Your next patient may be abusing prescription drugs: Here's what to do

Nurses in EDs are seeing rising numbers of cases

(Editor's note: This is the first part of a two-part series on caring for ED patients who are abusing prescription or over-the-counter drugs. This month, we give strategies for screening and assessing these patients. Next month, we'll cover serious medical problems that your ED patient may have as a result of prescription drug abuse.)

You're treating a 40-year-old man with a chief complaint of redness and swelling in his arm. Would you suspect prescription drug abuse was the cause?

The man admitted to ED nurses that he had crushed and then snorted acetamino-phen and oxycodone pain medication. "The pain and redness in his arm was from taking his father's Dilaudid pill, dissolving it in water, and injecting it into his vein," says Mark Graber, RN, BSN, CEN, patient care specialist at Lehigh Valley Hospital's ED, who cared for the patient. In another case that occurred in Graber's ED, when nurses assessed a man who seemed lethargic, they discovered he was chewing on a fentanyl patch.

According to data from the Drug Abuse Warning Network (DAWN), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), 495,732 visits to EDs in 2004 were related to nonmedical use of prescription and over-the-counter pharmaceuticals such as pain relievers. More than half of those visits involved more than one drug.1

Improved screening to identify substance abuse is needed in EDs, urges H. Westley Clark, MD, JD, MPH, director of SAMHSA's Center for Substance Abuse Treatment. Patients may come to your ED with an injury or illness related to prescription drug abuse, but "if you don't ask, they don't tell," says Clark.

"Patients may tell you only about the presenting complaint," he says. "If you don't ask about substance abuse, including prescription and over-the-counter medications, then you miss an opportunity."

Prescription drug abusers cross gender, race, and economic lines, he emphasizes. "If you jump to conclusions, you may be wrong," Clark says.

The ED visit is a "teachable moment," especially if the patient came as a result of an illness or injury related to their substance abuse, Clark says. "You can relate that consequence to misuse," he says. "The ED nurse is in a position of authority and trust."

Patients may not realize how serious a problem they have, or may not be aware they can't take prescription opioids with benzodiazepine, says Clark. In other cases, elderly patients may be misreading package inserts. Graber says, "By spending time with the patient, we may be able to have the patient realize that they have a problem. The patient must admit that they have a problem first, or they will not follow up after discharge with the resources we give them to seek intervention."

Of the nearly half-million ED visits related to nonmedical use of pharmaceuticals, 31.9% involved opiates and opioid analgesics, 29.1% involved benzodiazepines, and 5.7% involved muscle relaxants. Another 8% of ED visits involved both illicit drugs and prescription drugs, and an additional 14% of visits involved illicit drugs, prescription drugs, and alcohol, all in the same patient.

Patients who overdose can have life-threatening situations, warns Chantal Michel, RN, BSN, CEN, nurse manager of the adult ED at WakeMed Raleigh Campus. "We aggressively and appropriately intervene by using all resources," Michel says. "We also refer patients to social workers who can further assess and get them the resources that they need to overcome these addictions."

Since the ED is not the patient's primary care physician, there often is no continuity of care for these patients, says Graber. "We could have been the third ED visit of the same day for this patient seeking prescription medications, and we would not know this," he says. "If anything, the cases of prescription drug abuse are underreported. The patient may get angry and leave the ED when they don't get what they want."

In some cases, patients end up taking too much of their pain medications and run out before they are due for a refill, so they come to the ED, says Graber.

"A big red flag is when patients come from out of the area, driving 60 miles to come to our ED for something they could have gone to their family doctor for. They will come in asking for the most potent stuff we have right away," says Graber. "A big warning sign is when their complaints are out of proportion with their assessment."

For example, a patient brought by ambulance reported a score of 10 on a 0-10 pain scale, but when informed that he had to be moved from the transport stretcher, he sat up without any assistance and with no signs of pain, says Graber.

Perform thorough assessment

Typically, patients who abuse prescription medication come to EDs multiple times complaining of different pains, says Michel. "Usually, pain is musculoskeletal, in the arms, legs, ankles, or back," she says. "Abdominal pain and headaches are also often common complaints."

Always err on the side of caution and perform a thorough assessment for all of the patient's complaints, advises Michel. "The ED physician must also address their complaints and will then make a clinical decision as to what medications the patient will need," she says.

History: Who, when, and where

When obtaining a medication history, ask who prescribed the medications, when they were prescribed, and which pharmacy filled the prescription, says Michel. Also have the patient be specific about the location of pain, whether it increases or decreases with movement, and whether there are things that make the pain better or worse. "Many times, patients are vague about their symptoms or there are inconsistencies in a prescription drug abuser's answers," says Michel. For example, a patient may present with vague pain complaints and state that they are allergic to Tylenol but then specifically request hydrocodone-acetominophen, she says.

Many times, a person who has overdosed will not or cannot tell you what they have taken, says Graber. "If they say they've taken 10 pills, they may have taken a whole bottle. If they've actually taken a bottle of tricyclics and they die, we'll still be held at fault," he says. "On the other hand, people have told us they've taken 50 pills of this, 100 pills of that — and we get the tests back and find nothing."

For this reason, ED nurses do an emergency toxicology blood and urine test that checks for the presence of about 80 medications, including alcohol and psychiatric drugs, to find out exactly what's in the patient's system. "This is the most extensive test and is usually done for overdose patient, especially if it was multipharmacological or the patient is unresponsive or unstable," says Graber. "We can also do a urine drug screen if we are only worried about street drugs."

Reference

  1. Novak S, Ball JK. The New DAWN Report: Issue 23, 2006: Emergency Department Visits Involving Nonmedical Use of Selected Pharmaceuticals. Rockville, MD; 2006.

Sources/Resource

For more information on prescription drug abuse in the ED, contact:

  • Mark Graber, RN, BSN, CEN, Patient Care Specialist, Emergency Department, Lehigh Valley Hospital and Health Network, Cedar Crest and I-78, P.O. Box 689, Allentown, PA 18105-1556. Telephone: (610) 402-8160. E-mail: mark.graber@lvh.com.
  • Chantal Michel, RN, BSN, CEN, Nurse Manager, Adult Emergency Department, WakeMed Health & Hospitals, 3000 New Bern Ave., Raleigh, NC 27610. Telephone: (919) 350-8825. E-mail: cmichel@wakemed.org.

The DAWN reports are available at the web site dawninfo.samhsa.gov. Click on "New DAWN Publications," "The New DAWN Report — Special Topics," and under "Emergency Department Visits Involving Nonmedical Use of Selected Pharmaceuticals (July 2006)," click on PDF or HTML format.