A 55-year-old male calls an ambulance complaining of severe low back pain. He says he tried to transport himself to the hospital, but his pain is so severe he cannot stand, let alone drive. The patient reports the back pain is from a car accident several years ago. You examine him and find no visible evidence of injury; CSM is intact. The patient has no other medical problems, but he is allergic to ibuprofen and Toradol. He rates his pain a 10, sharp and constant, and is unable to find a position of comfort. He has already tried ice, heat packs, stretching. He says, "What I really need is some morphine. Can you give me something for the pain?"
Pain is the most common patient complaint, and patients' desire for pain relief often supercedes their desire to identify and resolve the cause of pain. Drug-seeking most commonly involves pain medications. Hydrocodone, a Schedule Two analgesic that is widely prescribed for the treatment of pain, is the most widely abused prescription medication in the United States. ED visits for hydrocodone abuse have increased 500% since 1990.1
Research shows that pain is undertreated in all healthcare settings, including prehospital care. Patients are the best judge of their own pain. Pain control, not the cause of the pain, is their primary concern. The pain management paradox is the caregiver's desire to relieve pain and comfort the patient weighed against the fear of being fooled by a drug-seeker, creating addiction or being investigated for improper use of pain medications.1 The opening case study included many assessment clues that may have caused you to question the patient's motives.
According to the DEA, diversion of prescription drugs is a significant drug enforcement problem. It includes physicians who sell prescriptions to drug dealers or abusers; pharmacists who falsify records and subsequently sell the drugs; employees who steal from inventory; prescription forgers; and individuals who commit armed robbery of pharmacies and drug distributors.2
In the prehospital setting, it is difficult to determine if the patient is tolerant, dependent or addicted to a controlled prescription medication. Being aware of the differences can help resolve the pain paradox.3
As an emergency responder, you are well aware of the pervasive abuse of drugs and alcohol. Many EMS calls are caused by drug, alcohol or tobacco use. Impaired drivers cause motor vehicle accidents, intoxicated spouses injure family members, and a host of medical problems are secondary to drug, alcohol and tobacco abuse. The most commonly abused prescription drugs are opioid analgesics, sedative-hypnotics and stimulants.1 Fortunately, most patients who use these medications use them as directed by their prescribing physician.1
The Controlled Substances Act of 1970 is federal legislation that strictly controls drugs based on their potential for abuse. Schedule One drugs have the highest potential for abuse.4
Other commonly abused prescription medications include benzodiazepines like Valium, stimulants, barbiturates and other sedative-hypnotic agents. Only ALS-level providers carry and administer a limited number of controlled prescription medications.1
Controlled prescription medications that are abused share several characteristics:1
Psychoactive effects that create a high, which gives them street value
Habit-forming, which creates a state of dependence when taken for a long enough time
Predictable dose and concentration
Cost less and are more easily obtained than other addictive substances.
Prescription drugs that produce a high are more reinforcing to the user if the drug:1,5
Has rapid onset of action
Has high potency
Has brief duration of action
Has high purity
Is water-soluble for IV use or has high volatility to vaporize for smoking.
How many medications do you carry that meet these criteria?
Drug abuse is use of a medication in a manner other than what the prescribing physician intended. This includes recreational use, larger dosages, different indications and different routes. Abuse generally leads to adverse consequences.1
Prescription drug abuse rarely occurs alone. Many patients also abuse alcohol and street drugs. During the course of their addiction, they receive controlled prescription medications to treat associated chronic illnesses.1 Benzodiazepines, like Valium or Ativan, are highly desirable for polydrug users because benzos enhance euphoric effects of opioids, lessen withdrawal symptoms, temper cocaine highs and augment the effects of alcohol.1 As much as 80% of benzo abuse occurs with abuse of other drugs, especially opioids and alcohol.
Tolerance is defined as the "state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time."3 The patient needs greater and greater amounts to achieve the same level of pain relief.6 If a patient is taking a narcotic for pain relief of chronic low back pain, the pain relief provided by the drug may decrease as his body adapts over time. The patient then increases dosages or frequency of use to achieve the same result.
Physical dependence is defined as a "state of adaptation that often includes tolerance and is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist."3 A patient can be physically dependent on a medication but not addicted.1 Have you ever had a coworker suddenly stop drinking coffee? In his initial days of caffeine-free behavior, did he complain of a pounding headache or fatigue? Was he short tempered? Sudden cessation from a physical dependence on caffeine can cause withdrawal symptoms.
Addiction is a chronic disease resulting from genetic, psychosocial and environmental factors. Patients with acute or chronic pain, anxiety disorders and attention deficit disorder are at increased risk for developing addictions.1 Addiction is characterized by impaired control over drug use, compulsive use, continued use despite harm and craving.3 An addict will continue to use controlled prescription medications despite either actual or possible negative consequences. The patient may clearly understand that forgery of a prescription is illegal, but will continue to do so anyway.
Who Are the Drug-Seekers?
Drug seekers are not necessarily drug abusers or drug addicts. The DEA estimates that the street value of controlled prescription medications is second only to cocaine.1 Many drug-seekers intend to sell or barter most or all of the prescription medications they obtain.
The drug-seeker, especially if his goal is selling medications, is looking for more than the single injected dose from EMS. His primary goal is a prescription for oral tablets.5
Abuse of controlled prescription medication is not an isolated problem that just involves football players, radio show hosts and spouses of politicians. In reality, controlled prescription medication abuse accounts for one-third of the U.S. drug problem. Conversely, drug-seekers are not just derelicts and dead-enders. Anyone, regardless of gender, income, race, ethnicity, health or employment, is a potential abuser and/or seeker of prescription medications.5 In 1999, nearly four million Americans were using prescription drugs recreationally each month. This is a greater number than heroin, crack and powdered cocaine users combined.5
Misunderstanding about the potential for addiction leads physicians to underprescribe pain medications. Patients, also fearing addiction, will refuse pain medication when it is indicated. In fact, the potential for addiction or abuse is low when medications are used as indicated and administered per prescription or protocol.5
Not all drug-seekers are faking symptoms. They may have a legitimate complaint, like low back pain from a lifting accident at work. Over time, they have become physically dependent or tolerant to prescribed pain medication, and in order to complete daily life tasks, they feel compelled to seek larger doses or additional pain medications.
Identifying Drug Seekers
Drug-seeking is not just an emergency department problem. It is a problem for all levels in the healthcare continuum. Recognition and documentation of drug-seeking behaviors is critical to BLS providers deciding if intercept with an ALS ambulance is indicated. Careful documentation and reporting to the ED can help identify inconsistencies in the patient's complaint.
Common behaviors of patients who abuse prescription drugs include:1
Escalating use by increasing dosage and frequency because the prescribed amount is not reducing symptoms.
Seeing multiple physicians for treatment of the same problem.
Scams orchestrated to obtain large amounts of high-street-value, brand-name medications. Scam artists are effective at pressuring healthcare personnel to treat their symptoms and might be emboldened by medication delivered prehospital.
Drug-seeking is using manipulative behavior to obtain a medication. What are some common drug-seeking behaviors? According to the DEA's Diversion Control Program, other common traits include:5
Assertive personality, often demanding immediate action
Unusual appearance-extremes of either slovenliness or being overdressed
Knowledge of medications and symptoms, or evasive or vague answers to history questions
Reluctance to provide reference information like address, insurance information and name of regular doctor
Patient requests a specific controlled drug
Patient exhibits mood disturbances or suicidal thoughts.
In the hospital, the following are common methods used by drug-seeking patients. Have you seen any of these prehospital?7
The patient must be seen right away
The patient waits until evening or night to call for a problem they have had all day
The patient states he/she is from out of town-traveling through, visiting friends or relatives
Feigns physical problems, such as abdominal or back pain, kidney stone or migraine headache, in an effort to obtain narcotic drugs
Feigns psychological problems, such as anxiety, insomnia, fatigue or depression, in an effort to obtain stimulants or depressants
Says that specific non-narcotic analgesics do not work, or that he/she is allergic to them
Contends he is unable to get an appointment with a primary physician
States that a prescription has been lost or stolen and needs to be replaced
Pressures the practitioner by eliciting sympathy or guilt, or by direct threats.
Even if your service does not administer controlled prescription medications, you may be the patient's entry into the health- care system. An ambulance ride can legitimize the patient's complaint to himself, his family physician and ED staff, as in "the pain was so bad I could not even drive myself to the hospital."
EMS providers are unlikely to be the end target of the scam, since we only give one or two medication doses. The scams we see in the ED range from verbal and physical intimidation to heartbreaking pleas for understanding and compassion. A few scams we have encountered include:
"I have tooth pain, and I am unable to see my dentist." Oral exam findings show no swelling, abscess, bleeding gums, damaged teeth, swelling or point of tenderness.
"I have an old war wound with shrapnel still embedded in my bones." X-rays are negative.
"I am new to the area and cannot get to see a doctor" or "I have an appointment next week, but need something to get me through the weekend."
"I was beaten up and they stole my Vicodin prescription I got yesterday."
"My insurance only pays if a prescription is for multiple refills or more than 50 tablets."
EMS is the in-the-home and on-the-street component of the healthcare system. As you assess the accident scene or the patient's living environment, you might see clues of prescription drug abuse. Clues include: quantities of medications larger than what seem appropriate for the problem; evidence of improper administration-is a patient smoking or injecting a medication that is normally taken orally and is there evidence of abuse of street drugs and alcohol?
We recommend EMS providers discuss with their supervisors and medical directors department-specific strategies for recognizing drug-seeking behavior, documenting pain assessment and reasons for denying delivery of controlled prescription medications. Work within the patient assessment to size up the scene, maintain personal safety, identify and treat the causes of altered mental status, and document and report suspected drug-seeking behavior.
An addiction to a controlled prescription medication may have started with an EMS call, such as a fall or accident that led to a chronic pain problem. The original pain complaint, assessment, treatment and documentation may play a critical role in determining initial pain control, follow-up pain control and ongoing care of the patient.
Use the patient assessment and your training to label and confront drug-seeking behavior. Follow department-specific policies and protocols to act on drug-seeking behavior. Actions might include:
Law enforcement intervention
Refusing to meet patient's demand for prescription medication
Communication to other healthcare providers
Offering the patient information on treatment resources.6
What do you do if a drug-seeker becomes confrontational? Few of us like conflict, but giving in to the demands of a confrontational patient perpetuates the abuser's positive reward cycle.5 If you believe controlled prescription medication is not clinically indicated, do not administer it. If the confrontation is escalating, stay out of arm's reach, call for law enforcement assistance and use verbal de-escalation techniques.
After treating life threats, our next task is to identify the cause or causes for altered mental status. Polydrug use is the common practice of mixing street drugs, prescription medications and alcohol. Use patient history, scene clues and bystander information to identify and treat the causes of altered mental status.
If you suspect drug-seeking behavior, you must decide if you will withhold medication. In the prehospital environment, we may be able to delay or defer medication until arrival at the emergency department, but how do you document the patient's symptoms and requests for pain medication if you denied treatment? Conversely, simply giving controlled prescription medications to known or suspected drug-seekers perpetuates the reward cycle for the abuser or seeker. It is tempting to give in to a drug seeker and give them what they want. Saying no and sticking to your decision is difficult. It requires conviction in your assessment and courage to stand up to verbal and physical aggression from the patient. Empowerment through training, practice and protocol will make you more effective at recognizing and responding to drug-seeking behavior.
Almost every prehospital patient has pain, but very few are drug-seeking. If you are suspicious that a patient is seeking drugs, perform a thorough examination appropriate to the condition. Carefully document examination results and questions you asked. Treat what you find. If there are physical exam findings, patient complaint or history to support the complaint, treat the problem per protocol and training. Only give medications when they are indicated. Trust and follow your instincts.
Drug Abuse Among EMS Providers
Finally, EMS providers are not immune from the temptations and destructions of prescription drug abuse. Healthcare workers have easy access to prescription medications and may divert and abuse drugs to relieve stress or improve alertness, or sell drugs for street value. Recognizing and reporting suspected or actual drug abuse in a coworker is one of the most difficult situations you will ever face, yet it is critical that suspicious behavior is acted on for the safety and well-being of ourselves and our patients. According to a guide from the DEA Drug Diversion Program, signs of a drug-impaired coworker include the following:8
Excessive work absenteeism
Frequent disappearances and long unexplained absences from the work area
Frequent or long trips to the stockroom where drugs are kept
Excessive amounts of time spent near a drug supply
Volunteers for overtime and is at work when not scheduled to be there
Unreliability in keeping appointments and meeting deadlines
Work performance which alternates between periods of high and low productivity-may suffer from mistakes made due to inattention, poor judgment and bad decisions
Confusion, memory loss and difficulty concentrating or recalling details and instructions-ordinary tasks require greater effort and consume more time
Interpersonal relations with colleagues, staff and patients suffer-rarely admits errors or accepts blame for errors or oversights
Heavy drug "wastage"
Sloppy recordkeeping, suspect ledger entries and drug shortages
Inappropriate prescriptions for large narcotic doses
Insists on personally administering injected narcotics to patients
Progressive deterioration in personal appearance and hygiene
Wears long sleeves when inappropriate
Personality change-mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures
Patient and staff complaints about healthcare provider's changing atti-tude/behavior
Increasing personal and professional isolation.
Intervention is critical to recognizing and overcoming addiction. The threat of losing a job may be enough for some addicts to seek help. Others may lose their job, friends and possessions before seeking treatment. If you know that drugs are being stolen for sale or abuse, do not intervene on your own. Inform your supervisor, security or the police. Drug addicts can recover. Encourage them to seek out assistance. Work with your supervisor or medical director to identify resources in your area. n
r 1. Longo LP, Parran T, Johnson B, Kinsey W. Addiction: Part II. Identification and management of the drug-seeking patient. American Family Physician, April 15, 2000.