Tuesday, September 11, 2007

The Drug-Seeker: an Urban Legend?

I doubt there are many people involved in the wonderful world of chronic pain on either the treatment side or the lack of treatment side who haven't heard of that malicious and devious creature known as the drug-seeker. Depending on one's point of view, he is either a Svengali-like manipulator able to hypnotize even the most jaded doctors into forking over Vicodin by the jugful or a pathetic, toothless rube claiming to be allergic to every drug known to man except that one beginning with a "d" (Dilaudid, or Demerol). To hear some doctors talk about it, it seems that everyone with pain is either a drug seeker or a wuss who couldn't handle a paper cut without an IV morphine drip. But it seems the drug-seeker is universally blamed by both doctors and patients alike for the hostile and negative attitudes people with chronic pain routinely encounter from the medical profession.

One of the interesting things about the drug-seeker phenomenon as it is often described on many medical blogs is that you often read accounts of drug seekers that are remarkably consistent from one blog to the next, as if everyone has encountered the exact same guy using the same pathetic story to scam for drugs. Usually, it will be an ER nurse or ER doctor talking about a guy who claims to be allergic to "Tylenol, ibuprofen, and every other NSAID, and Toradol doesn't do it for me; but I can take Vicodin and that other drug that begins with a "d"...uh, I had it the last time I was here...what's that thing called...oh, that's right! Dilaudid! (or Demerol, both powerful narcotics). If you read medical blogs a lot, and I do, you will likely encounter some version of this story with only minor variations.

In fact, this story is so common that someone has even begun marketing an assortment of magnets and buttons on cafepress.com with a guy in a hospital gown voicing this very story!

The caption reads:

Well, I hurt my back about three months ago and heat and ice just aren't cutting it. I'm allergic to Tylenol, Ibuprofen and Naproxen and Toradol just doesn't work for me. I had really good luck with that one medicine I got the last time I was here. What was it called? It started with a "D". I think.. Does Demerol sound right?

It starts with a "D" all right!

The thing about this story is that it's obvious that anyone actually using this line is going to earn himself a one-way ticket onto the blacklist and can forget about ever getting drugs in that hospital again. No doctor would be likely to give meds to a guy like this particularly as they all claim to have heard this story a million times, so you would think that by a simple process of evolution the drug scammers would either put their heads together and come up with a better spiel than this, or would be forced to give up on trying to score drugs at the ER.

Yet according to the DEA, drug scammers are so sophisticated that there is allegedly an "epidemic" of prescription drug abuse and diversion going on, and drug seekers must therefore be quite skilled at obtaining drugs (of course, the DEA is full of crap, too, but I digress). This is particularly true as most people with real chronic pain problems report incredible difficulty getting doctors to take their pain seriously and prescribe any painkillers at all, let alone an adequate dose, and frequently report being accused of drug-seeking or of being whimps who can't take pain. If soaking your spear with the blood of your first "drug-seeker" is a rite of passage for many docs, being falsely accused of being one is a rite of passage for people with chronic pain.

In truth I can see how a sophisticated drug addict who knows how to play the game would have a far better chance of getting pain meds than some poor girl who has never had severe pain in her life, but one day injures her back and limps into the ER complaining of severe pain. She naively says she's allergic to NSAIDs, but her friend gave her an OxyContin that worked great for the pain, and "can I have one of those?", not realizing that she just signed her own arrest warrant and won her doctor $50 bucks from the "first drug seeker of the night" pool.

So I would imagine anyone actually dumb enough to use a story like our poster boy above would more likely be a legitimate chronic pain patient who doesn't know any better than a scammer, and that this archetypal drug seeker you encounter on so many many med blogs is in reality just an urban legend, stitched together like Frankenstein from bits and pieces torn from real people with real pain who were too naive to know they were walking into a minefield when they stepped into their doctor's office and used the "P" word for the first time. It is highly improbable that so many different doctors, in so many different places, would have had so many encounters with this many individual patients who all presented with almost identical stories.

Snopes.com, the noted debunker of urban legends, defines urban legends as:

...narratives which put our fears and concerns into the form of stories or are tales which we use to confirm the rightness of our world view. As cautionary tales they warn us against engaging in risky behaviors by pointing out what has supposedly happened to others who did what we might be tempted to try. Other legends confirm our belief that it's a big, bad world out there, one awash with crazed killers, lurking terrorists, unscrupulous companies out to make a buck at any cost, and a government that doesn't give a damn.

Folks commonly equate 'urban legend' with 'false' (i.e., "Oh, that's an urban legend!"). Though the vast majority of such tales are pure invention, a handful do turn out to be based on real incidents, and whether or not something actually happened has no bearing on its status as an urban legend. What lifts true tales of this type out of the world of news and into the genre of contemporary lore is the blurring of details and multiplicity of claims that the events happened locally, alterations which take place as the stories are passed through countless hands. Though there might indeed have been an original actual event, it clearly did not happen to as many people or in as many places as the various recountings of it would have us believe.

It definitely seems as if our archetypal drug seeker story meets the definition of an urban legend, both in the sheer improbability of its being true in so many different areas, as well as the fact that it serves to "confirm the rightness" of the medical profession's "world view," which is to err on the side of undertreating pain in patients with legitimate pain problems. If you can convince yourself that everyone with adverse reactions to drugs or who requests a drug by name is an addict, you don't have to go home and hate the person you see staring back at you in the mirror each morning.

Perhaps you should.

How common is "drug seeking" really? No one has ever done a formal study of actual drug-seeking behavior that I'm aware of, but there have been numerous studies on the incidence of actual opiate addiction in chronic pain patients and in the general population as a whole, and every study I am familiar with show very low rates in both groups, the highest estimate being less than 3 percent for cp'ers using a rather bizarre definition of "opioid use disorder," whatever the hell that is, and 1 percent for the general population. So it is really hard to see where this legion of Toradol-shunning Dilaudid zombies is coming from, given the naked facts.

But facts are things that are readily discarded whenever they prove inconvenient in the world of medicine, just as they are in the rest of our world. Far better to cling to convenient half-truths and urban legends if they make you doctors feel better about yourselves, because after all, it's all about you. Most likely, there is at most a small minority of pain patients who fall into the category of drug-seeker and a very large majority of people with legitimate pain problems being falsely accused of drug-seeking out of ignorance and bigotry. Many of those people are forced into the role of drug-seeker by the very fact that doctors are reluctant and unwilling to treat pain aggressively, thus it becomes a self-fulfilling prophesy. If a guy shows up in your ER with excruciating pain and you give him 10 Vicodin, why are you shocked that he would add a "zero" to the "10?" What choice did you give him? Maybe if you had treated his pain appropriately with an adequate amount of medication for the $1,600 he brought into your hospital he wouldn't have had to do that.

But that fact is just too inconvenient for you to hear, isn't it?


scalpel said...

Sean, it's just a variation on the "I have a high pain tolerance, but this _____ REALLY hurts," which is code for either "I can sell the Lortab 10s for twice as much as the regular strength" or "I've abused vicodin for so long that I have to take 4 of them at a time just to get a buzz anymore."

They'd be more successful saying "I'm a wuss and I just can't handle any pain at all." But they rarely do.

If someone really has a high pain tolerance, they don't have 20 previous ER visits for various types of painful (but not physically or radiographically noticeable) injuries and conditions. Normal people don't run to the ER for every little bump and bruise. It costs too much, for one thing. These guys are all self-pay, which is code for "don't pay."

The Rx for ten vicodin is ER code for "I don't really find anything wrong with you physically, and I think you might be a drug seeker/seller but I don't feel like arguing with you, so here's just enough candy to get you out of the ER without me having to call security.

Payne Hertz said...

Sean, it's just a variation on the "I have a high pain tolerance, but this _____ REALLY hurts," which is code for either "I can sell the Lortab 10s for twice as much as the regular strength" or "I've abused vicodin for so long that I have to take 4 of them at a time just to get a buzz anymore."

Well, I'm glad your mind-reading abilities are so well-developed. Why don't you go to a few local banks, talk to the managers, and mind-read the codes to the vaults? You'll make more money that way than playing doctor.

"They'd be more successful saying "I'm a wuss and I just can't handle any pain at all." But they rarely do."

Perhaps if you just told them what you expect of them *you'd* be more successful, such as "give me lots of praise and narcissistic supply, and I'll give you drugs for your imaginary problem, but make a lot of noise while I'm doing something more important, like writing something nasty about you on my blog, and you'll get nothing."

"If someone really has a high pain tolerance, they don't have 20 previous ER visits for various types of painful (but not physically or radiographically noticeable) injuries and conditions. Normal people don't run to the ER for every little bump and bruise. It costs too much, for one thing. These guys are all self-pay, which is code for "don't pay."

Perhaps they are running to the ER because their pain is severe, whether you can see it or not. The simple fact is that our understanding of pain and its causes as well as our ability to detect it is not sophisticated enough for you to make value judgements on people like that. The fact that you feel the need to do so says more about your character than it does about theirs.

"The Rx for ten vicodin is ER code for "I don't really find anything wrong with you physically, and I think you might be a drug seeker/seller but I don't feel like arguing with you, so here's just enough candy to get you out of the ER without me having to call security."

It is both illegal and unethical to prescribe opiate medications for anything but pain. If a person is in pain, you should treat the pain appropriately and not play head games with them. It seems that what you will or will not prescribe is based entirely on what's convenient for you, rather than what is in the best interest of the patient. Unfortunately, you're not alone.

Payne Hertz said...

To Addiction:

I have deleted your post as it appears to be nothing but spam. If you wish to contribute something to the debate that is fine, but any post that consists of little more than a link to your site will be deleted.

Juba said...

Very nice article, Sean. Especially this part: "the drug-seeker is universally blamed by both doctors and patients alike for the hostile and negative attitudes people with chronic pain routinely encounter from the medical profession."

The greater acceptance of the use of opiates to treat severe short-term and chronic pain in the past twenty years or so has also created an opportunity for the DEA to justify its existence, after it had failed miserably in its mission to reduce the supply of illegal drugs.

The DEA pressures doctors and so doctors refuse to provide adequate pain relief for patients. Patients desperate for pain relief engage in pseudo-addictive behavior in their search for relief and so the cycle feeds on itself.

The saddest part of this situation is that it has also resulted in some chronic pain patients blaming other chronic pain patients for the DEA crackdown. They are so afraid of losing their own pain meds that they can be very quick to brand others unfairly with the scarlet letter of "drugseeker"

Payne Hertz said...

Nice comment, Juba. The DEA's role in all this is interesting, because most of the attitudes and prejudices pain patients face predate the DEA and even the War on Drugs, but the DEA has served to reinforce these attitudes both by propagating them in the media, and by pressuring doctors who then embrace these attitudes as a rationalization for their own moral cowardice.

I think cp'ers find themselves looking for someone to blame too, but I think people need to remember drug-seeking wouldn't even exist if it weren't for the War on Drugs, as no one would have to go to a doctor for pain medication and if they did, doctors would have no reason to fear prescribing them. In Switzerland, the UK and other countries there are programs where drug addicts are treated with heroin. These programs have been very successful at helping addicts clean up their lives and become functioning citizens again, even with their continued use of heroin. This is a civilized, modern approach based on reason and science. Drug-seeking is a medical problem, regardless of whether it arises from untreated pain or an untreated addiction to opiates, and it should be treated accordingly.

old goat said...

Well I found my doctor in our friend Mr Scalpel. No more office visits, just a phone call and he can diagnose me just like that. I am impressed, that's some amazing medicine.
Of course there could be a chance that the guy he gave the 10 Vicodin to may have had his appendix rupture a couple of hours later, but since it's one fewer "drug seeker" in the world, who cares?
I wouldn't wish pain on a soul, being far too well aquainted with it. Let me make that 100% clear, there's enough pain in this world of ours. But someday I do hope you have the luck to run in to a doctor that shares your opinion that all patients are seeking drugs, and you leave the ER in agony, after being labeled a pillhead, How successful would the patient have been if they told you that you don't know jack about treating pain?
I guess honesty is not the best policy when dealing with someone like you. So much for the "Psychic Medical Network...

codeee01@hotmail.com said...

Excellent article Payne Hertz.
I only wish every doctor READ Snopes,
but since they depend upon drug reps for "education", that's probably not likely. For those in chronic pain, the real tragedy of this is that many of us DO have horrible reactions to N-Saids, and the new COX-2 inhibitors. That automatically makes us drug seekers, even if we've been through the tests, have documentation, and are just seeking care after the good doc has retired of moved. We're damned if we don't and damned if we do...so are we to take a course of gut splitting N-saids just to make these chicken sh*t docs happy? I know of several elsewhere with hundreds of patients on heavy duty meds. When dragged into court, they put on a party hat and GO..and they come out of it just fine. It's a pity the rest are like Chicken Little, certain the sky is falling, and more willing to let you roll in agony or bleed out than write that prescription! After all of these years, and consistant
records, I KNOW I have bad reactions. Still, I took the Celebrex home, and spent a hellish two days. What are we to do to protect ourselves, yet not fit their pigeon hole definition of DRUG SEEKER!

Anonymous said...

scalpel-----you are a very scary man----please cease this charade at humanitarianism and seek employment or ownership in/of a coffeeshop, where you can sling caffeine and callous comments, whilst hopefully the vacancy in your previous job will be filled by a young freshly scrubbed bright young thing who has yet to become a jaded vessel of bile and bitterness -----

Anonymous said...

Great post. I esp. like the points about undertreatment of pain leading to what looks like "drug seeking." Who wouldn't seek drugs when their pain is continually undertreated or even untreated?

Indig Nation said...

Four years ago I went to the community hospital (Cheboygan Memorial Hospital) because I was experiencing severe backpain as well as many other symptoms like a racing heart and my mind screaming for relief.They did a few tests,ekg and xrays, then told me I had acid reflux.Then they gave me something that eased the pain and sent me home telling me when it bothers me to put my feet up on a pillow and take 4 or so bayer or something to help with the pain.Didn't work and after awhile I went back and they did the same thing make me wait 4 hours in the err.Finally they they did their tests and scheduled me for a ctscan,which produced nothing but a large bill.I suffered thru it more eatting bottles of over the counter pain relievers until I was sick of it and went back to the hospital.They didn't do much for tests anymore and one of the times they even gave me a nitro for the pain ??? Which worried me.Is there something wrong with my hearts?!? I was only 30!!!Then they sent me away again,but the pain continued.
So I went back again and again.After six months of this a doctor tells me they aren't going to help me anymore and the pain I had I was making up in my head,and that I was only there for drugs.I took off the gown got dressed wadded up the gown walked up and threw the gown at the doctor and told them they were quacks and didn't have a clue.I also told them not to bother sending me anymore bills and be happy with whatever they screwed BC/BS out of as payment cause I didn't come here to be insulted and I wasn't going to pay for it.then I stomped out of the hospital and went to another (Northern Michigan Hospital) which is about 40 more miles away.Told them what had been going on for the last 6 months and what had just happened and that I wanted them to get a copy of my records from CMH and notice the high white bloodcell count and decide if you agree with them or think they can help.The doctor said he had his suspicions and scheduled me for an ultrasound.I told him I wasn't pregnant as I'm a male but he insited and I said ok pretty much willing to do whatever was needed to end this problem that I wasn't imagining.So I went and took the ultrasound and the tech whispered to me that she thinks we found the problem ut she can't say it officially but I knew what she was talking about.The results end up getting back to me in a few days and the diagnoses was gallstones! Incredible!!

The surgeon took out my gallbladder and told me it was a little difficult getting it out and that it should have been removed a long time ago.He said my symptoms where textbook.

Finally the pain of that had ended.I payed my bill and onto the next problem,CMH.

They marred my credit,harrased me with collection calls.Accused me of things that weren't trued and did me no service in my opinion.The bill is more that what it actually cost to get my problem taken care of.Finally for years later were about to go to court over it.They are trying to sue me for the money unhappy with screwing BC/BS for six months.Greedy unhelpful bastards.I tried finding a lawyer to counter sue them but they arent any available here at this time it seems.They are either to busy or there isn't enough money in it for em.I wonder myself what it worth but it appears that I'll be going it alone before they top dollar lawyer and a court system that I have no faith in either.They have to garnish my wages to get any money out of me for their so called service even if the judge decides I should pay.If he does side with them which I hear they will I'm worried how I'm going to react cause i'm sick of getting screwed by all of em and would just as well like to blow them the fuck up.None of them care about doing whats right CMH doesnt provide health care and the 89th district court doesn't provide justice and I would rather be a legend......

Less Indignation said...

Ok I'm calmer today
So I'll try to be more helpful this time.

"Gallstones are the most common cause for hospital admissions of patients with severe abdominal pain."


Most of the time I felt as if I was suffering back pain but never had any prior back problems.At other times it felt like I was having a heart attack.Alot of the doctors put a time frame on this with eating but it never bugged when I ate or in a normal pattern to food consumption so I'd toss that theory and also the fatty food idea,while it may apply to some it didn't in my case.The causes are obviously still widely misunderstood as well as some of the symptoms.It is also a condition that may only happen once or may happen more persitently.

The article I linked to in this post is the best one I could find at this time but I did find other reports of the drug seeker phenom assosiated with this problem.

If you actually care about your patients consider it,learn the symptoms.You might actually help a few more people.Print it out an give a copy to your ER doctors.

Thanks for the opportunity to offer one suggestion Payne Hertz maybe you'll also prove the butterfly effect via your blog 8)

Anonymous said...

If you look at scalpel's profile you will easily see he's a right wing asshat fascinated by guns and violence. Unfortunately there are many like him in the medical profession. I have been fortunate enough to have had compassionate care in the past and I thank God I have not had a 'doctor' like scalpel.Bitter right wingers like him should not be parcticing medicine period!

docalex said...

Hello payne,

And hello to your distinguished Commenters - juba, oldgoat, and codeee are names I recognize from various blogs and forums about the drug war or the pain crisis or addiction or addiction treatment or pain treatment. These guys are drug/pain OG's, payne, as are you, as am I.

So, being as I am in such excellent company, I thought I'd mostly just say "hello comrades," but I'll also take the opportunity to answer a direct question you asked in your "Drug-Seeker: an Urban Legend?" post:

You asked what the hell "opioid use disorder" actually meant. This, admittedly somewhat tortured phrase, is actually the correct and current, and pretty good imo, Diagnostic Statistical Manual (DSM) diagnosis. Opioid Use Disorder includes two sub-disorders: Opioid Abuse, and Opioid Dependence.

The DSM is sort of like a Chinese menu, add up criteria to make a diagnosis, system. Opioid Abuse means, basically, an inability to control use such that harm to self of other results, and you still keeping using while your life gets worse and worse. Opioid Dependence is a superset of Opioid Abuse - that is, all of the above, plus signs and symptoms of "tolerance" or "withdrawal."

"Addiction" is, once again, a valid medical/scientific term, and is roughly equivalent to DSM Substance Dependence.

The contrast to Opioid Use Disorders is the average chronic pain patient for whom opioids are indicated. For this person, daily opioids, even in tremendous doses, improves global functioning and quality of life.

An interesting group who sort of fall through the cracks of this clinical nomenclature scheme are successful methadone maintenance patients. People whose live improve sometime to a state that could only be called complete remission from Opioid (heroin, say) Dependence. These patients are actually more similar to chronic pain patients who never had addiction problems, in that they do better on chronic daily opioids, and generally the higher the dose the better they do.

Blah, blah, blah. Ex-doc nerds like me find this stuff interesting in detail. The drug/pain OG's all know this stuff, in their bones from doing their homework; bluntly, they RTFM. Hell, they wrote and are writing The Manual, as they consistently fight the good fight, the smart fight, the educated fight.

Hat off to all. payne, hope this Comment finds you well. And let us in PRN know if you aren't, OK? You are a soldier. We love you and yours.



hannah said...

I never go to my doctor anymore asking for pain killers prescription and then be turned down at the end, all I do is order online from www.medsheaven.com hassle free and low cost, they have three pain killers listed on their website which are ultram tramadol celebrex that you buy, and the best part is no prescription required!!!

Touchet said...

This reminds me of the time I went to the ER in pain a couple of time within a week, and they didn't do any test but gave me that 10 bottle of "candy". The next month i was in an ambulance from a ruptured appendix. They STILL didn't believe me. I remember the pain, and being cold, and when I asked the nurse, she THREW me a blanket.

CT scan latter, the doctor is apologizing to me and saying we have to do immediate surgery.

My Opinionz said...

I was a seeker. Yes that devious evil drug seeker. A lot of seekers seek because they want to postpone the awful withdrawals. Its a horrific nightmare. I have been clean for almost 2 years now and it has been really hard. I dont have it in me to list all the withdrawal symptoms. Thats why i was a seeker. A cdiverters different entity than diverters and people wanting to get high. The withdrawal seekers just want to feel normal again. They dont want a buzz.