Tuesday, August 25, 2009

The Drug Seeker Dance

I love drug seekers, I love everything about them. I actually get a BIG smile when I see the complaint, and recognize the name. It wasn't always that way, I used to despise them. I used to groan, and complain about seeing them, and I would dread the coming confrontation. Not anymore. Now I've dealt with them so many times, that I actually enjoy it. I'm not known as being a "dispenser", in fact quite to the contrary, there have been times working at some of my locations where I have watched a familiar patient walk in, see me working, and watch their mouth open and sigh, and watch them walk right out the door. It's an unusual thing.

However, after seeing so many, there seems to be a common dance that they all do...regardless of whatever flavor they may be seeking.

Step 1, As you enter the room, the patient greets you with a smile, and an enthusiastic expression. (the first part of the buttering up phase), and seems to be comfortably sitting there...BUT wait, something is amiss....they are complaining of 10 out of 10 pain.....Hmm, now that's odd.

Step 2, As the interview progresses they repeatedly ask about your personal life and family, IE; do you have kids?, how old are they?, etc. (the second part of the buttering up phase).

Step 3, Now for the exam, this is almost always benign, and usually completely unremarkable, yet they might try to grimace, or act as though something is really wrong. The trick is to get them to repeat the motions, or pressure without them thinking it is an exam. IE; ask them if they need help sitting up, and press on the tender point in their back.

Step 4, the dreaded confrontation, I used to hate this, but now I don't mind at all. You calmly confront them about their frequent visits for narcotics, and how they should be obtaining ALL narcotics from one solitary primary care provider. This is where the patient goes almost invariably through several stages. First there is disbelief, and subsequently a defensive posturing. Then there is usually an excuse or story, IE; my meds got stolen, I lost them, my doctor is out of town, etc, followed by an attempt at bargaining.

Too bad it rarely works. I have no problem treating real pain, and I might be more liberal than some when treating fractures, occasional isolated migraines, pain related to cancer, etc. However, when I see a frequent flyer in the ED, with chronic pain, who is chronically drug seeking, and doctor shopping, well.....Not so much.

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