Headache - Morphine - No No

[gbrothers98]

Agree completely with Ventana- I see inappropriate prescribing more with physicians than midlevels, but I'm sure this is more of a selection bias.

 

Percocet and dilaudid are the bane of my existence. They are excellent pain relief medications....in the right setting. In the wrong hands and in the wrong situation they are truly evil.

What's a midlevel?

[KMD16]

^^ Yes. What's a mid-level?

[True Anomaly]

Oh cut me some slack- I slipped up :P

[KMD16]

Yeah. Meat-level. :)

[Acromion]

Based upon your post in another thread about a mistake you made and what you describe above, I think you have a poor practice environment to work in.

 

Providing narcotics to drug seekers is a violation of your DEA license. Ethically you are responsible for contributing to the social chaos in your community. If all the other providers in this ED are practicing this way, they are not practicing medicine. They are acting as predators on susceptible members of the community just like drug dealers do, there is just a more indirect payment process.

 

Eventually your state medical board and the DEA will catch on that your ED is an easy place to get controlled substances. The pendulum has swung the other way on opiates and these 2 entities will drop the hammer on overprescribing and unjustified prescribing. Just a matter of time. The local pharmacies and law enforcement already know, they just have to get someone to listen to them. Best not to get judged guilty by association. 

 

G Brothers PA-C

 

The community I work in is already plagued with drug addiction, in part due to a number of pill mills that had been operating in the region a few years back. There are a number of patients who routinely fake chest pain or abdominal / flank pain to get drugs. What do you do with these people? You can't dismiss their complaint just because they've cried wolf a dozen times. I've had more than one patient arrive via EMS after calling 911 for chronic back pain (complaint: "I ran out of vicoden"). 

 

I do my best to screen out the obvious drug seekers, but there have been many times when I've gone to the supervising doctor about a difficult drug seeker who will say something like "I want to see Dr. So-and-So because he always gives me dilauded for my headaches." I will then go to that doc and explain the situation and 9 times out of 10 they will just say "Oh give her the F-ing dilauded and get her the F out of here!" Some of these drug seekers cause huge temper tantrums when they don't get what they want. I've come to the conclusion that the docs, who are quite busy themselves, absolutely do not want to be bothered with these patients and it is my job as the PA to get them out quickly and with as little fuss as possible. 

[Guest Paula]

The community I work in is already plagued with drug addiction, in part due to a number of pill mills that had been operating in the region a few years back. There are a number of patients who routinely fake chest pain or abdominal / flank pain to get drugs. What do you do with these people? You can't dismiss their complaint just because they've cried wolf a dozen times. I've had more than one patient arrive via EMS after calling 911 for chronic back pain (complaint: "I ran out of vicoden"). 

 

I do my best to screen out the obvious drug seekers, but there have been many times when I've gone to the supervising doctor about a difficult drug seeker who will say something like "I want to see Dr. So-and-So because he always gives me dilauded for my headaches." I will then go to that doc and explain the situation and 9 times out of 10 they will just say "Oh give her the F-ing dilauded and get her the F out of here!" Some of these drug seekers cause huge temper tantrums when they don't get what they want. I've come to the conclusion that the docs, who are quite busy themselves, absolutely do not want to be bothered with these patients and it is my job as the PA to get them out quickly and with as little fuss as possible. 

 

You are not their slave and it is not your responsibility to fall in line with the ER Docs who have given up.  Do not be subservient.  Ask the drug seekers if you can get them into a detox facility for their chronic use of narcs and tell them that you are really concerned.  Then list a couple of facilities that you can call "right now" who you know can accept their care and will help them with the withdrawals.. Then given them the number of your local drug counselor. 

 

It worked for me when I worked in the ER.  I even had this discussion with a wife of a somewhat local sheriff (with him in the room) that I was concerned that she had developed an addiction/dependence to the morphine and oxy's she was on for chronic migraines.  I was not going to treat her migraine with another dose of a narcotic medication since she was slurring her words and had already taken the full day's dose of all her meds and was out of the oxy's for breakthrough pain. No, no dilaudid.  She was not happy.  She got the benadryl, IVF, decadron, tordadol and slept off the migraine.  I never saw her again but I imagine she showed up at her own local ER when I asked why they drove 30 miles to this ER when theirs was in their own town.  They didn't like that question, but I sure got the vibes that the sheriff was kinda glad I approached the subject from his silent nods.  He was stuck too in the revolving door of addiction. 

 

It's hard work to do the right thing.  I slip every now and then too with the prescribing but have gotten very picky of who gets what and for how long.  

[jmj11]

Get them to see a headache specialist to manage their headaches. We can't keep drug seekers or extremely refractory patients them out of the ER, but we can keep most compliant patients out of the ER.

[gbrothers98]

The community I work in is already plagued with drug addiction, in part due to a number of pill mills that had been operating in the region a few years back. There are a number of patients who routinely fake chest pain or abdominal / flank pain to get drugs. What do you do with these people? You can't dismiss their complaint just because they've cried wolf a dozen times. I've had more than one patient arrive via EMS after calling 911 for chronic back pain (complaint: "I ran out of vicoden"). 

 

I do my best to screen out the obvious drug seekers, but there have been many times when I've gone to the supervising doctor about a difficult drug seeker who will say something like "I want to see Dr. So-and-So because he always gives me dilauded for my headaches." I will then go to that doc and explain the situation and 9 times out of 10 they will just say "Oh give her the F-ing dilauded and get her the F out of here!" Some of these drug seekers cause huge temper tantrums when they don't get what they want. I've come to the conclusion that the docs, who are quite busy themselves, absolutely do not want to be bothered with these patients and it is my job as the PA to get them out quickly and with as little fuss as possible. 

Not trying to give you a hard time here but this is a very dysfunctional relationship that you describe with the docs you work with. Very easy for me to say this is suboptimal and can be damaging to your career not knowing what circumstances and conditions got you to this position.

But if you have the ability, take a look at your posts and what you describe to the forum. I think eventually you are going to question your position at this ED and your longevity there. 

I dont dismiss patient's complaints but when they come in with painful complaints, I provide them with a very thorough eval including imaging. If I cant readily identify an etiology that warrants opiate pain medication I dont give it.

I would also warn you that your interactions you describe with the attendings is a clear sign they are burnt out. Burnt out providers are poison to those that arent. These providers dont have insight into their negativity and the effect on others including family and coworkers. Again an effect on you that can be subtle but devastating.

I think you are in bad spot based upon these posts. From the docs that tried to submarine you to the patient population you describe to a lack of physician leadership in your department, I think your ED is getting profiled as a poor place to work. 

I hope I am wrong. Tell us something good about your shop to change my mind.

G Brothers PA-C

[Febrifuge]

Not to pile on, Acromion, but it's probably worth mentioning that a couple of different times now, I've thought to myself, "wow, that person has a crappy work environment." It's definitely coming through in your posts.

 

I had a lousy work experience when I was fresh out of school, and looking back, I wish I had run for the hills a lot sooner than the 5 months or so I was there. It's just about better to not work at all than to work someplace terrible.

[Iman]

Narcotic is off the chart !!!! but speaking of which ... I had a patient with chronic recurrent migraine H/A. Tried first NSAID without success then triptan same thing , then fioricet no relief, then per my SP advise I gave patient Midrin which she had a bad reaction to it. I ended up trying Topamax low dose, and given her a referral for neuro. I haven't heard from her yet ! what would you guys have done? She is 35 y/o without any other significant problems.