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Thomasrobey72x722Thomas Robey -- Anyone who watches television has heard of drug seekers. From “House” to the news, examples abound of prescription pain killer abuse. Who hasn’t heard of the high profile pundits and Hollywood "who's whos" getting into trouble because of addiction? I have to wonder if these interest stories are painting an accurate picture of drug use and abuse. Something tells me there’s something more to the story. The drug and research minded blogger DrugMonkey brought to my attention an interactive map detailing trends in pain killer consumption in America. And while it’s hard to gather whether this map correlates best to street use, addiction or even just prescribing habits, total use is clearly on the rise. Thanks to media coverage of pain-killer use, it’s plausible to look at this map and think only about the white-collar narcotic users.

Other people abuse prescription pain meds. For me, these are the wrenching cases. If I follow a career working as an ER doc in a public hospital, I’ll be a seeker myself -– a seeker of patches for a broken heart. It’s only been a week and I’m already trying to suture in my first.

Back when I was entrenched in a life of cell culture, pipettes and animal colonies, my weekly dose of medicine was as a volunteer STD counselor at a free medical clinic for homeless teens. My job was to be an information portal. I helped kids live safer, told them if they had gonorrhea or that they were HIV negative (thankfully, all my consults gave this result), and could point them in the direction of other community resources. Many of these kids used illegal substances. Harm reduction and motivational interviewing were my modi operandi. I wasn’t connected with prescription or other medical issues, and I certainly was not involved with pain control -– as a matter of policy the clinic never distributed or wrote scripts for narcotic pain meds.

The outcomes of this volunteer experience were:

* I now love working with homeless young people.

* I can talk with kids about sex and drugs.

* I feel like I understand a little more than the average bear about the complexities of homelessness, especially in the teen and young adult population.

It’s this last point that has already gotten me into trouble. Now that I’m working in a county hospital ER, I’m encountering these same kids (even the same individuals) in an entirely different capacity. No longer am I simply an information portal; I’m responsible for their health. Previously, I could aspire to be a friend so that the information was more relevant to them. “Friend” drops much lower on the physician’s priority list, especially when the patient is aiming to take advantage of a perceived friendship for gains in conflict with their own good health.

An opiate addict will pursue any opportunity to acquire substance to sate his craving. This includes finding friendly doctors. Helping the medical student find a vein for an IV makes the student feel good, and improves the chances of receiving IV pain meds. Walking in the door wearing a cervical spine collar (even if it is medically indicated) may help the doctor sympathetically overlook a not-so-distant history of polysubstance abuse. In this setting, it’s not good enough to try to be friends with the patient. Can you trust an addict with pain meds? I don’t think so. Addiction removes the capacity for trust. There’s always something more important to an addict: the addiction. That’s why I reminded the attending of my patient’s recent heroin and cocaine use before he prescribed oxycodone. After my shift (and after his discharge from the ER), I noticed that my patient’s 3/5 strength (can’t move against gravity) during my exam had changed to full capacity. As I watched him pick up a bag and step onto a bus, my feeling of vindication quickly was at war with guilt for not deciphering the patient well enough to offer some sort of medical or social help.

But does this mean that providers need to erect walls around caring for addicted patients? Personally, I think walls and policies would cause me to limit the amount I care for my patients, thereby limiting the quality of their care. My goal is to get it in my head that being a bad guy to them is as helpful to their health as sating their needs. I think it’s going to be tough -– even tougher when I’m the one signing prescriptions.

This entry is dedicated to Mavis Bonnar, an advocate for homeless teens for the better part of three decades.

July 24, 2008 in Thomas Robey | Permalink


Speaking as an ER doc--yes you will see a lot of addicts seeking drugs. Many of those seeking drugs will actually be people who look like your friends and neighbors. It would be great if all drug seekers fit a stereotype--but they don't. (Luckily, most states now have systems that allow you to look up recent prescriptions filled state-wide.) Often, the request for drugs will come at the very end as you discharge a patient and many times you will be surprised because there were no prior hints during the ED course.

Your real challenge will come when a known addict comes in with real pain as opposed to "faked" pain. How will you be able to tell the difference?

I think one of the most important things to remember is that we need to treat the pain and that--not being omnipotent--we can't tell who is or isn't telling the truth. It's a "use your best judgement" scenario. Personally, I would rather send an addict back out of my ED with a prescription for 5 mild percocets than send someone away in genuine pain because I thought they were an addict and therefore didn't give them appropriate meds. While I realize that 9 out of 10 times the person might be faking it to get meds, I don't want to be the cause of that 10th time of unbearable suffering. Luckily, this is the policy at my facility and it is one I feel comfortable following.

You will have to decide what is your personal comfort zone and find a way to incorporate that into your workplace guidelines.

Posted by: Lou | Jul 29, 2008 6:49:32 PM

Doc, those drug seekers really scare me ...

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An opiate addict will pursue any opportunity to acquire substance to sate his craving.

Posted by: buy generic viagra | Jan 20, 2010 10:12:11 AM

Well, it's a matter of what pharmaceutics want, because if you pay attention to the TV spots, you will agree with me about the fact that at least the 30% of them are drug advertisements! It's a whole campaign behind!

Posted by: Generic Viagra | Nov 4, 2010 10:13:58 AM

I consider doctors can work deeply with those drug addicts, because they need help. Indeed, many doctors have helped many addicts but to be a drug addict is difficult, so many of them want to be out but they are still flowing on that terrible situation.

Posted by: Generic Viagra | Nov 4, 2010 10:42:14 AM

There are people that are more vulnerable to this kind of threat. The problem is the surrounding because more people are getting more stress in different forms that they try to escape of it with these kind of addiction.

Posted by: Sildenafil Citrate | Nov 4, 2010 11:04:22 AM

I think that painkiller like any other drug is very common but it is harder to get it because you need prescription in order to get it. Probably that kind of drugs are more accepted by society because you can get it from a Hospital or Drugstore.

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I think that you understand what pain is. What should people do if they cannot purchase pain killers legally?

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