Drug-seeking behavior is a challenge for any ED
RNs must identify these patients without putting patients in pain at risk
Carole Jakucs, MSN, RN, PHN
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Emergency room nurses are finding themselves on the
frontlines of the opioid crisis
, caring for patients who are experiencing pain from a trauma or medical condition, while also encountering patients with an opioid addiction who are drug seeking. It’s an ongoing dilemma in emergency rooms across the country.
Balancing the need to treat patients’ pain effectively while avoiding the prescribing of pain meds to individuals with addiction issues is a delicate dance performed countless times each day in EDs around the U.S., said Jeff Solheim, MSN RN, CEN, TCRN, CRFR, FAEN, FAAN, president of the Emergency Nurses Association in Des Plaines, Ill. “Nurses are now faced with balancing the delivery of appropriate medical care without further propagating the opioid epidemic.” Every year, there are millions of patients seeking relief in EDs around the country from pain caused by various mechanisms.

“In 2015, approximately 137 million people were seen in emergency departments in the U.S.,” Solheim said. “Upwards of 39 million of those ED visits resulted from injuries, with numerous others due to severe pain from an acute or chronic medical condition. One of the primary goals of emergency care is to safely and effectively alleviate pain — that often necessitates the use of opioid medications. The catastrophic rise in opioid abuse and misuse, coupled with the drastic increase in opioid-overdose related deaths, poses a new challenge to emergency providers.”
How to identify drug seekers
Some experts feel there are no specific, consistent signs that can help ED staff determine if a patient is truly in pain or feigning pain to fuel a drug addiction, while others think that some behaviors can be attributed to drug seeking.
Susanne J. Pavlovich-Danis, RN
Susanne J. Pavlovich-Danis, MSN, RN, ARNP-C, CDE, CCRN, currently a nurse practitioner at a private medical practice in Plantation, Fla., who also writes continuing medical education content for ED clinicians, said behaviors sometimes exhibited by drug seekers include:
Claiming allergies to non-narcotic pain relief medications, or to diagnostic test contrast medium to avoid tests
Showing up at off hours or on holidays when it is less likely their usual care provider can be reached for a discussion or confirmation of their history
Claims of extraordinarily rapid relief from injectable medications
Instructing staff where to place injections
Suggesting specific meds and dosages to the prescribing clinician
Presenting with specific complaints that are often subjective (back pain, headache)
Excessively talkative, friendly or helpful
Inconsistent behavior from the waiting room to the treatment area
It’s important for clinicians to know drug-seeking patients with addictions are not the only ones who may act this way. “Over time, patients with true chronic pain can elicit some of these same behaviors,” said Pavlovich-Danis. While there are no agreed upon signs of drug-seeking behavior, Karen L. Guzi, MSN, RN, ACNS-BC, BCEN, a board-certified adult clinical nurse specialist within Cleveland Clinic’s Emergency Services Institute in Cleveland, said patients who see multiple providers can raise suspicion that it’s possible they are doing just that. Solheim said, “It is incredibly difficult to identify individuals who might be seeking a secondary gain from presenting to the ED with a complaint of pain. That said, the primary goal of alleviating the patient’s pain still remains.”

There are some tactics that can help when evaluating patients according to Solheim:
Involve the entire team: Observations of patient behavior should be evaluated from the interdisciplinary team, noting any inconsistencies or suspicious actions.
Obtain a thorough history of present illnesses and ask clarifying questions, if needed.
Look for consistency throughout examination: Posture, point tenderness, percussion tenderness, passive and active range of motion, as well as active resistance, should tell the same story.
Adhere to the recommended prescribing guidelines.
“It’s important for clinicians to know drug-seeking patients with addictions are not the only ones who may act this way. Over time, patients with true chronic pain can elicit some of these same behaviors.”
— Susanne J. Pavlovich-Danis, RN
Changing practices to combat opioid addition
Guzi said it is essential to relieve pain for patients. “Looking at narcotic alternatives and medicating more judiciously is a trend that is occurring nationally,” she said. “We don’t know why some people become addicted and some don’t. Genomics is believed to play a role. Moving to non-narcotic medications whenever possible, providing comfort measures such as ice, warm blankets and repositioning, and using alternative therapies when appropriate such as music and pet therapy can help make patients more comfortable and less reliant on narcotics.” One key driver of the opioid epidemic is the treatment of chronic pain with long-acting opioids, said Solheim. “Rarely are these medications being prescribed from the ED. While emergency providers are not the primary cause of the opioid epidemic, they do play a role in combating it through the care they take in prescribing opioid analgesics.” Overall, very little has changed in the treatment of pain in EDs said Solheim; however, many guidelines and policies have been established to facilitate safe prescribing patterns. Some of the key themes of many of the new prescribing guidelines and policies according to Solheim include:
Determining the appropriateness of situations for prescribing opioids
Screening patients to identifying those who are at risk for developing, or who actively have, substance abuse disorders
Considering non-opioid analgesics and nonpharmacologic therapies (physical therapy, behavioral health interventions, meditation, biofeedback, etc.) for pain management 
Reviewing of state-based PDMPs to determine risk for diversion or misuse
Consider short-acting opioids for relief of acute pain
Refrain from providing prescriptions for lost, stolen or destroyed medications
Prescribe a minimal amount of opioid analgesics for serious acute pain for a period lasting no more than three days
Recommend prompt follow-up with primary care providers
Utilization of
pain contracts

Solheim said emergency room providers also are advised to consult with resources provided by national organizations like the American College of Emergency Physicians’ emergency prescribing guidelines, in addition to their respective state’s prescribing rules. 
Don't overlook patients who are truly in pain
Given the current climate and concerns about opioid addiction, Guzi said it is important not to label patients when they present with pain. “Whether a patient is experiencing pain from a chronic illness, acute pain from an injury, or the pain of withdrawal, patients are seeking relief from their pain. The pendulum appears to have swung a bit more the other way. We need to look at patients without bias. Our behavior should be the same for each patient.” Even if a patient has a history of addiction, if they get in an auto accident and suffer a broken bone or burns, they still will need pain relief, said Guzi. “Changing the terminology to ‘relief-seeking’ versus ‘drug-seeking’ can help reduce bias. And patients do need relief whether they have an addiction or not.” Some clinicians become reluctant to prescribe narcotics as “Some fear being scammed by drug seekers and are less likely to prescribe the strongest available pain relief options unless overwhelming objective evidence supporting severe pain exists,” said Pavlovich-Danis. “For example, some may not give opioids for back pain or migraines but will readily prescribe them for a fractured femur or third-degree burn.”
Using statewide data bases
prescription drug monitoring programs
are helpful resources for emergency care providers. These electronic databases track the controlled substance prescriptions within a state. Accessing a database enables a provider to view a patient’s history of controlled substance prescriptions written for them.

“Currently 49 states have PDMPs,” said Solheim. “Missouri is the only state without a PDMP. Sixteen states have laws requiring providers to consult PDMPs prior to prescribing opioid analgesics.” Guzi said Ohio’s system is called OARRS or
Ohio Automated Rx Reporting System
. Florida’s database is called
said, Pavlovich-Danis. While use of an online system is an integral tool when prescribing, “It’s only helpful with prescriptions legitimately prescribed to and filled by patients,” said Pavlovich-Danis. “As we know, folks who seek and use drugs may get them from a variety of sources including borrowed from friends/family, stolen, purchased from the street, and taken as illicit substances (heroin).” In addition to curtailing the prescribing of opioids, “many EDs are recognizing their role in screening for, and treatment of, substance use disorder,” Solheim said. “Too many Americans go without treatment, largely due to their disorders going undiagnosed. Screening tools such as CAGE, Audit-C and NIDA Drug Use Screening Tools, are being leveraged to identify-substance use issues and help emergency clinicians risk-stratify patients.”

Patients who truly need pain relief face undue stress - Visit these sites to learn more:
Emergency Nurses Association’s Opioid Practice Resources page
ENA Opioid Safety Pamphlet
American College of Emergency Physicians Opioid Patient Handouts
Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit

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Carole Jakucs, MSN, RN, PHN, is a freelance writer.