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.
