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Friday, January 15, 2016

In the Drug War’s Emergency Room

Drug prohibition hurts hospitals

Every day, I see people during the worst moments of their lives. As an emergency room doctor, I see the victims of violence, disease, and age at their most vulnerable. During one of my more depressing shifts, a nine-year-old girl (let’s call her Nancy) came into the emergency room with an arm broken at a 90 degree angle. On that same night, a drug-seeking patient (let’s call him Richard) came into the hospital for the fifth time that month with the same concocted excuse.

While I worked on Richard’s fake ailments, I was unable to alleviate Nancy’s excruciating pain. She suffered with little more than a stuffed animal to comfort her because Richard needed his fix.

In an environment of drug prohibition, patients like Richard are not rare. But it is not the sheer number of drug seekers that exacerbates what is already a problem of ER overcrowding. It is also the ailments that drug seekers like Richard create. They tend to invent symptoms indicative of serious illnesses that offer a quick ticket to the back and the best chance for intravenous drugs.

Unfortunately, those complaints require hefty ER resources, which would have otherwise helped people like Nancy. Worse still, addicts repeat the trick. One of my drug-seeking patients made 183 visits to my emergency department in a year and visited at least two other emergency rooms. Based on my experience, I estimate that drug seeking accounts for 20 to 30 percent of all ER visits.

Scholars corroborate my estimate. One researcher claims that drug seeking comprises as much as 20 percent of all ER visits. Meanwhile, ER visits for narcotic medications rose at least 75% for all age groups between 2004 and 2009. ER doctors prescribed 49 percent more painkillers in 2010 than in 2001. Painkiller prescriptions (drug seekers’ favorite fix in the heroin-opioid epidemic) for ER dental complaints alone rose 26 percent between 1997 and 2007.

One study found that a group of patients at risk for drug seeking averaged over twelve ER visits per year. Participants also visited multiple hospitals — over four, on average — using multiple aliases. Another study found the situation to be worse, with drug seekers visiting the emergency room an average of 14.5 times per year (versus non-drug seekers visiting about two times a year).

ER drug seeking is so rampant that it has become a favorite online topic among healthcare providers. They discuss it in forums, dedicate numerous blog posts to the subject, and even write parodies with titles including, “ER Places Bowl Full of Percocet in Waiting Room, Lowers Visits.” Healthcare providers (such as ER doctors and nurses) have even reported violent addicts who had been denied drugs waiting to exact revenge in parking lots.

Many providers have become so frustrated that they prefer to risk under-treating pain in non-drug seekers than be burned again. (This is a shame, considering that identifying drug seekers is difficult, leading to widespread — and racially unevenunder treatment of pain.) Some healthcare providers now sadly believe that ER patients with honest pain complaints are the minority. Presumably in an effort to relieve the side effects of drug seeking, one ER doctor won a “Best of Craigslist” designation for anonymously telling drug seekers how to obtain drugs quickly and without annoying the staff.

Healthcare administrators have taken action to combat ER drug seeking. They have created “habitual patient” files in order to track suspected drug seekers. Some hospitals have also adopted computer systems to identify and track suspect patients. For example, patients are enrolled in one such program if they visit the ER more than four times in one month, whenever a staff member is concerned, or if the state has convicted the patient of prescription fraud. Other hospitals have increased physician education to help identify drug seekers. Administrators have also considered adopting screening tools utilized by pain clinics.

The prevalence of ER drug seeking has also caught the attention of legislators. Nearly every state has a prescription drug monitoring program, intended to help providers determine whether a patient is lying or over-prescribed. Some states have linked these databases in order to limit out-of-state “painkiller tourism.” Several states prohibit “doctor shopping,” by which drug seekers obtain prescriptions from multiple providers.

New York City limited ER opioid prescriptions to a three-day supply and imposed other rules. The FDA, DEA, and other federal bodies have guidelines affecting ER prescriptions. Perhaps the most telling sign of an important social problem is the contradictory policy requirements intended to solve it. While the DEA threatens loss of licensure for excessive ER prescriptions, other publicly-recognized bodies threaten hospital staff with retribution if they inadequately prescribe.

This preoccupation with ER drug seeking is the result of the sizable problems that it creates. For example, drug seeking almost certainly increases wait times and sucks up ER resources. That damages the healthcare of anyone who needs hospital care — so essentially, everyone at one time or another. Considering that drug seekers are rarely well to do enough to afford health insurance, ER drug seeking probably drives up healthcare costs, too. And because prohibition encourages addicts to game the healthcare system, instead of patronizing legal businesses offering safe and inexpensive drugs, the law victimizes addicts as well.

I don’t blame Richard. Under drug prohibition, he has two places to get his fix: medical outlets like emergency rooms, or the streets. Some are surprised that people like Richard favor hospitals with their bureaucratic hurdles, gatekeepers, and other annoyances. But on the streets, he faces violence, incarceration, job loss, and impure, expensive drugs.

If there were a third option — to buy drugs legally — drug seekers would face a new equation. Under these new incentives, at least some (and probably most) ER drug seekers will prefer legal highs from salons and shops over clinical and bureaucratic emergency rooms and dangerous corner dealers. And as ER drug seekers disappear, so do all of their associated problems. So support an end to the Drug War, if not to right its other innumerable wrongs, then for anyone who will ever urgently need ER care — like Nancy, your family, or yourself.

  • Dr. Geoffrey Hosta is a board-certified emergency room doctor with over thirty years of experience in emergency medicine.