Sometimes, first responders are faced with philosophical and ethical dilemmas, problems that arise that are outside of their medical protocols. So, the resolutions aren’t black and white.
One such question that I’ve been pondering is, “How do we treat the ‘drug seeker’”?
Pain treatment or not?
Drug seekers are the patients who call on us for pain medication. They might be addicts, or they might be suffering psychologically. Our medical training tells us that they don’t qualify medically for pain treatment. Or do they?
As I often do, I surveyed my crew at the kitchen table and asked, “How do you handle the drug seeker?” Initially, the overwhelming response was that first responders shouldn’t give pain medication to drug seekers.
Playing devil’s advocate, I posed two follow-up questions:
- “What indicators direct first responders to arrive at the conclusion that the patient isn’t suffering from legitimate pain, in which case medical intervention is necessitated?”
- “For a drug seeker, is calling an ambulance the most cost-effective way to a quick high?”
A very lively debate ensued.
“You just know when you’re dealing with a drug seeker. They call all of the time. You can tell they aren’t for real.”
Given the possibility, too, of “frequent flyers,” first responders are less likely to treat patients who cry wolf.
Level of intervention
At its root, withholding medication from patients could be interpreted as a negligent behavior. So, how do you navigate those waters? Diving deeper, I referenced the medical protocol on pain management.
In my medical system, we use a person-centered method to assist the first responder in determining the level of intervention. Specifically, we are directed to use a threefold approach:
- Consider whether pain is due to acute, chronic or acute on chronic exacerbation causes
- Assess pain medication history (over-the-counter, prescription and herbal)
- Is the patient opioid-naive, opiate-tolerant, opiate-dependent or known to be misusing opioids?
Regardless of the number of times that you transported a patient for pain management, your aim as a first responder is to provide that person with an individualized pain-management goal.
My EMS system goes as far as to spell out the pain-management goal: Pain is to be reduced by at least two points on the pain scale—zero (no pain) to 10 (the worst pain imaginable)—or to tolerable levels. The treatment could include a progressive approach, perhaps starting with a nonopioid option, such as splinting, distraction, imagery, cold packs, Tylenol or nitrous oxide.
Being excellent paramedics, my crew understands the protocol inside and out, but they also understand that a drug seeker isn’t looking for imagery techniques, etc.
Often, we are told by drug-seeking patients that they are allergic to the lesser pain-management interventions and that only morphine, ketamine or fentanyl will work.
I reiterated my previous question: “Is calling an ambulance the most cost-effective way to a quick high?”
Nodding in agreement, my crew understood where I was going but stood fast that it didn’t matter. The reality: Many patients seek drugs via ambulance transport. It happens across the country and, probably, all over the world.
My crew collectively agreed that the ambulance ride is a means to an end. Once the patient is at the hospital, the individual might be able to obtain a prescription for pain medication, then the cycle plays out again and again.
Experience and protocols
First responders learn early on in their training that pain is subjective, not objective, and we must rely on context clues when treating patients.
When confronted with ethical obstacles, such as whether to treat the drug seeker, we as a medical community must draw on experience and rely on our protocols to guide us in the best course of action.
