Regardless of your practice’s specialty, drug-seeking and drug-addicted patients are almost certainly part of your daily reality. As more patients struggle with prescription abuse and misuse, the number of overdose deaths is reaching epidemic proportions. In fact, prescription drug overdoses have surpassed car accidents as the leading cause of accidental deaths among people ages 25 to 64, according to the CDC. As the numbers continue to swell, physicians need to reevaluate how they approach, and potentially dismiss, drug-seeking patients.
The toughest conversation
If your patient is exhibiting several red flags of drug-seeking behavior (see sidebar below), what's the first step you should take to address the situation?
Shawn Williams, acting medical director at Willingway, a Georgia-based addiction treatment center, said it is confronting the patient. He typically begins the conversation by saying, "I am concerned about writing for further narcotics or controlled substances for you. I'm more than willing to take care of your medical needs, including your pain. But, it will involve non-controlled substances at this point."
That approach nets one of two outcomes: The patient either agrees or disagrees.
Still on the Fence about Whether a Patient Is Drug-seeking?
These red flags for drug addiction may help you decide.
• Patients frequently request early refills because their medication was "lost" or "stolen."
• Patients claim they are allergic to numerous non-opiate pain relievers.
• Patients specifically request a higher-potency drug by name.
• Patients prefer shorter-acting narcotics instead of the recommended longer-acting medications.
Williams finds if patients are truly drug-seeking, they may deny any addiction and reject help rather quickly. And then, they'd move on to find another physician to temporarily feed their addiction, until they were confronted yet again or finally acknowledged the problem. So, essentially, they would dismiss themselves from your practice as a result of that initial conversation.
But Williams also sees patients who genuinely want to mend the damaged doctor-patient relationship. "The patients that are legitimate often will say, 'Listen, I've built a relationship with you and I hate the fact that I've broken your trust,'" said Williams. For those patients who are truly open to change, reconfiguring their treatment plan so that it eliminates or severely limits the use of controlled substances is critical.
Undoubtedly, these conversations will be difficult to have, especially with patients whose judgment may be clouded by addiction. Patients may become defensive, angry, and belligerent — all while still desperately trying to excuse their behavior.
While it's vital that physicians approach every suspected at-risk patient, the bulk of interactions may not yield successful outcomes.
Damon Raskin, a board-certified internist and addiction medicine specialist in Pacific Palisades, Calif., said that only a small percentage of drug-seeking patients really do want to get better. "Maybe 20 percent of them will actually try and get better or realize there's a problem," said Raskin. "And then, probably 70 percent to 80 percent are just going to continue their addiction until they're ready. A lot of the time, they're just not ready."
Continuation of care
So for the roughly three out of four drug-seeking patients who, once confronted, aren't ready to address the issue, physicians can still provide indirect care options.
"It's not like I'm going to abandon the patient. I'll provide them with referrals. I'll provide them with information on where to go for help in terms of addiction issues," said Raskin.
Those referrals may be to Narcotics Anonymous meetings or outpatient and inpatient treatment facilities. And since mental illness can be a risk factor for addiction, evaluations by psychologists and psychiatrists may prove helpful as well.
By taking the time to establish a network of professional resources, physicians can make those referrals more easily and confidently. "If I wasn't a practitioner who was experienced in treating addiction, I would probably have an addiction medicine physician on my speed dial," said Williams. "It's better to get a second set of eyes on the patient, especially if it's not your area of expertise."
Final destination: Patient dismissal
Many states have created online databases where physicians can report, as well as track, the dispensing of controlled substance drugs, and see if a patient is doctor shopping. For example, California has enacted the CURES Program.
Patient dismissal shouldn't be a knee-jerk response. Physicians should take care to exercise due diligence by following the steps recommended above: confront the behavior, offer alternative pain-management therapies, and then provide outside referrals too. And all of it should be thoroughly documented in the patient's chart.
But, despite your best efforts, patient dismissal is sometimes inevitable.
"Eventually, it is a liability to give drugs to patients who you think are addicts — that's ethically, legally, and morally wrong as physicians," said Raskin. "I send the patient a letter that says, basically, I have to dismiss them from my practice."
The letter doesn't list all of the reasons for dismissal, but it does serve to further extend a physician's due diligence. It states that, for the next 30 days, the physician will continue to be available to the patient for emergency situations. It also expresses the importance that the patient seek treatment from another physician as soon as possible and that their medical records will be forwarded as necessary.
[Download a sample dismissal letter to use at your practice.]
This is an oversimplified version of the dismissal process though. There are specific guidelines physicians should follow to avoid further legal implications. Due to the intricacies of the law, physicians would be best advised to consult legal counsel for the specific procedure in their practicing state.
Unfortunately, patient dismissal due to drug-seeking activity is no longer an uncommon occurrence. "I've had to [send the letter] on several occasions," explained Raskin. "It protects us as providers, and hopefully, sends a sign to the patient that they need to get help and not just switch doctors."
Steph Weber is a freelance writer hailing from the Midwest. She writes about healthcare, finance, and small business, but finds her passion for the medical field growing in sync with the ever-changing healthcare laws.
Editor's Note: In a previous version, some data from the Trust for America's Health and the CDC were inaccurately reported.