Analyzing Addiction: Part 1



Mitigating the effects of opioid-seeking behavior on hospital staff

A mushrooming increase in the abuse of opioid painkillers across the nation has cities, counties, states and the federal government all mobilizing task forces to investigate the crisis and act to reduce the deaths and misery stemming from this phenomenon.

The desperation of addicted people has had a ripple effect on institutions that come into contact with them, including a big impact on hospitals and their front-line staff. Stark consequences of the crisis can be seen and felt in Indiana emergency departments and other hospital settings on a regular basis.

A distressing trend of aggressive behavior by addicts seeking opioids has jolted the working environment, increased confrontations and, at times, made staff fearful for their safety. Hospital executives are moving to safeguard their employees while strategizing how to reduce the pressure that hospitals are experiencing.

The impact of addiction has spread to inpatient units, obstetrics and even intensive care units, but it plays out most intensely in emergency departments (ED), says Warren Forgey, president and CEO of Schneck Medical Center, Seymour.

“Of all the issues before me at this point, my first priority has become the protection of my own staff. Not discounting the needs of the patients at all, I don’t want to do that, but in order to take care of patients, I’ve got to have staff in place and feel comfortable doing their jobs.”

Michael Keller, M.D., an emergency medicine physician with a specialist staffing group, estimates that confrontational situations happen once every other shift in EDs he helps run, including in Marion and Fort Wayne. “We encounter patients who are verbally abusive, physically abusive. Nurses especially are front-line on a lot of that stuff. They get kicked, punched, spit on…and it’s assault by a patient, and sometimes it occurs because we aren’t giving them what they want.”

Confrontation or not, the experience is draining and rife with second-guessing, says Ann Vermilion, administrative director of medical staff services for Marion General Hospital. Often when a doctor, nurse or other ED staffer finished a shift, “They just felt like, ‘Wow, I would sum up that a lot of our patients today were really just seeking opioids.’ And the hardest part for them was to make that emotional decision to say, ‘Did they really need it? Were they in pain?’ Because our business is to take care of pain, to understand what’s going on in a patient’s body and take care of it.”

An encounter in mid-March at Lutheran Hospital in Fort Wayne typifies what happens regularly, says Keller. A woman came to the ED with a common cold, including a cough, and when told it would go away on its own kept demanding cough medicine, specifically with codeine and hydrocodone. Keller typed her name into INSPECT, a state-run database reporting opioid prescriptions, and found that during the past 365 days, she had at least 65 scripts filled for hydrocodone, oxycodone, Tussionex (containing hydrocodone) and cough syrup with codeine. Her request this time was refused.

The patient’s reaction was a torrent of complaint about how the hospital was not doing anything to treat her, and a demand to talk to a nurse manager, who spent valuable time trying to de-escalate the situation, Keller says. “It’s a real burden, it brings the emergency department flow to a halt, because now I’m tied up with the lady with a cough and cold, which should take 10 minutes for the whole encounter, [and] now it’s turned into a 45-minute ordeal that involves a nurse manager…while other patients are sitting out in the waiting room.”

Diversion of hospital resources goes much further. Forgey says he approved hiring armed guards as of Feb. 1, something he thought was never going to be necessary in rural Seymour. “When I have nurses, clinicians, even physicians coming to me and saying, ‘We don’t feel safe, we don’t feel like we want to come to work’ because of these situations, that was my first priority, to protect staff and bring armed guards in.” With their mere presence a deterrent, Forgey has already noticed a decline in these incidents.

Stiffer policies on dispensing opiates in the ED are trying to turn the tide. At Scott Memorial Hospital in Scottsburg, medicines are prescribed “not to give you a supply to go with you, but to treat your episodic condition,” says CEO Michael Everett. At Schneck, clinicians try to use non-opioid drugs, and often that is a reasonable approach, says Forgey.

“Unfortunately, patients sometimes aren’t satisfied with that,” Forgey adds. “Many patients will not only give us the name of the drug, they’ll suggest the dosage.” And if refused, “They’ll tell us if they can’t get it here, they’ll go down the road to the next ER. And we usually tell them, ‘They’re going to be looking at the same INSPECT [record].’ ”

Marion General Hospital went so far as to develop a greatly restricted policy on opioid dispensing meant not only to guide ED practices, but also to be handed out to all incoming visitors, read in full and signed, says Vermilion. A comprehensive initiative came together to hammer out the policy in 2014, after data developed by the hospital determined that the ED had prescribed an opioid or other controlled substance for 21 percent of all patients in 2012-13.

The pain policy doesn’t interfere with physician judgment on whose acute pain needs medication, says Keller, Marion’s medical director of emergency services. But for people with chronic pain under physician management, the ED won’t be the one to refill medication. The patient likely has a plan already in place with a pain specialist, who typically requires patients to sign a pain management contract that stipulates they can’t seek drugs from someone else. The ED policy reinforces that.

“It helps take the burden off the provider,” Keller explains. “We can say, ‘Here’s the department policy, and I can’t give you pain medicine because we have this policy in place.’ And then the patient realizes, ‘Okay, this is a systemwide thing, it’s not just a provider being a “jerk” and not refilling my medicines.’ ”

Besides the altered approach in the ED, physicians throughout the community underwent a series of briefings to understand the problem of overprescribing opioid medications and their impact on the community, Vermilion says. The hospital also worked closely with law enforcement officers.

The resolve to gain control of the opioid abuse issue had its roots in a reality check arising from discussions with local police about the rising epidemic. When Vermillion pointed out the gravity of the problem to a law officer, “he turned to us and said, ‘Yeah, and every case where we arrest or are working on [an arrest], the prescription bottles that we find are from your doctors.’ And that is the worst feeling in the world.”