Drug Seeking Behavior in ER Doubles, Feeds Growing Addiction to Pain Pills

VIDEO: Vanderbilts Dr. Peter Martin: Addicts put ER docs in a tricky situation.
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Sherry Ragan tracked down her brother in a local Utah Emergency Room. He wasn't hurt or sick; he had run out of Adderall and needed a new prescription to feed his addiction to the drug.

Ragan told the nurse and the doctor about her brother's drug-seeking behavior, and that he and his doctor had been trying to wean him off the drug. But the doctor said he'd give him a little bit of Adderall despite her concerns. Ragan said she's not sure whether the doctor didn't have the time, didn't want to be bothered, or he was simply not well-versed in substance abuse. At any rate, she was upset by the outcome.

"If my brother can do this, that means everyone coming here can get whatever they want," said Ragan, a Utah County Drug Prosecutor. "I work with people who work their whole lives trying to help addicts, and to find out that we're being undercut was really shocking."

Janet Frank, spokesperson for Intermountain Healthcare, which includes American Fork Hospital under its umbrella, said, "We don't have permission to talk about that instance due to federal privacy laws, but we are acutely aware of the prescription drug problem in our community as well as across the nation, and all of our staff in all of our staff are committed to being a part of the solution."

Although Adderall is not a pain medication, which is the more common sought-after type of drugs in emergency rooms, the story brings to light a growing problem of prescription drug addicts who find their fix 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.

"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," said Dr. Jason Hoppe, assistant professor in the department of Emergency Medicine at the University of Colorado School of Medicine.

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

"This problem has increased tremendously over the past years," said Dr. Ziad Kazzi, an assistant professor of Emergency Medicine at Emory University. "It is hard for me to estimate its frequency in my practice but I would like to say it is at least once per shift."

A Well-Known Problem Discussed Everywhere

The issue of drug-seeking ER patients is a well-known problem. The topic has been featured in popular medical dramas, discussed on blogs, written about in editorials, and even vented through Craigslist posts.

One anonymous Craigslist post, written by a supposed doctor who was frustrated by drug seekers in his ER, wrote the 2007 post entitled, "Advice from an ER Doctor to Drug Seekers." The satirical writing gives doctor's advice for people seeking pain medication without the needed pain.

For his third rule, he writes: "Never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I've seen people in 10/10 pain and you sitting there playing Tetris on your cell phone are not 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8."

On the other side of the coin, a person can easily access the Internet to find suggestions on how to get their hands on pain pills at the ER.

Opiophile.org is a website that offers discussion forums for people who use opiates, and for those who are researching or have questions regarding opiates. In 2007, a member under the name, limitless_euphoria, posted suggestions on how to convince ER doctors of pain:

"I think it's ONLY when I started making it known that I've had a whole history of problems for a while and this and that—right there I'm setting off the "drug seeker" alarm. If I play like I'm just a first timer dumb-dumb (which is easy to do at a location I haven't burned) perhaps I'll fair better… LE should at least walk away with 10-15 percs or maybe 10-20 vics. If God is really smiling down upon me maybe even a morphine or a dilly shot (doubtful nowadays: the only thing they gave me dilly for was the appendix—and I still can't get that sh** out of my mind)."

A System to Control the Growing Problem

Many ER doctors say they don't have time to debunk whether a patient is telling the truth, and most want 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?

"I think a cooperative database that is more comprehensive across states would be helpful as long as it is updated regularly," said Dr. Abhi Mehrotra, assistant medical director at the University of North Carolina Department of Emergency Medicine. "We need coordination on the federal level."

And some hospitals have already put such databases into place. In fact, 38 states have prescription drug monitoring programs. Many more are due to come into play soon.

At Baylor College of Medicine in Houston, Texas, an Electronic Medical Records system is in place that connects more than 20 clinics and two large hospitals in the Harris County Hospital District. Dr. Bobby Kapur, associate chief of Academic Affairs at Baylor College of Medicine, said that physicians are able to keep track of patients' visits and medications in the region.

But the system, like many others that have been set up in large, prestigious hospitals in the United States, has limitations since it does not span across regional or state lines.

"If the patient had visited an [emergency department] in a hospital outside of our system, then we would not have access to that particular patient visit," said Kapur.

And even if they do have access to the records, resistance and persistence from the patients can continue. Dr. Jeffrey Guy, an associate professor of Surgery at Vanderbilt University, said that when drug seeking patients show up in the burn clinic, he usually prints out a state database record with the patients' medication history, and then asks if they are getting medication from other providers.

"They universally deny other sources, and then I will present them with the information in our database," said Guy. "The usual response is that the claim in the database in wrong."

While the database is helpful in looking at a patient's history, many doctors still value that doctor/patient relationship. "I prefer to believe my patients and I prefer to act as a physician based on the relationship of trust," said Dr. Angela Gardner, assistant professor in the department of Surgery at University of Texas Southwestern Medical Center. "It's a touchy issue to talk about people's pain because it can't be measured in a blood test."

But Most Pain is Real

But the majority of patients seen in emergency rooms are in pain. They need medication. Suspicions aside, some doctors fear that reacting to their skepticism could lead to deserting a patient who is in severe pain and needs assistance.

Dr. Todd Knoxtarget ="external", director of the Pain and Emergency Medicine Institute, said that pain is the most common reason patient come to the emergency department and chronic pain is seen in 40 percent of these patients. Pain is far more common a problem than substance abuse in the emergency department, he said.

"I feel our potential contribution to the problem of drug diversion and misuse is small, but our opportunity to identify and treat patients with prescription drug abuse problems is much larger," said Knox.

"ER physicians are in a difficult position," said Mehrotra. "This is a larger issue, a societal issue, which we need to address. We have the tip of the iceberg here."

Dr. Paul Ragan, associate professor of psychiatry at Vanderbilt Medical Center, agrees strongly that substance abuse begins outside the hospital and within the communities that which we live.

"I have said for a long time, the emergency rooms of America see the problems that society at large does not want to address," said Ragan.

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