comments are spot on v-a-v the “system,” but misdirected as to EDs. Having a pain management specialist or other provider that we can contact is a way of assuring safety. Sometimes I call that provider and am told, “No. Do not give that patient more narcotics.” Usually, I can negotiate an early appointment for the patient with that provider. (Of course, this all fails when a doctor in the community is led out in handcuffs or just has his license revoked for prescribing narcotics inappropriately, which happens around here about once a year.) When there is no one to confirm the patient’s history of legitimate drug use, it really is harder to justify prescribing addicting drugs.
The 2 most obvious angles on this issue are individual and societal. Most importantly, I have to ask what is in my patient’s best interest. I have discussed this with many former and current addicts, and while pain is an idividual experience, many “clean” patients have said, “Do NOT give me narcotics,” even when suffering from obvious injury or other painful conditions. When I interview someone who was drug free for a time and then went back to it, I often ask why. One not uncommon answer I get back is that “some damn doctor prescribed them and that got me started again.” (Ouch!) It IS hard to tell who will be put at risk.
The other obvious facet is my/our societal responsibility. The interface between pure exclusive “golden rule” decision making and broader Benthamite considerations is often a rough patch on the ethical road for many dedicated healers. You might not care about the fact that the Percocet I prescribe sells on the street for $10/tab, but society wants me to, and I should, take that into account. You may not be the patient bouncing among providers, picking up narcotic scrips from multiple sources, but I worry about that possibility. When we set up a departmental policy on chronic pain, we have to consider those wider responsibilities. I can do a pretty good job of ignoring the threats of those who promise to wait for me in the parking lot because I won’t give them their favorite drug, but I don’t think I should ignore the influence of law enforcement, police and prosecutors, and their positions.
This is another reason for health reform and efforts to cover everyone. I have served as a hospice physician and know what a blessing pain relief can be, how some patients are enlivened and can function with good pain management. But as an ER doc, I have to and should be careful and reluctant to prescribe large amount of these drugs. Even as the last social safety net, ERs should not be managing chronic pain — including because and when the patient cannot get help elsewhere, anymore than we should be doing non-emergent major surgery because the patient can’t afford a needed operation. We hope and pray for universal access to quality and appropriate care.
http://www.medicalbilldog.com Dennis (Investigator/Negotiator) at Medical BillDog
Well, with any luck the Health Care Plan will set a lot of this to rights. I agree, patients with chronic pain need an established reginem, and that requires a single PCP, which you can’t get from the ED. The Health Care Plan is supposed to mandate insurance for a lot more people. I’d like to believe that that will decrease the number of chronic sufferers who have no PCP. Unfortunately, I know that I can’t trust that to happen. With no Public Health Option on the table, some will continue to go without care. Many (I have a close realative in this group) still won’t be able to afford insurance or a PCP.
So what about them, Hugh? Who takes care of them if not the EDs? They don’t have another option.
Russell B
Well, First I have been a chronic pain patient since 1977 when I broke my back in the Army and then re-injured it 6 months later because at that time the Army didn’t believe in a lot of rehabilitation time. They put me out of the service as unfit for active duty and gave me 10% disability. It took me 6 months to gain enough strength in my back to get a on the job training program in cable television. I couldn’t begin to tell you how many times I hurt my back up until the year 2000 when the fusion completed the fracturing process which completely disabled me.
I have been through all the so called conservative treatment options which mainly consist of steroid injections, epidural nerve blocks that the Veterans administration done without the help of an x-ray machine hitting nerves on at least 4 different occasions, they also did facet joint injections and God only knows what else they done to me. I’ll tell anyone those injections may help for a year 15% of the time, they will eventually get to they do not work at all but inflict more damage and cause more pain.
I said all that to say this. I have a pain specialist that treats me with high doses of opiates, notice I do not say narcotics because automatically people that know nothing on the subject think OH my God are you on those terrible things. I have a lot of so called doctors say a little pain never killed anyone, well I can tell you this, that statement has been proven wrong beyond a shadow of doubt. It stresses out your adrenal glands, causes hypertension, increased heart rates that some people in pain at a resting state their heart rate is 95+. So you ED, ER or what ever you want to call yourself doctors don’t tell me a person in chronic pain is not an emergency and they may seem like a drug seeker because they are being under treated by their pain specialist because of the damn DEA wanting to play doctor and set dosage levels that they know absolutely nothing about. This is called by the way pseudoaddiction, I was labeled a substance abuser at the Veterans hospital and that label by a first year pain doctor almost killed me. It followed me for several years until I found a young doctor that knew the proper blood work and other things to check to verify my liver was metabolizing the opiates at almost twice the rate of a so called normal person. We have been working together now for over 2 years and we still haven’t titrated my pain meds to a high enough level. There are times that I twist the wrong way or just get out of my truck the wrong way and it will send me into a pain flare that makes me go to my knee’s and cry like a baby. At these times I go to the ER and take my meds and my last 6 months of medical records so the doctor has all the information he should need to make a sound decision. I have had them tell me “Well you got medicine what do you want me to do?” Well to all you doctors out there, We pain patients get a 30 day supply of medicine if we take extra for a situation such as that we will run out early and then I don’t have to tell you what happens. On top of that if we do injure ourself chances are the meds we are taking for the baseline pain will not be strong enough to handle an extreme flare up that believe you me we wouldn’t do just to come and set in an ER for 2 to 3 hours to get a shot of morphine mixed with diazepam to ease the pain and stop the muscle spasms long enough so we could lay down and maybe get our pain back under control.
Sign Me- Been There Done That
godschild
thank you for all the comments.. The First situation Doctors & Nurses should have is unbearable pain , identification is the key.
Secondly too all you doctors who have issues and biases concerning whether a patient is in pain , this is for you, may Karma find you as you have allowed patients to suffer. When the Severe pain is upon you, remember the faces that layed in front of you in agony. for ever second of pain you endure it is actually the patients pain you denied..Remember this for you will never forget or be denied the pain you refused to treat or make better, if only for a few moments of relief you will live.

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