WhiteCoat

“The List”

If you’ve worked in an ED, you have a list. It may be written or it may be kept in the back of your head somewhere, but you have a list.
You always give the benefit of the doubt to patients in pain, but there are a few that keep coming back that make you say “hmmmmmm” to yourself. After a while, the “hmmmmmmm” turns from a little whisper to a Sam Kinison scream (this YouTube video is way more amusing than this post will ever be). They have chronic pain, ran out of their medications two days ago and come in at 6PM Friday night after their physician’s office has just closed and another doctor in the office just happens to be on call that weekend. Or they’re visiting from out of town, their physician doesn’t carry a pager, and they can’t remember what hospital their physician works at. Perhaps they have been diagnosed with temporal arteritis, but when you try to find the biopsy results there aren’t any – the patient refuses surgery because there are too many risks. The story just doesn’t quite fit.
You call the pharmacies to get an idea of what the patient’s medication history is like and the pharmacists can tell you what clothes they are wearing that day — because they’ve been there already to pick up a prescription from another physician.
You’re torn, because you want to alleviate pain, but you don’t want to be taken for a sucker.

Well, a lot of people have been making my List lately. Some of them haven’t even been ED patients.
One patient made it after being in the ED with a friend. It was a busy day, so the patient and her friend were waiting in the room reserved for critically ill patients. After they had left, we got a call later that day and it was the friend’s mother. She wanted to know if we gave her daughter medications even though she had not been seen. Her daughter had a bag full of a medicine packets labeled “Dop-a-min” in her room and was trying to figure out how to use it.
Another patient had been to the ED in the past, but was recently admitted directly to the floor. The nurse came and offered the patient’s roommate pain medications. The roommate refused. Later that evening, her roommate went to the nurse’s station and told the nurse that the patient told her to call the nurse back, ask for the pain medicine, and give it to her.
Another patient made my list last night. Chronic pain after surviving a helicopter crash years ago. The site of pain keeps changing, though. He’d been in previously for headaches, neck pain and back pain. He had picked up prescriptions for Fentanyl, Vicodin, Dilaudid, and Valium two days ago and immediately afterwards, someone broke into his apartment and stole his bottles of medications. Only the medications. Not his computer, his TV, or his watch. Only his medications. It was after hours and he wanted me to refill his prescriptions for the medications to relieve his severe back pain. We ended up finding out from a family member that the patient filled a prescription for 30 Valium tablets 8 hours earlier. Went back and asked the patient about the pills. “I took most of them. The rest are in my pants pocket.” Twenty tablets of Valium 10mg were missing. Three to four hours after ingesting 200mg of Valium and you’re still vertical? I don’t think so.
“Sorry, but you’ve been here multiple times for multiple pain complaints and frankly, I don’t believe that your medications were stolen. Besides, if you did take all those Valiums, you have a drug problem that needs to be addressed. You’re going to have to see your physician in the morning and explain it to him.”
“So you’re not going to treat me?”
“I’ll be happy to treat you, but you won’t receive narcotics from this emergency department any more.”
He got a shot of Toradol and his back pain suddenly improved to the point that he was able to stomp out of the emergency department in a gait that wasn’t possible only 30 minutes before.
Several people have been able to have their names taken off The List. Last year two of them died from drug overdoses. This year two have been arrested on drug charges. One was sentenced to 3-5 years in prison, the other to 2 years in prison.
The good thing about The List is that once people know they are on the list, they don’t visit the ED nearly as much.
The sad part about the list is that we have to have a List at all.

19 Responses to ““The List””

  1. hashmd says:

    We aren’t allowed to have “The List”. That is discrimination. Just like the military, it is “Don’t ask, don’t tell”.

    If a patient complains that I didn’t treat him or her appropriately because I even suspected drug seeking behavior based on a “list” then I will be punished by having that complaint permanently placed in my Quality file, brought up every time I come up for recredentialling even though I only work at the Hospital Urgent Care part time (because my practice can’t make enough money) and I am applying for full Family Practice priviledges.

    The only out we have is that we don’t stock any injectable narcotics at Urgent Care. None. We advertised that with word of mouth and suddenly the Demerol seekers vaporized. Still have the Vicodin seekers, Xanax seekers etc. but we get by by giving them only #5 or #10 if we so desire.

  2. Carol says:

    I am a phamracist and I have a list too. I work relief only and it’s rather funny when I see the same patient from yesterday come in with the same rx from the day before. The disheartening part is that even if I call the police and they charge him/her with uttering a forgery the judge gives them a $250 fine and sends them on their way. Even with a list of priors longer than I am tall. sigh. It’s still good for a laugh, though.

  3. shadowfax says:

    Before going into any room to see any patient I do a quick “visit list” biopsy. I don’t pre-judge, but make sure I go into the room with an idea of how often and for what reasons this person visits the ER.

  4. Legend says:

    I guess I can say that I’m your worst enemy. I lied. I forged prescriptions. for all outward appearances, I was not only a drug-seeker, but a junkie!

    Well, the likes of me don’t get away for it for long. I as caught. I went to detox. It failed. I went to prison. I served my term, and was released.

    here’s where things change. I go to an outpatient rehab (condition of parole). I see a parole officer. The Parole Officer, noticing something in the way I walk, and hold myself, insists that I see a doctor about my pain. On advice from my lawyer, I ask her permission before getting a prescription for opiates filled. she agrees-heartily!

    Pain management has had its ups and downs, but I no longer visit emergency rooms for the sole purpose of obtaining drugs, and seeing untended prescription pads doesn’t even tempt me! I attribute this to two things:
    1) My feelings, while not condoned, were vindicated.

    2) I finally got decent treatment for my pain!

    I should explain: I had 3 accidents, from which I didn’t fully recover, from 1079-81. No one Thinks of treating my pain…when I don’t get better, I get cut off, medications included. I was past 40 when I committed my first criminal act!

    So, you don’t know everything about the subject! And, I saw many doctors-NOT ONE even told me there was such a thing as Chronic Pain!

    Me-I’d like to see drug use made into a choice-for any reason-available to adults, and for any reason. Like it or not, you are the gate we must get past to get what we need to function. You’re already talking about us as if we weren’t human. To expect onesty and respect, you have to give it first. A law that abides to everyone

  5. Sindi says:

    I guess I am on “The List” I was sent a certified letter by the head of Emergency Medicine saying I was visiting the Emergency Department too often and they would no longer give me IV pain medications or write any pain prescriptions. I have a history of Adhesional Disease and have had 7 small bowel obstructions in the past year. If the narcotics that I have at home are not helping then I know that I have an obstruction. As this is the only ER in my area I have no choice but to continue to visit this hospital of which I am labled a drug-seeker, but of course my last 4 or 5 visits to this hospital they gave me no pain relief. I just got out of the hospital again yesteday with another bowel obstruction (which is extreamly painful) the ER Dr. came into my room and said “you got sent a narcotics letter, so you won’t be given any pain meds”. I had to have an NG tube shoved up my nose into my stomach with no pain meds. I showed this letter to my primary care DR. and he couldn’t believe it and wrote a response to this ER Dr. with of course no reply and this was several months ago and it was obviously not removed from my file. I’m at a loss as to what to do, all my visits to the ER have a documented cause, I’ve been admitted to the hospital for at least 4 days each time. I’m sitting here right now scared to death of the next time this is going to happen and of the pain that I will have to go through, and it really sucks. I’m thinking of hiring a lawyer, does anybody have any advice for me? Colosrgsvtgirl@msn.com

  6. WhiteCoat says:

    There are patients who do have chronic pain problems and there are patients who falsely use complaints of pain as a means to obtain narcotic medications. Sometimes it is very difficult to differentiate between the two.
    An approach that may help both you and the ED physician to reach some common ground is to have your physician write a letter to the emergency department stating that you are under his care for chronic pain and to contact him if you come to the emergency department in need of pain medication. Most people who use false pain complaints as a means to obtain narcotic pain medications don’t stick with one physician because once they have been worked up, nothing has been found, and when the physician begins to question their motives, they find another physician and start the process all over again.
    There is a huge difference between someone with mystery back pain that shows no etiology after CT scans, MRIs, nerve conduction studies and myelograms (when the patient is seen in the community bars dancing like John Travolta) and someone like you who has an obvious source for recurrent pain.
    I can’t imagine why a physician wouldn’t treat you for pain if you have a documented bowel obstruction.
    Maybe you should try contacting the administration at the hospital and talking with them about it.

  7. ben says:

    Narcotics for pain of bowel obstruction??? Beats me!!! Which comes first, the chicken or the egg?

    Pain meds for NGT insertion? Boooogggguuussss!!!

    Stick to having an -ostomy…it might help you avoid bowel gangrene.

  8. [...] Older white patients received narcotics more often than younger non-whites. Therefore, the researchers come to the conclusion that there is a “differential undertreatment of pain in minority patients.” Then they discuss how “emergency department physicians may be less likely to detect signs of abuse in white patients than in nonwhite patients.” Good segue. So older white people are a bunch of drug addicts and the ED physicians are just too dumb to catch them at it. I knew I should have given that 98 year old with toothaches some Motrin. Dang it. Next time I see her in MY emergency department, granny’s going on “the List.” [...]

  9. labmom says:

    I have a 3 level cercical disc fusion. DDD and Cervical Facet Disease. I have had medial branch nerve blocks, and last year my Dr. did a rhizotomy to burn the nerve that sends the pain signal to the brain. Helped ALOT. The nerve regenerated. I have had times of really high pain levels where I stay in bed, cry and take my pain meds until the major spasms go away , sometimes for days. There have been times when I called my pain dr (once or twice) and they told me to go to the ER when my pain meds just were not working.
    There is no way I am going to go to the ER unless I have pain levels thru the roof. I worked in a hospital lab for 18 years. I heard how the staff talked about the people there for pain meds. I have been in pain management for 4 years. I try everything my dr suggest to relieve the condition that doesn’t involve narcotics. Unfortunately, to have some quality of life with my husband and 5 kids I have to take the Lyrica, and pain meds, as well as topomax and antidepressants. I take them as prescribed and by doing so, I never run out of meds. When I go to my appointment each month I always have meds left over.
    If all pain patients would take meds as prescribed, wouldn’t they not run out? Or maybe they don’t have a Dr. that prescribes enough to cover the pain that they have. I am not trying to judge, just throwing out a thought.
    I have the cervical facet injections being repeated next friday. Hurts like hell, but really helps. I would recommend it definately… labmom

  10. Honesty says:

    Some people have pain clinics that see them every 3 months, so that can cause an issue with remembering refills. Granted I’ve only ever had a problem once when they switched me to a new pain medecine. I saw I only had six left, tried to call in a refill friday and forgot the clinic was closed on fridays.

    There are legit reasons, but I’m sure more often than not they aren’t legit.

  11. Mellee says:

    Iuse to be on “the list”. It took me getting just that type of note from my doctor, for them to know I am NOT messing around. I have been a recovering addict for 2 years and have had the same doc 2 1/2 years. I only use one hospital, and 2 pharmacies. It’s kinda funny in a strange way, when I was addicted I loved those ER visits, now I won’t go near one unless I am truely sick. The last time I went was for one of the “worst migraines I have ever had” got the whole work up (ouch!!) had meningitis. Got all the narcs I could handle

  12. Marilyn says:

    I can’t figure out why anyone would take Vicodin on purpose. It gives me a nightmares and a headache and doesn’t work on pain. Guess I’ll never be a junkie!

  13. new nurse says:

    “The List” what is the list? Is it in a patients file saying that the patient is drug seeking? How I wonder are all of the Doctors being treated for addictions-but not treating the patients they see?? Ha Ha, so thats why my husband doesn’t get any pain control when he is diagnosed for Pleurisy?! So this is why I don’t get any pain control when nerve damage is found in my neck, I went to the ER needing pain relief for….I guess we are both on the list….What does a person do? Buy it off the street instead of seeing the doctor I suppose. I am thinking of leaving the medical field if I cannont give meds to people in pain! Good God give them 10 or 20 Vicoden is this really gonna create addiction? OH never mind you would say yes.

  14. "Drug seeker" says:

    I am a young female and I have pretty severe endometriosis. Don’t make the mistake of thinking that it doesn’t hurt. I’ve had surgery and I am currently on hormone injections and while that might keep the endo in check for a little while, there are still times when I am in severe pain.
    My doctor has me on percocet, but I am not in constant pain. So, sometimes I don’t have any medication on hand. Besides, if I am in severe pain, my doctor WANTS me to go see a doctor face to face to get checked out.
    I went to a local urgent care clinic a few weeks after my lap because I was in a lot of pain and although it was wednesday, my doctor’s office was closed. I saw a compasionate doctor who ran some tests, talked to me and prescribed me a few days worth of vicodin and toradol.
    About two months later I went to the ER where I had my lap for pain. I had already called my doctor’s answering service and was advised to go. After being told that the wait would be about 8 hours, my husband took me to that same urgent care clinic. It just so happened that I had been there about six months earlier for a pretty bad cold and had been prescribed some cough syrup that I never even took. I didn’t really think about that in the state I was in.
    A nurse brings me in the room and takes my vitals and asks about my complaints. I give her a brief summary of my medical history and explain that I am in severe pain.
    She leaves the room only to pop back in after two minutes to inform me that the doctor working that day had lost his license to write narcotics. I said “Ok, but my doctor still wants me to get checked out. Besides, there are other methods of pain relief right?” She said ok, and that she just wanted to inform me in case I wanted to leave now.
    I had already caught a glimpse of the doc and he happened to be the same man who had prescribed vicodin a few weeks before so I had to wonder. I did suspect that they had mistakenly put me on their “list” but I wasn’t really in a state to be too offended.
    The doctor came in and we talked. He told me that he needed me to calm down because my pulse and blood pressure were too high. Like, waaay elevated. It didn’t go down even though he spent 20 minutes chatting with me. He said it was because of the pain I was in. He told me the nurse was going to give me a demorol injection and xanax. I said I hate xanax, I don’t want it. Well, he said he wouldn’t discharge me until I was calm. When he was leaving the room I asked him if he could prescribe something for pain, something non-narcotic. He stepped back into the room and told me that the nurse had lied because she thought I was a doctor hopper. He apologized for their mistake and prescribed percocet. But still, I am pretty freakin’ offended.
    And I suspect that I would still be on “The List” at this clinic if this doctor’s mother hadn’t suffered from severe endo (he told me so.)
    Most of you doctors and nurses need to start out by assuming that we (the patients) are telling the truth. Just imagine that we were someone you care about, and maybe then your attitude would change.
    But I hope you can agree that it is better for a doctor to assume that all his patients have real medical problems. If not, you risk labelling a sick person as a “doctor hopper” and if one person leaves your ER/clinic without proper care and has serious complications, that is all ON YOU.

  15. John says:

    WhiteCoat

    I can give you the names of at least six doctors I have seen (I have a well documented severely painful illness) that chuckle and said they “don’t do pain”. They “don’t prescribe pain meds in any case.” I will send them to whatever e-mail you ask.

    John

    You may need to visit a pain clinic/pain specialist. Do a Google search for docs in your area.
    You can’t force a doc to treat conditions with which they are not comfortable.

  16. RageVMedicine says:

    what are you guys? The Abwehr? The Gestapo? That is the last time I heard anyone talking about medicine and list of people it was Mengele. What the heck to you care if some poor son of a gun want to waste 10 hours 1 or 2 days a month in the freaking ER Room for a script of probably only 10 Vicodens, the maybe another 5 hours in the hospital pharmacy? How many times have you had governmental action taking against you for writing a script for someone in the ER for whatever? You guys are the biggest bunch of wussies. Haven’t any of you ever been in combat or served in a forward area? Or at least had your freaking back to the wall? Scared of the DEA? Their pigs. They are lower than pigs. They are the bully on your playground right now and you all cower behind the swingset. Why the heck don’t you get the vaunted AMA to help, or better yet, band together in small units at first, link up and learn to fight! The DEA is cowardly and I will tell you why. South American and Mexican drug lords are no longer viable options due to their lethal abilities and armaments paid for by the 17,000% markup on imported cocaine. Interestingly enough, the same day the warrant was handed down for Noriega, there was also another warrant handed down for the apprehension of Ka Sahn, leader of the Shan warload states in the golden traingle. Unfortunately he has been very well armed by the CIA (Read Politics, Heroin and Southeast Asia to get a clue) and it was felt to be better policy to leave the group of sleeping dogs over 8,000 miles away alone. Can’t you see the DEA cannot stop the flow of drugs from outside the country. S0 what do they do? They pick the easiest targetlike any bull, in this case, you guys and pain doctors in particular, manufacture a crisis (there is a tremendous pharmaceutical drug problem know – forget about all that crack, heroin, coke, X, LSD and the worst of all offender drugs “Marijuana”, and now we would like to concentrate on shooting MD’s in a court barrel, most of whom have done nothing but help people like me their entire professional careers. Hell, if you’re that rabbit scared and shaking like French soldiers, why don’t all of you get togetther and do what the MF doctors here do and say with a childish supercilicious smile, “Oh, I’m sorry, I don’t ever prescribe narcotic medications. YOU PEOPLE TOOK AN OATH. First and foremost to do no harm. Well history would agree I thing, that inaction is the very worst and sould perverting action that can ever be taken. Better to do something than nothing Churchill said.

    Also, I do not understand this. Our justice system was predicated upon the premise it would be better to have 1,000 guilty men walking the streets, than 1 innocent person in jail. Why in the name of God and all humanity doesn’t this apply to people who claim to be in pain, whether they are or not? Would it not be better to also have 1,000 people who faked their pain for the scrapings from your pharmaceutical tables than to have 1 person suffer the indescribable torment or severe, unrelievable pain year in and year out? Believe me I know whereof I speak. Lastly I leave you frightened little childrent with this:

    It is not the critic who counts. Not he who points out where the strong man stumbled or where the doer of deeds could have done them better. No the credite lies with the man who is actually in the arena. Whose face if marred by dust and sweat and blood. Who strives valiantly. Who errs and comes short again and again. Who knows the great enthusiams, the devotions and spends himself in a worthy cause. And, who at the best, if he wins, knows the triumph 0f high achievement. And, at the worst, if he loses, at least loses while daring greatly so that his place shall never be with those cold and timid souls who knew neither victory nor deafeat.

    This for you doctor Whitelabcoad or whatever ever your handle is. Shame on you. Busting some poor women and making her suffer the hell of withdrawal. You didn’t have to do that. She probably goes through it once a month on her own anyway.

    In closing, I have a great respect for ER personnel and also for all paramedics. But what I have read here is exactly how petty little organizations come to great power — WHEN GOOD MEN FAIL TO ACT!

  17. EMTdude says:

    Wow, this post really brought out the haterz. I guess drugseekers constantly search the intarwebz looking for confirmation for their lifestyles.

  18. Nuclear Fire says:

    @new nurse: pleurisy is treated with anti-inflammatories, not narcotics. It’s also a symptom, not a diagnosis. Treatment is outpatient, not an ER. Are you sure you graduated?

  19. SeaSpray says:

    I missed this one. GOOD post!

    And it is sad… frustratingly sad for the med professionals and for the sincere pts hurt by the fakers.

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