A patient comes to the ED frequently, always reporting pain, always asking for opioids. Before charting the words “drug seeker,” ED providers should think twice, says Bryan Baskin, DO, FACEP, quality improvement officer at the Cleveland Clinic Emergency Services Institute.
Baskin says EPs should ask themselves several questions: Is this drug-seeking label truly needed to complete the chart? What message are you trying to convey, and to whom? Who is going to read that chart once you close it, and why? What does labeling the patient this way in your single encounter add to the history, examination, or medical decision-making? How does it change the plan on that day of evaluating the patient for a medical emergency? “If making this description is truly needed, there are objective ways to quantify drug-seeking behavior in the chart that other medical professionals reading it will understand,” Baskin says.
An EP could chart a history of previous ED visits during which the patient demanded certain medications. Also, he or she could refer to any ED or hospital-based, patient-specific care plan already in place in relation to pain medication. For instance, the care plan might state, “This patient has had frequent visits for chronic abdominal pain. Opiates are to be avoided unless absolutely clinically indicated.”
“Referencing these plans can be a way to objectively describe historical pain medication use in a patient,” Baskin offers. EPs also could pull and list data from the state prescription drug monitoring program showing multiple prescriptions from multiple providers.
“Labeling the patient as drug-seeking gives the connotation they were malingering,” Baskin explains. “This conveys the same message without appearing oppositional to the patient.”
Clinicians should objectively describe the patient’s appearance, vital signs, and demeanor, says Alfred Sacchetti, MD, director of clinical services at Virtua Our Lady of Lourdes Medical Center in Camden, NJ.
“Many patients with chronic pain have developed techniques to address their pain, which lead them to appear to sleep as they lay quietly on a stretcher,” Sacchetti notes. However, clinicians should document when patients demonstrate rapid changes in behavior in response to the presence of ED staff. For instance, if a patient loudly vocalizes their need for pain medication between periods of laughing while talking or texting, describe that in the medical record. “The clinician should be careful not to make it appear that a pain management decision was based solely on patient behavior,” Sacchetti cautions.
It is best to leave these statements as isolated observations. The justification for the treatment of pain can be stated separately. Sacchetti suggests a statement in the record to the effect of “Patient’s description of pain does not coincide with my physical findings or diagnostic studies.”
“Phrasing the encounter in this manner allows the clinician to express their concerns about the patient while not labeling them a ‘drug-seeker,’” Sacchetti says. Patients who suffer from addiction can experience pain from real medical etiologies. An example is a patient with chronic back pain who develops an addiction to narcotics, then transitions to IV drug use, later developing a spinal abscess. “IV drug users are at increased risk for intraspinal infections. When they have this infection, they often present to the ED with a complaint of back pain,” Baskin reports.
That patient’s chart is going to appear suspicious because it reflects a history of drug abuse with multiple prior ED encounters for back pain. “It is easy to get biased and dismiss the presentation,” Baskin admits.
The provider could easily miss a spinal infection diagnosis. “It is common for spinal infections to be missed by several providers before being diagnosed. It can be a difficult diagnosis to make, especially in its early development,” Baskin laments.
Even if the provider missed the spinal abscess diagnosis on the first or second visit, it is possible the standard of care was met. “But if it appears it was missed due to bias against the patient, it increases risk for that specific encounter,” Baskin warns. If any ED patient is labeled as “drug-seeking” without an appropriate workup and later experiences a bad outcome, a malpractice claim is hard to defend. “It appears as though the patient’s complaint of acute pain was dismissed as drug-seeking behavior and not true medical etiology,” Baskin observes.