In Practice: A Painful Dilemma

Looking back, Danielle shudders at the memory of her dishonesty. But at the time, manipulating physicians was necessary to feed her addiction to prescription painkillers. “It helps when you’re a woman - and a good-looking woman. I could really schmooze the doctors.”

She didn’t mean to get caught in the cycle of addiction. Danielle (not her real name) had never taken a painkiller stronger than Tylenol until she began having migraines after the birth of her daughter and her family doctor prescribed an opiate. “It sat on my shelf for months,” she says. “Then, suddenly, I’m taking these pills even without the migraines. I was taking more and more, and then, whoops, you’re out of your prescription. That’s when I branched out. I saw other doctors I’d known a long time. If you have a core group, you can make it work.”

Could this happen at your practice? Absolutely, if you don’t know how to tell the difference between an honest plea for pain relief and a doctor-shopper. And the repercussions can be much more serious than just getting duped. You could be investigated, raided, charged, and convicted by the Drug Enforcement Administration (DEA) for illegally trafficking Schedule II controlled substances - a list of drugs, including hydrocodone and Oxycontin, maintained by the federal government that mandates extremely strict handling.

An endangered species

Estimates vary, but somewhere between 34 million and 50 million people in the United States are currently suffering from chronic intractable pain (CIP). This translates into real money - $61 billion annually gone due to loss of productivity, states a 2003 study published in the Journal of the American Medical Association. The loss is not a result of absenteeism, but rather reduced productivity due to chronic pain. The biggest offender? Back pain, but headaches, arthritis, fibromyalgia, cancer, and many other chronic conditions also sap the vitality from these people’s lives.

Over the past three years, approximately 1,800 physicians - of all specialties - have been investigated by the DEA for some sort of alleged mismanagement of Schedule II controlled substances, including improper billing practices, a suspicious number of prescriptions written, or a failure to keep proper care documentation, to name a few infractions; 1,200 of these physicians lost their licenses. Compared with the 1 million physicians who hold a DEA license to prescribe narcotics, this seems like a negligible number. Should you be worried?

Yes, insists Joel Hochman. As the executive director of the National Foundation for the Treatment of Pain, he claims there are 4,000 pain specialists in this country who have received extra certification and training in pain management practices (none of which is required by law). Each pain specialist is only one person and can therefore see only so many patients in a year. Hochman says that if, for example, each treats 300 patients annually, which he deems a reasonable amount, that’s 1.2 million people, or less than 3 percent of the total CIP population in America. Who is serving the rest? You are.

Certainly, your patients have the right to be taken seriously when they say they’re in pain. But what of your rights? Surely the law protects doctors as well as patients. Unfortunately, Hochman thinks not, saying, “Every single doctor in the U.S. stands naked and alone trying to do what they’re trained to do - relieve suffering.”

What can you do to protect yourself?

Screening is believing

Pain is arguably the most common catalyst that gets people into your examining room - earaches, menstrual cramps, ingrown toenails, sore joints, wrenched backs, and any other condition spanning the “ouch” spectrum. Acute pain - such as that caused by kidney stones or broken ribs - is actually easier to deal with: diagnose, treat, cure (you hope). But headaches and back spasms? Much more elusive, with the increased possibility that you’re being played by a substance abuser or drug diverter - one who procures a controlled substance for street sale. You already know to take a full history and to conduct a physical exam of any patient complaining of chronic pain, but if a patient - especially a new patient - comes to your office with this sort of complaint, guard yourself while offering proper care:

• Get positive identification. Ask for and then copy the identification you receive from a prospective pain patient for whom you write a prescription.

• Gather complete background information. Ask for contact numbers of other practitioners currently caring for the patient. If you have any doubts as to the legitimacy of a request or the information the patient has provided, call those practitioners to double-check.

• Consider all the treatment options. This may seem obvious, but it bears repeating: Many alternative, non-narcotic pain management treatments abound, from surgery to brain stimulation to good ol’ aspirin. Even nonpharmaceutical therapies, such as hypnosis or biofeedback, can be highly efficacious. Patients who seem to resist any treatment that doesn’t include narcotics should be viewed with suspicion.

• Use a pain scale. Asking a patient, “How much does it hurt?” often yields a vague and diagnostically unhelpful answer. Consider using one of various pictorial and numerical scales, which can greatly help to quantify a patient’s pain. The patient simply indicates the pain level according to the scale. Even better, patients can build their own versions of the Randall Chronic Pain Scale by inserting meaningful descriptors at each pain level.

David Peereboom, an oncologist at the Cleveland Clinic, uses such a tool. “It helps as a baseline, and it helps as a follow-up,” he says. Cancer patients often minimize their pain to doctors when asked. The scale tends to bring out a more truthful answer, he says: “Some say, ‘It’s not too bad,’ but if you ask for a number, they’ll say a seven, which is pretty bad.”

On a related note, refer to the McGill Pain Index to help understand the intensity of a particular pain. You can find the McGill Index all over the Internet.

Code-red flags

What are the chances that the patient in front of you is addicted to narcotic pain relievers? Pretty slim, actually. Peereboom says he sees it occasionally. “There are some patients every once in a while whose cancer is in remission, and they will run into a drug dependence problem.”

Hochman’s experience is similar. “For the 3,000 patients I’ve treated, I’ve found one who was an addict, and he was an addict before,” he says. “Yes, people do get addicted. But addicts are born, not made.”

It’s important to understand that addiction is not dependence. With two distinctly different conditions, this is often a source of confusion. Yes, patients suffering from CIP often do indeed become dependent on their pain meds, but this is because if they do not take the drugs then they cannot live their lives normally. That’s critically different from an addict, who follows the traditional course of any addictive behavior: indulgence in the activity/substance with increasingly shorter duration between episodes and at the expense of his (and usually others’) well-being. In short, a CIP patient takes drugs to improve his quality of life; an addict takes them at the expense of that quality.

One major differentiating aspect between a genuine pain patient and an addict is that of tolerance. A pain patient has had to cope with pain on a daily basis. A body will react by “toughening up,” says Jonathan Lipman, a neuropharmacologist and president of Neuroscience Toolworks, a medical technology development company specializing in improving pain management. “Pain patients can tolerate more than ‘normals.’ If you’re faking it, you can only tolerate what you can tolerate.” So it wouldn’t necessarily be an addiction or a diverting tip-off if a genuine pain patient “needed” a higher dose.

Drug diverters and doctor-shoppers tend to display distinct characteristics. When someone comes to your office complaining of a bad back or headaches, stay alert for any of the following behaviors:

• A suspicious story. If your gut tells you a patient’s story doesn’t sound quite right, it probably isn’t. Doctor-shopping patients will often claim that they are traveling on business and forgot their medication, or whoops, they knocked it right down a flushing toilet with the hotel hair dryer, doggone it. Also watch for excessive flattery aimed at you or your staff.

• Dubious symptoms. Those attempting to procure drugs for unlawful reasons are likely to exaggerate their symptoms and alter lab samples, such as putting a drop of blood from a pricked finger into a urine sample. They tend to stick to a subset of conditions, including lower-back pain, kidney stones, headaches (especially migraine), toothaches, or neuralgia problems, as the legitimacy of these complaints can be difficult to fully ascertain.

• Strange requests. Drug-seeking patients will very often insist on the last appointment of the day, citing crushing work responsibilities or a plane to catch. They may also claim to have lost their paper prescription, left their meds at home, or even had them stolen during their business trip. Shields should go up if a patient asks for or insists on a specific medication and/or resists accepting a generic form or a substitute, claiming allergy or ineffectiveness. The real reason? Generics offer lower street value.

• Uncooperative behavior. A drug diverter or addict will volunteer as little information as possible: When was he last treated for this condition? Gee, he can’t remember. No, he doesn’t know the name of the clinic he goes to at home, sorry. You may even be told that his previous place of treatment has gone out of business or was involved in a catastrophic fire.

• Medication “expert” or “dunce.” A patient illegally seeking drugs often possesses a vast array of knowledge on specific medical conditions and their associated narcotic treatments. So does a legitimate pain sufferer. But listen closely to your patient: A diverter’s knowledge will sound more like a textbook than a real-life experience. Conversely, an addict seeking drugs may feign ignorance of narcotic medications by deliberately mispronouncing the name or acting as if she does not quite understand her painful medical condition.

Sign these and call me in the morning

If you do establish the legitimacy of a patient’s claim of chronic pain, you must now administer treatment. By adhering to the following guidelines, you will best serve your patient while helping to protect yourself:

• Explain the opiate drug “rules” to the patient. Make sure your patient understands he cannot share the drugs with others, that the drugs must be locked in a secure place, and that he should never increase the dosage without first discussing it with you, the doctor. Also ascertain any other medications he making be taking, especially those related to depression or blood pressure, to head off potentially dangerous drug interactions.

• Use a pain contract. This document fully outlines the nature of a patient’s pain, what shall be done about it in terms of opioid treatment, and repercussions if the patient breaks the agreement. By signing the contract, the patient acknowledges that he fully understands the efficacious limitations of using the opiate painkiller and agrees to follow the agreed-upon treatment plan. This contract also gives you leverage if the patient becomes noncompliant or begins to act in a suspicious, “doctor-shopper” manner.

• Have the patient write in a pain diary. This ongoing documentation can benefit both of you: A patient can better learn to qualify her pain and perhaps begin to see patterns not evident before. You can use it to verify your patient’s condition and to “tweak” the treatment.

• Devise a comprehensive treatment plan that includes appropriate physical activity and other alternative treatments that make sense for that patient’s pain. Both you and the patient should understand that as pain is very personal, it may take some time to settle on a final treatment plan, which should also include alternative treatment methods to complement the narcotics, such as exercise, hypnosis, nerve stimulation, and more. Investigate the possibilities together.

Drug addicts feel pain too

So how do you treat a drug addict with CIP? Your natural, knee-jerk response might be to cross opioid pain relievers off the list of treatment options. And who could blame you? Prescribing a narcotic to an addict seems akin to putting out a fire with vegetable oil. However, if you fail to provide proper pain management treatment, you could actually reinforce the addictive behavior, because a person in pain will resort to whatever measures he deems necessary to relieve that pain. Addiction - of any sort - as a chronic disease is an established fact. According to Oregon Health & Science University, there is no scientific evidence that proves that opioid analgesics increase addictive disease. Handled correctly, you can respect this person’s right to treatment while protecting yourself during the course of that care. Note that you must take an addict’s current status into account to devise the proper treatment plan:

• Active - currently using or has less than one month of abstinence.

• At Risk - neither currently using nor in an active recovery program, or possibly in early recovery (less than one year of abstinence).

• Recovering - abstinent for at least one year and participating in an active recovery program.

As with any pain patient, nonopioid treatments should be tried first. But if it becomes clear to you that narcotics are indicated, you can still prescribe them for an addict if you keep communication at the highest level. Specifically:

• Discuss the patient’s addiction history and current recovery status.

• Develop a written treatment plan in partnership - you, your patient, and any other involved caregivers.

• Notify other clinicians as well as the patient’s health plan, always with the patient’s knowledge and consent.

• Prescribe a generic, slow-acting, single opioid if possible to avoid the fast-onset “rush” of fast-acting ones, such as Vicodin; also, provide the opioid on a regular schedule rather than PRN.

• Document everything.

• Follow-up regularly, adjusting the treatment plan as needed.

Who’ll stop the pain?

As palliative as they are, opiates are not wonder-drug cure-alls. For starters, not all pain responds to them; each pain case must be assessed on its own merit. And even if opiates do help, they may not completely take away a person’s pain. Lipman says that adjunctive treatments such as rehabilitation should be introduced, if at all possible. “There are adjunctive drugs you can use that will potentiate opiates: tricyclates, low-dose amphetamines. The reason you want to avoid [increasing the narcotic dose] is because the drug will top out.”

Additionally, you shouldn’t accept all the responsibility for a patient’s malaise. Many CIP patients exacerbate their own pain problems by adhering to a lifestyle fraught with bad habits. To maximize success, make sure the patient is a partner in her own treatment. Elicit the patient’s perception of the problem and its physical and emotional effects on her lifestyle. Set goals together. “People in pain learn maladaptive ways of moving, thinking, acting. They gain weight. They adopt a certain posture,” says Lipman. “The doctor should say, ‘We’re going to get you healthy first.’” The ultimate goal is to get off the opiates entirely, says Lipman, because long-term use causes “organic changes in the brain. The drug becomes less effective. Then there is a temptation to increase the dosage, and that’s not necessarily the best thing to do.”

Without question, all who come to you for pain issues must be treated with the utmost respect - and the utmost caution. This may be challenging at times, but consider the words of “Barbara,” whose testimonial letter appears on the National Foundation for the Treatment of Pain’s Web site: “People who have never experienced real, continuous pain don’t understand what it does to you, how it wears away at your soul. I don’t understand how our society can be so caring and compassionate for people with just about any disease but can then have such a ‘problem’ with people who need narcotic medicines for the pain. If medicines that weren’t narcotic helped just as well I’m sure most [chronic pain patients] would be taking them, but they simply don’t.”

Remaining sensitive to patients such as this is surely the best reason to offer palliative care while staying wise to the charlatans - and key to your success as an effective reliever of human suffering.

Shirley Grace, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the January 2007 issue of Physicians Practice.