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Saturday, February 11, 2012

Seeking Drugs In the ER

In emergency rooms across the country, 
drug seekers regularly cause a terrible outcome: 
People in legitimate pain who need strong medication 
may be viewed as suspects involved in illegal drug activity
and denied certain treatments.

For good reason or not? 

How in the world can ER doctors distinguish those who have real pain from those who are lying or exaggerating to obtain opioids for psychological or recreational purposes? Recreational or psychologically motivated use of opioids, if allowed to occur with any degree of frequency, will result in physiologic dependence.

Research exists that shows in the emergency room screening process, 90% of the patients who abuse opioids deny it. (Rockett IRH, Putnam SL, Jia H, et al. "Assessing Substance Abuse Treatment Need: A Statewide Hospital Emergency Department Study." Ann Emerg Med 2003;41 6:802–13.) This is probably no great surprise to most. After all, these people use ERs for illegal purposes. But, the vast numbers of these so-called "drug seekers" have seriously affected views on proper pain relief and caused considerable damage to the health system.

Drug seeking is a growing problem especially since prescription drug addicts often seek and sometimes find their fixes in the ER. According to the Centers for Disease Control and Prevention, the number of ER visits that involved non-medical use of narcotic pain medications more than doubled in the United States between 2004 and 2008.

Screening for drug addiction or for drug abuse is particularly difficult at the ER. "This is a huge issue for emergency departments because, unlike the office setting, the ED treatment of pain is frequently indicated without the benefit of an established doctor-patient relationship and often in an environment of limited resources," says Dr. Jason Hoppe, assistant professor in the department of Emergency Medicine at the University of Colorado School of Medicine. (Mikaela Conley, "Drug Seeking in ER Doubles, Feeds Growing Addiction to Pain Pills," ABC News Medical Unit, October 28 2010)

Dr. Ziad Kazzi, an assistant professor of Emergency Medicine at Emory University, says, "It is hard for me to estimate its (drug seeking) frequency in my practice but I would like to say it is at least once per shift." Imagine irresponsible facilities "handing out" medication and prescriptions without strict screening procedures.

Drug abusers may insist on specific medications, claiming no other medications work, or they may claim to be allergic to all pain medications except their drug of choice. A preoccupation with opioids during the
visit also tends to be associated with abuse. (Robinson RC, Gatchel RJ, et al. "Screening for Problematic Prescription Opioid Use." Clin J Pain 2001;17 3:220–8.) Abusers engage in various scams, such as faking kidney stones, to obtain narcotics.

The abusers tend to be younger. One study reported that patients over age 65 were 10 times less likely to abuse drugs than those aged 18 to 44. (Rockett IRH, Putnam SL, Jia H, et al. "Assessing Substance Abuse Treatment Need: A Statewide Hospital Emergency Department Study." Ann Emerg Med 2003;416:802–13) In a study of drug-seeking patients that presented themselves to emergency rooms, the mean age was 34.3 years. These patients also averaged 12.6 visits per year, presenting to an average of 4.1 different hospitals, and used an average of 2.2 different aliases.

But, what about those ER patients who legitimately need relief for chronic pain? Problematic use and dose escalation have been attributed to undertreated or increasing pain; however, alcohol abuse has been found in up to 40.5% of chronic pain patients. (Katon W, et al. "Chronic Pain: Lifetime Psychiatric Diagnoses and Family History." Am J Psychol 1985; 142:1156–60.)

This, along with the known prevalence of drug abuse among non-pain patients, suggests that it is highly likely that a significant number of chronic pain patients abuse their medications, probably at a rate at least as high as the general population.

Pain Management in the ER?

Problems associated with frequent opioid use -- for either recreational abuse or for pain control -- make it imperative that physicians understand and appropriately manage patients who request psychoactive drugs.

Behaviors associated with addiction include an inability to restrict medications or take them on an agreed-upon schedule, taking multiple medications together, doctor shopping, isolation from friends and family, the use of nonprescribed psychoactive drugs in addition to prescribed medications, inability to recognize psychosocial and psychological aspects of chronic pain, noncompliance with recommended nonopioid treatments or evaluations, a preoccupation with opioids, and insistence on rapid-onset formulations and routes of their administration. This extensive list of potential negative behaviors must be a nightmare for a doctor practicing in the ER who has little, if any, long-term contact with patients.

And, of course, prescription opioids are currently the number one cause of poisoning deaths in the country, surpassing cocaine and heroin as causes of drug associated death.

An Example of Legitimate Drug Seeking?

You can easily understand the problem a person in pain may encounter at the emergency room. Here is an account by Melissa Velez-Avrach, who became a patient of an ER room in Florida. (

"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 find this account very interesting for many reasons: 

* Not the least is that the ER was in Florida, a state smothering under an epidemic of rx drug abuse. This fact alone is a huge "heads up" for the hospital. 

* In addition, Melissa delivered the bottle of opiates (11 of the original 15 oxycodone/APAP that were prescribed to her quite a long time ago) to the ER. Not quite typical behavior for an addict, I would guess. 

* Her commitment to tolerate pain and use alternative methods to relieve pain are other factors which would seem to prove she was not a drug seeker. Still, it seems strange she had taken two oxycodone meds that day and she was still seeking relief. Unfortunately, Melissa did not elaborate either on the additional treatment she was seeking or on the treatment she actually received at the ER.

* Should she even be using opioids for chronic pain? Many researchers do not recommend this because of the risk of physiological and psychological dependence.

Help For Screening ER Patients

Many ER doctors say they don't have time to debunk whether a patient is telling the truth, and most want to err on the side of compassionate care anyway. Others say it is past the point of their job description. So, in a high-impact, high-stress environment, what systems can be implemented to avoid feeding into this growing problem?
Dr. Abhi Mehrotra, assistant medical director at the University of North Carolina Department of Emergency Medicine, says, "I think a cooperative database that is more comprehensive across states would be helpful as long as it is updated regularly," Mehrotra also advocates  coordination on the federal level." Some hospitals have already put such databases into place. Many states presently have tracking databases.

Some sources of information have been established by medical institutions on regional levels. To keep track of patients' visits and medications, Baylor College of Medicine in Houston, Texas, has an Electronic Medical Records system in place that connects more than 20 clinics and two large hospitals in the Harris County Hospital District.

Of course, visits to healthcare providers outside any system would not be available for tracking purposes.And even if ERs do have access to the records, resistance and persistence from the patients can continue.

Having a pain management specialist or other provider available to the ER could also be a way of assuring safety.

And, of course, many doctors still value the doctor/patient relationship and the trust established between the patient and the physician. Dr. Angela Gardner, assistant professor in the department of Surgery at University of Texas Southwestern Medical Center, says, "It's a touchy issue to talk about people's pain because it can't be measured in a blood test." Such subjectivity comes with the issue of pain, itself. Suspicions aside, some doctors fear that reacting to their own skepticism (of the need for medication) could lead to deserting a patient who is in severe pain and who needs assistance.

I hate to see anyone in pain -- that includes sufferers of temporary pain, sufferers of chronic pain, and sufferers of pain caused by dependence or addiction. We must come to grips with the escalating misuse of emergency departments. A pain patient must be given proper treatment at the proper facility by those who manage all aspects of recovery. We must provide services to those who suffer while, at the same time, insure that these services help heal patients. Nothing can be left to chance and no patient should be denied medical treatment to ease pain.

Emergency rooms cannot treat the problems of drug seekers. These people need facilities that manage their recovery with the latest treatments and medications. The public must understand rehabilitation for addiction is tremendously demanding of doctors, staff, and patients. The truth is that "Hollywood" visions of recovery are media-coated and often fictionalized. To become permanently clean requires near super-human dedication and work. And, depending upon the extent of the addiction, rehabilitation must be given for an extended time or for multiple revisits.

I respect those who conquer their demons so much. If only more facilities would be available to  help those with the disease. As far as all pain sufferers are concerned, I want all of them to be treated with dignity, extreme care, a constant view of recovery, and management that prevents dependency. To do any less is to put them at risk for greater suffering.

"The two enemies of human happiness 
are pain and boredom."
                     - Arthur Schopenhauer, Philosopher

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