Drug Seekers

   It's 1430 when my partner and I are dispatched to 105th and Edes. As we hear the address, we look at each other, and he says, "I'll bet money it's John." I chuckle to myself and silently agree. However, the chief complaint appears to be abdominal pain, which is not John's normal complaint. Maybe we're wrong.

   As we pull up in front of the Board and Care, we see our patient sitting on the sidewalk, holding his abdomen as if in pain. Sure enough, it's John.

   His complaint is no real surprise--he is always in pain. But is there more to the story, and what are my treatment options? Should I manage his pain with morphine or BLS him to the hospital? These are all questions we face when treating drug-seekers; unfortunately, we don't have many good answers.

   John is what we call a chronic patient. The first time I met him was about six months before this call, when he was intoxicated and complaining of back pain. Since then, I have picked him up four or five times. He always "just ran out" of Vicodin, and each time looks a little more haggard than the last. His pain is always a 10/10, and his vital signs are always pretty normal: no hypertension, no tachycardia, no tachypnea. His skin is always normal, warm and dry. You get the picture. He has a self-pitying story about how he needs to change, which typically means he gets an easy ride to the hospital and probably a chair in triage.

   This time, I decided to try a new approach. John said his stomach was hurting because he had taken seven Vicodin the previous night for back pain. He also complained of dark, tarry stools. After completing a thorough assessment, I started an I/V, gave him 5 mg of morphine, and began a very straightforward conversation. I said I didn't believe his pain was a 10/10. I told him that he had a drug problem and was after more pain medication.

   The look on his face was one of shock, consternation and disbelief; however, I had just given him IV morphine, so he couldn't be that mad, right? Instead of being mad, he actually confessed to the truth of the situation. He admitted that his pain wasn't "that bad." He acknowledged that he had a drug problem and needed help. About then, we arrived at the hospital.

   I transferred care and was finishing the patient care report when a nurse advised me that the patient wanted to speak with me. As I walked into the room, John looked up and said, "I need to tell you the truth. There was no blood in my stool." No real surprise, I thought. "And I didn't just take seven vicodin; I took all 30 between last night and this morning." That was a little more than I expected.

   We've all run those calls. We feel 100% sure the only "emergency" is the patient's addiction to opioids. The question then becomes, "What is the appropriate treatment?" I have yet to find a system with a "drug-seeker" protocol. However, this is an issue we face every day, and we need an answer.

   First, who are the drug seekers?

   Most medics and EMTs I've spoken to seem to think that you are a drug-seeker if you just ran out of meds, you have a chronic pain condition, you used to use illicit drugs, your v/s are normal, you don't look like you're in pain, you know what meds to ask for, you are allergic to Toradol and other NSAIDS, and they have transported you before.

   Doesn't it seem logical that if you have a chronic pain condition for which you are being treated and you run out of pain meds you would then be in pain? Makes sense to me. However, these patients often get no treatment en route, and they might even get a grumpy care provider. "But they don't look like they're in pain!" you say. True, sometimes they don't look that way; however, that is not always the case, and if we don't believe our patients, why do we ask them questions?

   Others seem to think that because the patient is on methadone, or previously used heroin, meth, crank, ecstasy or marijuana, they don't deserve pain medication. Did we get into EMS to judge and condemn? We live in a country where people are innocent until proven guilty. Shouldn't we treat our patients the same way?

   Some might argue that vital signs are an indicator of pain level. People tend to believe that if they are in real pain their HR, B/P and RR should be elevated. Aren't a large number of your patients on beta-blockers? Mine are. At this point, we really need to think about physiology. Most patients with an acute pain response, i.e., broken bone, car accident, assault victim, have a lot of reasons for their body to have a fight-or-flight response with associated changes in vitals. The patient with a chronic pain condition will not have these types of sympathetic response. It's like the first time you drove code 3, when your heart rate and blood pressure went through the roof. Now when you drive code 3, you just get annoyed by the sirens and people who park in your path.

   I don't know why some people tend to be allergic to NSAID pain relievers other than the obvious answer--they are allergic. In most of the systems I'm familiar with, our pharmacological options are limited. Morphine works wonders and sometimes brings about a confession. But beyond just doing what the patient wants, we ought to be concerned with what the patient really needs.

   Physiologically, the patient's body is telling them it is time for ______ (fill in opioid of choice). Why don't we just give them what their body needs? We all have reasons for not giving patients the pain medications they are seeking. By far the most common reason I have heard is that it will cause the patient to call 9-1-1. This seems a little erroneous, considering that most of them have been transported before, and if you are treating them right now they have no problem calling for an ambulance.

   Here are some other reasons we should be aggressive with pain management:

• We might be wrong about their pain and suffering.
• They might be suffering withdrawal.
• They might become violent otherwise. (I'll tell you that story later.)
• They might open up and tell you the truth.
• They will definitely be more cooperative.
• They may have to wait for quite some time for the doctor to order pain medication.

   In the end, we are here to help people. We do not get to choose the people who need and ask for our help. We don't even get to choose what medications we have to treat them. So the next time you think you have a drug-seeker in your ambulance, remember, it is not your morphine, and you aren't the one in pain.

Author's Note: Vicodin generally contains 5mg of hydrocodone, a narcotic analgesic, and 500mg of acetaminophen, a NSAID. The amount of acetaminophen taken by this patient far exceeds the LD50 and may have resulted in liver failure and death. This information was only obtained as a result of the care provided in the field and became critical for this patient's inhospital care and recovery. This is all the more justification for us to provide high quality, humane care to those who call us.

   Adam N. King, EMT-P, works as a paramedic in Alameda County in northern California. Contact him at adamkingems@hotmail.com.