Drug-Seeking Patients

Imagine being addicted to a prescription drug -- pain medication, muscle relaxants, or perhaps sleeping pills. To what lengths would you go to get your drug of choice? Feign low back pain? Present to an urgent care center holding your left flank, wincing, and claiming that your urine is pink? Would you go so far as to have elective surgery to secure a supply of pain pills and sleeping aids? It may be hard to fathom, but if you were genuinely addicted you'd do all of this -- and more.

According to a recently released President's National Drug Control Strategy report (www.whitehousedrugpolicy.gov), 6.2 million Americans in 2002 reported having used prescription drugs for nonmedical reasons during the month prior to the study. In terms of illegal use of drugs, this ranks second only to marijuana use. As a practicing physician, the odds are that you are faced with the occasional (or more-than-occasional) drug-seeking patient. How you respond to them is important.

Unfortunately, drug-addicted patients are not always easy to spot. College students, executives, suburban moms, academicians -- even physicians themselves -- can all succumb to addiction. In addition to those who self-medicate to ease emotional pain, there are plenty of addicts who started taking narcotics for a legitimate reason -- perhaps following an injury or major surgery. These patients can be more motivated to kick their habit, and physicians would do well to talk to them about getting into treatment for addiction.

You may also encounter individuals trying to secure narcotics for a family member or friend, or to sell on the street for a profit. This is known as diversion.

Recognizing drug-seekers

Phoenix-based addiction specialist Mike Sucher, MD, says the best way to know if you've got a drug-seeking patient in your office is to pay attention to your intuition. "If you think you're being conned, you probably are," says Sucher. "But a lot of the time you don't have a clue." Addicts will go to great lengths to obtain their drugs. As they become more addicted, seeking their next fix becomes a full-time job for many of them. 

"I kept waiting to see if this patient would ever tell me where he was hurting," recalls Timothy McNichols, a Springfield, Mo.-based internist. "He just kept saying he was in pain and needed narcotics. He didn't appear to be in any pain. I ordered a CT to give him the benefit of the doubt but it didn't show anything. When a patient is genuinely in pain they look like they're in pain and they'll tell you where, and describe the pain."

Faking pain, "losing" medications, and claiming allergies to all nonnarcotic pain relievers are common tactics used to get drugs -- but dedicated drug-seekers will go to great lengths to get their drug of choice. L. Todd Stewart, MD, confronted one such patient when he discovered she'd been getting drugs from multiple physicians and multiple pharmacies. "She said she was an undercover agent trying to trap street drug dealers. When I suggested we contact local authorities to confirm her story she said we shouldn't because it would blow her cover," says Stewart from his pain treatment practice in Gainesville, Ga. 

Stewart believes common sense goes a long way in identifying these patients. "I always ask myself if the pain makes sense, if it follows an anatomical pattern. If a patient says their pain starts in the back, runs up the shoulder then to the back of the head, around to the nose and into their chest, well, something's not right."

The flip side of being vigilant in recognizing drug-seeking patients is not allowing yourself (or your staff) to become jaded or overly skeptical, as William Dachman, MD, an internist at the Maricopa Medical Center in Phoenix, found out. "An elderly patient said her daughter had been stealing her medication so she hid her pills in the oven, but forgot they were there and turned on the oven. We had her bring in the ruined medications and, sure enough, she'd baked them." 

Finding the balance

Concern over potential legal issues when it comes to prescribing medications can be a stress factor for already overloaded physicians. "In the big scheme of things this is not something I spend a lot of time worrying about. But I do think about it every time I write a prescription. I stop to think if someone is looking over my shoulder. Am I writing too many? What's too many?" says Dachman.

In recent years physicians have found themselves in a difficult situation, at risk for censure both for over-prescribing and for failing to adequately treat the more than 10 million Americans who suffer from chronic pain. The answer lies in having consistent policies and finding the right balance so that you feel confident in prescribing without getting yourself into trouble.

In a joint statement from 21 health organizations and the U.S. Drug Enforcement Administration (DEA), it's clearly stated that undertreatment of pain is an issue, that the use of opiates is "often the only treatment option," and that helping both medical and law enforcement personnel be more aware of the issue will enable wise decisionmaking.  (See the full statement at www.deadiversion.usdoj.gov/pubs/pressrel/painrelief.pdf.)

Physicians can take some comfort in the fact that in 2003, less than 1 percent of practicing physicians were subject to investigation by the DEA. 

Create office policies

"Pain will usually fall into reasonably predictable patterns. If a patient continues to complain of pain beyond the time when the pain from whatever procedure or problem they've had should have dissipated, then there is one of three things going on -- the patient has a complication, another condition has arisen causing new pain, or they're conning you," says Sucher. It's important to have a plan for how you will deal with these patients.

Often physicians just want to get a drug-seeking patient out of the office as quickly as possible. They don't have time to negotiate with a difficult patient, don't want to risk being accused of improper prescribing, and the thought of getting into a conversation about substance abuse can be daunting. 

McNichols makes his policies clear at the outset. "If I'm at all suspect I simply tell people that I don't prescribe narcotics for new patients until I've reviewed their old records. I also tell them that if there is any discrepancy between what they've told me and what their records indicate, they won't be my patient." 

Here are some ways to keep drug-seeking patients from slipping into your practice:

• State your position clearly -- don't be seen as an easy mark.
• Ask for a list of all previous doctors on the new patient intake form.
• Ask about all current medications and those from the recent past.
• Get a medical record release and let the patient know you'll be reviewing records from their previous doctors.

If you find yourself caring for a drug-dependent patient who has no diagnosable pain, you can:

• Offer nonnarcotic treatment options, but realize that a drug-seeking patient will likely not go along with such a plan and may seek care elsewhere.
• Point out the risks of addiction and refer the patient to a psychologist, addiction specialist, or drug treatment program.
• Refer the patient to a pain specialist.

It's important to remember that pain medications are not the only problem. Plenty of people are addicted to benzodiazepines, muscle relaxants, and sleeping pills. Sucher points out that it's extremely difficult to get patients off benzodiazepines, the determining factor being the dose they've been taking and for how long. Great care must be taken to wean these patients properly -- or have them undergo supervised withdrawal -- in order to avoid potential adverse effects.

Protect your practice

Whether you're prescribing narcotics or choosing not to prescribe them, documentation is critical. Thorough notes regarding your decision-making is the best defense should any questions arise. 

If you are prescribing, records should include a history and physical, evidence of any nonnarcotic treatments that have been tried, what adjunct therapies are being used (such as physical therapy or relaxation techniques), periodic re-evaluation of the diagnosis and pain levels, and how the patient is responding to treatment. If a patient has a history of substance abuse, that should also be included in the record, along with how you are approaching their care given that history.

When you elect not to prescribe narcotics, be honest about your reasons. If you feel that taking care of a patient who needs ongoing narcotics is simply beyond the scope of your practice, you have the right to refer the patient elsewhere. 

Pain specialists are very adept at managing these patients, but they're not immune from being taken advantage of. "You have to care enough to keep a clean practice," says Stewart. "In our practice every patient getting narcotics signs a contract. It says they'll get their meds only from us and only from one pharmacy, that they may be required to be evaluated by a psychologist, that we will drug test them, that we never prescribe on weekends or after 4:00 p.m., and that if any of these conditions aren't met we reserve the right to dismiss them from the practice and refer them elsewhere."

He adds that two-thirds to three-quarters of patients he tests for drugs in their system "come back positive for something -- marijuana or other street drugs, some other prescription medication, or sometimes they don't have the drug I'm prescribing in their system at all. If a patient refuses a drug screen they're dismissed from the practice with arrangements for a weaning schedule." 

How to Spot Drug-Seeking Patients

• Vague symptoms of pain.
• Conditions that are difficult to prove or disprove -- low back pain, neck pain, migraine, renal colic, toothache.
• Pain that doesn't make sense; symptoms that don't add up.
• Requests for medication by name and dose.
• Medical knowledge beyond the realm of what you see in the average patient.
• Allergies to nearly everything -- except the drug of choice.
• Patient calls ahead to see who is on duty at the clinic, ER, or urgent care center.
• "Bad-mouthing" previous physicians.
• Hesitant to follow through with a work-up to get to bottom of a problem.
• Losing prescriptions or medications.
• Alert from a pharmacy or insurance that a patient is getting meds from several sources.

The bottom line is, if you suspect a patient is addicted and seeking drugs, use common sense, listen to your intuition, document thoroughly, and always keep the best interest of the patient at the forefront. It's your responsibility to prescribe the right drugs for the right patients at the right time. Be attentive, compassionate, and prudent with your pen so that both you and your patients are comfortable.

Karen Childress can be reached at editor@physicianspractice.com.

This article originally appeared in the June 2004 issue of Physicians Practice.