Tips for the ED Drug Seeker

Tonight I experienced a patient who reminded me there are limits to drug seeking behavior in the Emergency Department. Having been on the receiving end of this, I’d like to pass on some words of wisdom.

Basic rules: don’t put

  • “allergic to hydrocodone 5’s, but not the 7.5’s”
  • I’m just here for a pain shot
    • and I need “Demerol”
  • “yes, I have some hydrocodone, but need more”

on your triage list.

Advanced rules: don’t

  • start screaming for another doctor 30 seconds after being told ‘no pain shot’
  • ask the nurse “is taking 7 darvocet like one hydrocodone 7.5?”
  • ask for refills of Soma, Duragesic and Oxycodone at 2 AM, on a weekend, without being able to supply name doctors at hospitals that have previously treated you.
  • think “the only drug that works for me starts with a D…” isn’t going to make us less wary…
  • ask “is doctor ‘X’ on duty?” (knowing the names of the EM docs is never a good sign)
  • And, True, the clothes make the man, but they often give away the drug seeker

And the most basic rule: and ED nurse can smell BS at 20 paces, and can point out ‘not right’ in about 3 seconds. Never, ever, screw with an ED nurse.

Oh, and ticking off the ED doc isn’t good, either.


Comments

  1. Something we have in Kentucky now is “eKasper” (http://www.kyma.org/News/EnhancedKASPER.htm) which is a computerized access to patients’ prescription information (controlled substances).

    One of the ER docs here was showing me one day the listing on a patient he was seeing, which showed many, many prescriptions for narcotics, sometimes 90 tablets and only a few days apart, so this guy was obviously selling.

    If there is a downside, for some reason when this rapid access was instituted, it was decided this info could not be used to prosecute someone with (i.e., the ER doc could not call the police about this guy, but just tell him to get lost).

  2. ROTFL!!!
    Have to admit those are some doozies.
    Prior the VA removing Demerol from the formulary (a great move, BTW – still available for rigors, conscious sedation and pre-ampho admin, but not for ER/urgent care use), most of the patients that came in to my urgent care clinic asking for “Demerol” got “Toradol”- with the emphasis on the “ol” – they only fell for it once and if were return customers, got nothing other than to be shown the door.

    The VA now has direct linking between facilities and we can tell when patients are getting duplicate Rxs. Once had a guy with real pathology (s/p recent THR for AVN) who was getting large doses of MS Contin from another VA about 30 miles away. He came into my urgent care clinic seeking more MS Contin saying he was transferring his care. What he did not know is that, before even seeing him, I was able to determine that he had just rec’d 120 MS Contin pills less than a week before. I politely declined to give his meds, my collaborating MD counseled him and we flagged his chart so that class 2 narcs were not dispensed without reviewing other VA records.

  3. I wish I had that kind of information access. This could be yet another of the unintended consequences of an EMR.

  4. I have a sneaking suspicion that the ED nurses you work with really like you. ;-)

  5. Very amusing, dude!

    You can add listing allergies to tylenol, benadryl, and haldol.

  6. TheNewGuy says:

    Yeah… good advice.

    And be realistic about your demands… NEVER demand percocet 10’s for a not-even-visibly-swollen ankle sprain. I laughed in a guy’s face one night for doing exactly that… he wasn’t happy.

    Having a gentlemens’ agreement among the docs for no-unverified-refills (for scheduled narcotics) is also a big help… word gets around, and it only takes one candyman to bring in people shopping for party supplies. Simply from a self-preservation standpoint, it pays to be careful about prescribing the heavier stuff… the DEA has nailed several docs in my area over the last several years for questionable prescribing. Remember, they can afford more lawyers than you can.

    And frankly, you should be careful about large prescriptions of anything. We have no mechanism for follow-up for dosage adjustments, reactions, and other necessary surveilance. I do short-term refills, but long-term stuff they must get from their regular doc.

  7. And don’t sign in while still wearing the hospital bracelet from the ED that kicked you out 1 hour ago.

  8. The EMR comment is a good one… particularly when it comes to linking pharmacies together.

    The military did this a few years back for a group of hospitals in San Antonio… they stopped over a million dollars in prescription fraud the first year alone.

    A central database of all schedule 2 narcotic prescriptions would go a long way toward slowing down the doctor-shoppers. Kentucky’s system sounds like a winner…Good for them. They need to be checking that database during patient registration, and attaching a printout to every chart.

  9. Major LOLOL! Great post. Don’t slur your words and begin to snore during triage. That’s always a major sign. I remember being stunned at how fast I saw “Toradol” as an allergy in our repeat visitors as soon as it came out on the market. Sometimes I wonder if I have the word “Stupid” stamped on my forehead; do they really think I’m so dumb that I don’t see manipulation from a mile away?

  10. Have to also play a bit of devils advocate here and just mention that not all folks with who come into the ER with a long ‘current med list’ are not abusers. I find that as a disabled adult with a number of daily prescriptions I am often put through the wringer with ER nurses. I ALWAYS say I am not looking to get ANY more meds, just putting accurate data on my intake form but it’s amazing how terrible legitimate users of medication can be made to feel.
    I mean how many times do I have to shout “I’m just here for the gdamn xrays my PCP told me over the phone I should come here and have done?”

    Just wanted to give the flip side of the coin…….

  11. To add to the last comment: my preceptor told me the other day about a patient of his with documented spinal pathology who went to the ER for what his PCP considered a real emergency one night, and made the mistake of asking for a specific narcotic – because he was a graduate student in addiction medicine, and was trying to be careful what he took!

  12. But this probably illustrates what I think is a lost or fading courtesy. The concerned and helpful PCP can always call ahead and explain to the ED doc that his patient is coming, he is a long-term patient and doesn’t complain about trivial things…instead he didn’t bother to help his own patient.

  13. Thanks all, so far.

    Greg P, I get a lot of calls from PCP’s, and it’s nearly always “work them up and call whoever’s on call for the group’.

    There’s very little patient ownership these days.

  14. I completely agree.

    Last time my PCP told me to go to the ER for emergency xrays (I’m a spine patient also) I asked if someone from her office would be calling ahead. She said yes absolutely but no one ever did, so when I starting insisting this at the ER it only made me look like some crazy rather than a patient going on what my doctor had told me.

    Frustrating for the patient and for the ER staff.