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Monday, March 7, 2011

Riding the Old BS Train to Narcotic Town


In case you didn't know, I am a medical doctor, specifically an ER doctor. I have been a doctor for 31 years and full time ER for 15 so I have seen a good bit of water flow under the bridge. It seems like every shift I work I see one or two people, sometimes more who are trying their best to obtain narcotics or some other controlled substance. Most of the time this is never a simple encounter, rather the person has wrapped themselves in some kind of a convoluted story with a heaping helping of vagary and out and out bullsh*t.

I fondly refer to this exercise as, "riding the old bullsh*t train to narcotic town with stops at Hydrocodoneville, Percocet Place, Morphine City, and Fentanyl Flats." ALL ABOARD!

There are warning signs that the ER staff is about to take a train ride and if you don't mind, I'd like to share a few of them with you.

1. The person is from out of town. They have a doctor in another town (and frequently can't remember his/her name). They are visiting a friend in a third town when they suddenly started having this excruciating pain and somehow they end up in my town in MY ER. IMMEDIATE RED FLAG!

2. Many times they have a large envelope with them containing xrays, hospital records, clinic notes, and other stacks of dead trees. The documents are usually from a VARIETY of other health care facilities. IMMEDIATE RED FLAG!

3. They claim to be "allergic" to everything except the particular drug they are seeking as well as a variety of non-narcotic analgesics. IMMEDIATE RED FLAG!

4. They frequently present with illnesses that are hard to objectively diagnose. A couple of favorites are headaches and back pain. Now many people present with legitimate causes of headache and back pain and some of those can in fact be life threatening. Herein lies the problem. Sometimes the bullsh*t train ride can be long and expensive as we run many, sometimes costly tests in an attempt to separate the sheep from the goats as well as protect ourselves from lawyers.

A less used complaint is kidney stones. Blood in the urine is a frequent finding but this can easily be faked by placing a drop of blood in an otherwise clean urine sample. I am not opposed to obtaining a specimen with a catheter on a person of whom I am highly suspicious. It can be most amusing to obtain a clean "cath" urine sample from a person who minutes before gave you a grossly bloody one. It is fun to watch as the old bullsh*t train suddenly derails and plunges into the gorge below. Also with the advent of a thing called "renal stone protocol CT scanning" it is pretty hard these days to fake a kidney stone. So the once old reliable kidney stone complaint is a lot less useful than it once was for the average drug seeker.

Here are a few of the convoluted complaints I have heard over the years from people trying to score their favorite drug. All these will immediately raise a red flag:

5. "I ran out of my pain medicine. I called my family doctor and was told to rush to the ER." I cannot speak for everybody but when I was a "family doctor" I never told anyone to rush to the ER if they ran out of their pain medicine. If they truly needed a refill I would refill it. If they were abusing their prescription and running out "early" I would refuse, but rushing to the ER was not an option. I don't doubt that there are some of my colleagues out there who really do tell people to rush to the ER for their narcotic needs (mainly because they don't want to fool with them), but that is a topic for another post.

6. It is the weekend. "I just ran out of my morphine". I explain that a reasonable person would look in the bottle ahead of time, realize the supply is getting low, and contact the personal physician for a refill. Strange that nobody ever seems to run out of blood pressure medicine, or stomach medicine or insulin on the weekend.

7. "I missed my appointment at the pain clinic." I always love to hear this one because most reputable pain clinics assume full responsibility for a person's pain control needs. Many patients have to sign a contract with the pain clinic which prohibits them from obtaining narcotics from other sources. I explain to these people that it is their pain clinic's responsibility to manage their pain meds and it is THEIR responsibility to follow the pain clinic's directions. If they "missed" and appointment, they should have rescheduled an appointment.

8. "I accidentally flushed my hydrocodone down the toilet." Hmmmm, how do you "accidentally" flush anything down the toilet? And in all my years of doctoring, I don't ever remember someone's blood pressure medicine or asthma medicine getting flushed. It's always some kind of controlled substance that goes down the bowl.

9. "My oxycodone was stolen." Again, it seems the only thing ever stolen are controlled substances, never BP drugs or antibiotics. I always tell these people that we need to CALL THE POLICE and have them come up and take a report. Many times these people want nothing to do with the cops and will leave. In any case I will explain to the person that I am very sorry but it is THEIR responsibility to secure their medication and if they need more they will have to see their family doctor.

10. "I ran over my bottle of Vicodin!" Yes, indeed! I actually had someone tell me this and the person brought me a crushed, empty, unidentifiable medicine bottle. I did not even board the bullsh*t train that day.

11. "I am here on vacation from Georgia and I went off and left my medicine." This actually happened last year. I listened to this guy ramble on and on, in fact I could not for the longest figure out why he was in my ER. After about 15 or 20 minutes of this incoherent rambling and riding the bullsh*t train, it finally became clear that he was wanting morphine.

I performed an examination, checked his vital signs once again and advised him that the best thing for him to do was to "head back to Georgia."

He was taken aback and said, "You're kidding!"

Not missing a beat nor cracking a smile I said, "No, I'm not."

One of the most egregious things that I have seem while riding the train is an activity I call "drug seeking by proxy". I have on occasion had a drug seeker bring a relative or even worse a child to the ER with a concocted complaint in an attempt to get narcotics for themselves. This is usually pretty easy to detect since the proxy is never as adept at lying and steering the BS train as the actual drug seeker.

The State of Tennessee Board of Pharmacy has been helpful. They have created an online website where the dispensing of controlled substances in Tennessee is continuously monitored. I can look at anyone's pharmacy records and get a complete listing of any narcotics they have received. Anytime one of my red flags goes off, I will go to the computer and inquire about this person. It is amazing to watch the color go out of their face when I present to them multiple pages of narcotic prescriptions they have received from different doctors and different institutions.

I would like to say that these incidents are few and far between, but sadly they are not. For every shift I work I usually have one or two people who appear trying to scam a narcotic prescription out of me. I have been cursed and even threatened for refusing to board the old bullsh*t train with them, but hey, I'm a big boy. The nurses frequently take more abuse than the doctors unfortunately with the drug seeker unleashing rage on the person they perceive as less powerful. I have explained to a few of them that doctor shopping is a crime and attempting to deceive a health professional into prescribing controlled substances is also a crime and that I would be more than happy to have the friendly policeman come up where we can discuss the situation. This usually results in miraculous cures. I have seen many come in limping and in wheelchairs only to almost run out the door.

Some of these people manage to obtain so many drugs that it is blatantly obvious they are selling them. Vicodin and Percocet I understand will bring top dollar on the street. Frankly, if these people spent as much time actually working as they do scamming the system, they could end up doing great things.

In Tennessee this problem has been exacerbated by Tenncare. When Tenncare first started, people moved in in droves to get "insurance". Many of these were narcotic seekers and before long the whole thing snowballed. Last time I checked, Tennessee was number one in the nation for hydrocodone prescriptions. Now you know why.

40 comments:

  1. Times haven't changed a bit, I remember the same thing years and years ago in the ER.

    Debbie
    Right Truth
    http://www.righttruth.typepad.com

    ReplyDelete
  2. It's good to see that someone has the balls to tell these turds where to go!! Randy

    ReplyDelete
  3. I have no problem sending turds away. These people take up time and resources needed by really sick people.

    ReplyDelete
  4. For this I put my wife through medical school. Sure wish I could go back in time 15 years...

    ReplyDelete
  5. Oh, it's not all that bad, Scott, but it does wear thin day after day, people seeking drugs with the same old worn out stories. I guess what really perturbs me more than anything is that these people think I'm stupid and gullible enough to believe all that nonsense.

    ReplyDelete
    Replies
    1. Answer this please. I'm a 36 yr old female and fir the past 3 yrs I've been dealing with kidney stones. Usually about one a week. I've also been diagnosed with Bilateral msk. I've been hopialized several times for large stones and infections. I've had several surgical intervention, lithotrypsy,and stents. I'm on my 2cd urologist. When I'm passing a stone I call my urologist 9 outta 10 times he sends me to ER. I always go to same ER but they treat me like a drug seeker they make me feel so awful. Honestly if I was a seeker id much rather buy them off the streets then go through a er visit. I feel that if a doctor is that jaded its time for a new profession. My hands are tied. I have pain.medication (percocets) but if u gave ever passed a stone you know a percocet is a joke. I use to take toradol but my kidney doctor took me off due to high creatine numbers. What do I do?

      Delete
    2. I am in the same boat you are in except I am actually allergic to toradol, but like you I go to the same er and they to treat me like a drug seeker and you feel terrible. My primary care sends me to the er and the er sends me away. What are we to do doc. When we have actual issues and because doctors are so afraid to help because of the drug seekers that people like us are being screwed. I don't blame you or any of the doctors because I know it's the jersey who are the seekers that are the actual problem. Can you give us an idea of what to do instead of just telling people what to look for?

      Delete
    3. You won't get an answer... Most likely you'll need to be irradiated with 700 mGy to be vindicated. 15% of stone patients don't even have hematuria. I just came back from ER myself For 2k I should be treated appropriately... I did get tramadol, but I'm a little unsure about SNRIs, especially if I'm on a 30 day loop for rhythm issues (norepinephrine). Thankfully I'm not a seeker and I have leftovers from previous surgeries. I'm intolerant of NSAIDs too- I had to have a scope to prove the ulcers.

      I honestly hate seekers because they make it difficult for everyone else. I just want to get decent and compassionate care.

      Delete
  6. Welcome to the blog world. 1st time reader, today.

    The movie "Requiem for a Dream" comes to mind. [ http://www.imdb.com/title/tt0180093/ ]. While I have not worked up the nerve to buy and watch it, it speaks directly to your ERP experience. I have always wondered why people do this kinda of thing. I have been wondering for 30 plus years. No I'm not a Doctor. Not even close.

    I guess we all says to ourselves that I won't do that. It can't happen to me. Some people learn by reading about others, some learn by seeing others, and some only, put you hand in the fire.

    "Riding the Old BS Train to Narcotic Town"

    This is the title that caught my attention. just like the movie title. It got me and I remember it.

    Anyway I enjoyed the blog.

    ReplyDelete
  7. I have had allergic reactions to hydrocodone and to some morphine drug [prescribed for when I had foot surgery two months ago]. I need foot surgery again next month and am going to ask for a Fentanyl patch. Please let's hope I'm not allergic to it. Aleve doesn't quite cut it for the pain of having one of your toes sawed in half... Abuser of pain killers? I think not. Who wants to live in a drug induced haze all the time?! I just don't get it, and it is the abusers who make it so difficult for those of us who truly needs something for legitimate ailments close to impossible to get.

    ReplyDelete
  8. Sabra, Good luck with your foot surgery. The Fentanyl patch may be just the thing you need. Since Fentanyl is purely synthetic it does not have the same allergy profile as morphine. The patches are very effective providing a constant dose to keep the pain away. They don't seem to mess up your mind either like so many other forms.

    ReplyDelete
  9. I do understand where you are coming from & everyone has a right to vent but it is so unfair to be labeled as a drug seeker. I've never gone to the hospital purely seeking drugs, I go because I need relief. I'm 22 years old, have had crohn's disease for 7 years, 3 bowel resections because of it but I also have kidney stones, ovarian cysts & complex migraines all of which run in my family except the crohn's. I don't think it is fair that I should have to go beyond anyone else to prove that I am really ill because of people who have completely taken advantage of the system. I have no appendix nor do I have a gall bladder anymore & guess what?? I'm still sick. But on top of that because of all the pain meds I have been on due to hospital stays my tolerance has just gone up & up. I think if I were to get my leg cut off by a chainsaw dialadid wouldn't even be able to help me. I know it doesn't help that my husband is military & we move a lot but I refuse to see military doctors but sometimes it would be nice to not be looked at like all you want is your fix. When we lived in Hawaii & I would have issues not even necessarily crohn's related issues but the moment I mentioned I had crohn's, you know what the doctor's did?? They gave me pain meds & nausea meds to treat my crohns even if I was there for a darn ovarian cyst. I try not to mention my crohn's anymore because they immediately seem to stop trying to figure out whats wrong & just assume it's the crohn's. Sorry for the rant & I have met a dr like you who absolutely refused to give some guy pain meds, he had a cast on his leg but looked incredibly dirty but the biggest thing was he wouldn't let anyone touch his backpack & he was slurring his words so bad it was insane. Those type of people make it harder for the rest of us to just survive.

    ReplyDelete
    Replies
    1. MysChic14, I cannot assess your situation since I don't know you. I find it interesting that you "refuse to see military doctors". You did not elaborate on the reason. I used to be a military doctor many moons ago. Military doctors are just like doctors everywhere. Some are very good. Some are not so good. Some are very likeable, while others not so much. So I have to wonder, where do you seek care?

      Do you go to a private civilian physician or do you simply go to the ER? If you simply go to the ER you are already doing yourself a disservice. Anytime you end up seeing multiple physicians, the all important continuity of care is interrupted.

      Many ER doctors such as myself view the primary goal of the ER as determining if an emergency medical condition exists and if so provide stabilizing treatment for that emergency medical condition. In fact that is what the law requires we do, nothing more, nothing less. Therefore people who routinely appear at the ER door with long standing chronic medical problems (real or fabricated) automatically raise red flags in the minds of many. The first thing I think is why is this person not under the care of a personal physician?

      Another choice is a pain management clinic which is targeted at relieving patients dealing with chronic pain. They also address issues of narcotic tolerance.

      Whatever your situation, it is up to you to choose to find an appropriate avenue of care. This might mean seeing a military doctor. When I was a general medical officer, I had "dependent clinic" every day and I developed a rather large clientele of patients. I would encourage them to try and see me and me alone for their problems and not rush to the ER. I knew them and they knew me. If they needed specialty care, I arranged it for them. I kept in touch with the specialist and I knew what was happening all the time. This is the way it should be.

      Patients move and military doctors move on to other duty stations. Nothing in life remains static so sometimes patients have to locate a new physician. It happens. That's just the way it is.

      So my best advice is find a PERSONAL physician, civilian or otherwise, and stick with him/her as long as possible.

      Delete
  10. Great blog, Grouch. I am an ER doctor in the southwest. I was so annoyed when I worked this past 4th of July, I have been "Googling " drug-seeking topics on my days off this week. My first patient on my 4th of July shift was the typical drug-seeker clone you describe. From out-of-town, severe dental pain, the typical allergies, came in on a holiday, etc., looking for oxycodone.
    None of our group carries ( purposefully ) a Class II prescription pad.
    When I generously offered to write him a few Vicodin to last him a day or two, his true colors emerged. " If I wanted f##king Vicodin, I would have asked for f##king Vicodin.!!" He then stormed out of the ED shouting profanities at me when I told him I remembered him from one of our other facilities.
    This in a huge problem in our area and only getting worse.

    ReplyDelete
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  12. I have to admit, I do enjoy narcotic analgesics from time to time. I'm out of work right now, and the VA is putting me through Paralegal school, so, maybe there's hope for me. I actually do have issues with pain, I was an LPN and worked mostly in nursing homes for about 15 years, then did a 14 year stint as a Special Ed. paraprofessional. Both occupations wreaked havoc on my back, and I also have multiple joint arthritis. I'm a fairly young, old bird at 58. I'll be honest, the Ibuprofen and Naprosyn take the edge off, but Im still uncomfortable, ya know? I'm not trying to ruin anyone's day when I come into the ER or DRs office, I just want something to make life a little easier, enjoyable even. How would you respond to a completely honest patient who approached you with the words somewhere along the lines of: "Look, I know neither one of us has a LOT of time to waste, so lets cut to the chase. I'm here for a controlled substance because my back aches and my knees hurt. Can ya help me, or no? I'll understand whatever your reply may be, Dr."

    ReplyDelete
    Replies
    1. EZ reply, Lola. I'd simply advise you that there is just no doctor like your FRIENDLY family doctor. Make an appointment.

      Delete
    2. Lol thanks. But what if I used the SAME line while standing on one hand and juggling 5 dinner plates with my feet? Im just not a regular Dr, person, but I guess I'll have to go that route.....love your blog, by the way. You rock, and your wife is gorgeous.

      Delete
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  14. interesting post Grouch. I have been in pure agony for months. I have been admitted 4 times in two months for severe chrons disease flare. I am on Humira, prednisone, flaglye, probiotics, etc. nothing is working at keeping this at bay. At first I would refuse any pain meds, but then my nurses yelled at me to quite being a tough guy. Now, the pain is so bad I gave in and take them. Whats sucks though, is I get severe break through pain, and then when I start getting dehydrated and running a fever, I end up in the ER. I have been in the ER so much from this BS disease, that some of the staff treats me like im a drug seeker! Its as if they don;t take the time to even look at my chart...even when I was just admitted there! They start pep talking me about narcotics...Im like dude...im running a fever and have a clear document case of chrons disease. Yes im in alot of pain, but thats not primary reason for my visit.....

    This disease is VERY painful, and yet I now am hesitant to go to the ER because I get treated like a junkie rather then a legitimate patient with a painful chronic disease. Its very frustrating. Any advice?

    ReplyDelete
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  18. This comment has been removed by the author.

    ReplyDelete
  19. sounds like all you do is seek our drug seekers. must feel good to be you!

    ReplyDelete
  20. with docs like you "DR Grouch" is no wonder why people buy them off the street. one because it is cheaper than er visits and the whole bs song and dance just to be taken seriously. my brother in law died because of this. he had been hurt at a young age in mva. he could not afford to pay high co pays and MAYBE get pain meds so he took it upon himself (not wise i know) and would buy them on the street. by doing this and mixing them he had a fatal seizure and died at 38 years old. i never saw him high or drug up. he was a wonderful person who due to his age was never taken seriously. thanks dr grouch i am sure stories like these really make you feel great. let me ask you a question do you get some sort of medal or gold star when you send that er pt that is in pain home?

    ReplyDelete
    Replies
    1. And of course " DR Grouch " does not respond to ur post! Well put Robin, seems like that's only what he gets off doing.

      Delete
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  22. WOW! Really, Hmmm I cant really grasp this information. Simply because I think its arrogance. Hundreds to the thousands of people live with Chronic pain everyday that dont have health insurance ( because they cant afford it) and Not everyone has a Primary care physican simply because it is hard to find the right one that you as the patient feels comfortable with( not because you want a doctor that easily prescribes narcotics). I have had so many bad experiences with doctors that it makes me weary of going and seeing one. I think the problem with most doctors is that 1. its a power trip they hold the pad and pen and they decide what they prescribe. 2. Doctor shopping is not an indicator for drug seeking I look at it as shopping you go to different stores til you find the item you are looking, for example, you may want a certain type of brand of something and walmart may not carry that brand but kroger may or publix what have it. Same difference when trying to find a doctor. 3. I also think that if doctors actually put themselves in the shoes of their patients and really understood their situation and I dont mean the situation of I got a paper cut so gimme narcs I mean their history. For example, I have severe scar tissue damage from having multiple surgries to fix some problems i had as a child. Scar tissue damage is painful and never heals, I have 3 herniated disc in my back often times i cant even get out of bed but doctors dont see that they hear the story and go straight to the pharmacy page and pull up drugs they have gotten automatically Ooops druggie. IF i as a doctor id go full force, hmmmm car accident at 25 received head injury....due to this experiences severe headaches yea here's a script ill monitor it in a week. 4. Doctors do the math if you give a script for vicodin and its 20 and it says on the bottle take 1 tablet every four to six hours as needed for pain. Guess what you are looking at anywhere from a 6 to 7 day supply if i give a script for 20 and its suppose to last 7 days and on the 10th day that person is still having the same pain and same symptoms and i see them back in the ER heres another one, because its not abusing drugs. DO THE MATH

    ReplyDelete
    Replies
    1. Oh i also forgot to mention that due to those medical problems I have I also have a job where I have to use labor tactics to do and performing this job 5 days out of the week sometimes 6 40 hours or more lifting tugging and pulling on people who cant move yea id say thats the bullshit side of the track I deal with pain everyday yet i still do what i need to do Your a doctor. I'm not saying give in to the bullshit but learn to decipher between the chronic pain people and those that are trying to tweek the system.

      Delete
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  25. These physicians present to their ERs with RED FLAGS of pure ego. 'I'm a Doctor -- how dare you try to fool me!' Right or wrong, if that is the perception, the patient's punishment is untreated pain. As a physician myself -- I am baffled by this cohort of 'Doctors.' Why? There is no quantitative measure for pain. ERs prescribe rarely more than 12-15 low-level narcotics home with a patient. Sure -- big sale on the street! Sure -- great high for the abuser. If not within medical establishments, it will be on the streets. The war on drugs is unwinnable by economic fact: where there is a market, there is a supply. Unless it is clear by study or tracks a yard long -- try empathy.

    ReplyDelete
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  30. there is this great spell caster in the states i just met through a friends description, and he have just helped me to get back my husband who left me for 2 years, I am so glad that i met with this spell caster, he is just in the US to help people and i am among those he have helped and i am telling you to also go and get hold of your own solution as he shall soon be living the the States, he said he was in the STATES to help his client. So i met with him and told him about how my husband left me.
    I visited his email address, after a friend talked about how she got help from him. After contacting him, then I found out he is currently in the US.
    It is even because his spell is so strong that is why someone invited him over, And through this medium he has brought home my husband with this spell powers. I contacted him, not up to 2 days, he told me that after 24 hours my husband would return back to me, and that day I was at work when my husband (Collins Mark toddle) called and said he is in the house,and i was so surprise when i really saw him and he just ask me to forgive him so that was how Dr aluda helped me to get my husband back to me so his email address is aludaspelltemple@gmail.com or call and whatsapp him on +2348063930531 if you still want him to help you solve your problems for you
    I am Benson Toddle.

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