Is It Chronic Pain or Drug-Seeking Behavior?
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Current healthcare headlines frequently contain two words: opioid epidemic. As VOX recently reported, the number of opioid use disorder diagnoses has grown by nearly eight times the rate of the most effective treatment. A person can get opioids with a prescription from a healthcare provider—or on the streets.
An internet forum post from a student doctor doesn’t mince words. It’s directed at a "drug seeker" who visits the emergency department in need of a script. It’s also important to note that use of the term has fallen out of favor in recent years, as healthcare professionals focus more on "the disease" and its treatment.
The post says: "I hate you because you think you can march in to any E.R. in the country and demand narcotics your way like it is Burger King. I hate you because your fake symptoms force me to throw away millions of dollars of our national treasure on tests that don’t need to be done…I hate you because in wasting the time of our E.R. staff, a harmless grandmother in the room next door must be tied to her bed because there is no sitter."
But there are two sides to every story, right? There’s the other side, as former EMT Christina Phillips documents in her March Kevin MD blog entitled, "My mother isn’t a drug-seeking patient. She’s in pain."
She writes: "I still haven’t forgotten how easy it is, as a clinician, to see the symptoms first and the patient second, and to reach quick conclusions based on previous experience. How can I forget, when just months ago I had to help my mother contend with a doctor who, despite the chart in his hand and the eleven-inch scar across her abdomen, refused to believe that she’d had her pancreas removed?"
Distinguishing and dealing with drug-seeking behavior can be a challenge for any healthcare professional—even those with experience. Meet your fellow physicians on the front lines and learn how they approach the patient who comes seeking drugs. Yes, some really need them, and some do not, but it’s how these patients are managed that makes all the difference to you, them and the healthcare system.
[ Read: Psychiatry’s Role in the Opioid Crisis: What Should It Be? ]
Patients Behaving Badly
Not so fast with judgments, suggests R. Corey Waller, M.D., M.S., FACEP, DFASAM and chair of the legislative advocacy committee of the American Society of Addiction Medicine. An addiction, pain and emergency medicine specialist, he’s also senior medical director for the Camden Coalition of Healthcare Partners in New Jersey.
"Drug-seeking behaviors are predictable and identifiable, and should be looked at as symptoms of chronic brain disease—addiction—not defined by lab results," Dr. Waller says.
"Neurobiological changes support a drive that asks, ‘How do I survive?’ Chronically-addicted, drug-seeking patients are scared of withdrawal, horrible pain and of not being able to control themselves or handle job or family responsibilities," he says. "If they’re yelling or ‘want to see your boss,’ that’s a sign of a higher degree of illness."
He "gets" when physicians eventually abandon E.R. work because "those patients drove them insane," he says. Dr. Waller knows that even though he has specialty training in addiction medicine that helps him understand, not everyone does.
"As doctors, we like to fix things," he says. "We’re all Type As, and it’s frustrating when we can’t change the outcome for a person. And for some reason we as humans often shy away from this subset of the patient population."
He thinks it’s because we’ve all had personal experiences with addiction—with family or friends—and it raises an "emotional context" that hypertension, for example, does not. "Couple that with stigma, and it certainly deserves some soul-searching," he says.
Raising Red Flags
One of his habitual drug-seeking patients made 183 visits to his emergency department in a year, said emergency-room physician Geoffrey Hosta, M.D., in Newsweek.
"This kind of behavior can sometimes even interject a level of aggression with the potential for violence in this setting," says Rade Vukmir, M.D., J.D., FACEP of Pittsburgh, Pennsylvania. He is a professor adjunct of emergency medicine at Temple University and a spokesperson for the American College of Emergency Physicians.
"In the E.D., we’re America’s safety net, and our goal is to treat people appropriately, do a medical screening exam on every patient, and determine the appropriate diagnosis and treatment for the patient’s best benefit," he says. "This process shouldn’t be adversarial, but sometimes it can be in circumstances such as this."
[ Read: How to Determine If You (or Anyone) Has a Substance Abuse Problem ]
Drug-seeking behavioral signs can be telling, he says. Most people describe symptoms and experiences, but a patient’s inappropriate focus on a particular medicine, specifying specific formulation, dose, and route of administration, often stands out.
‘I Want It That Way’
"’This is what my doctor prescribes for me in this dose,’ they might say. A patient who repetitively presents at off hours to a hospital when their primary care physician is closed, or a cross-covering physician is involved, may raise a red flag," he says.
Additionally, patients may request refills early because medication was "lost" or "stolen," they may say they’re allergic to non-opiate pain relievers, and they may want shorter-acting narcotics versus recommended longer-acting meds, according to an analysis in Physicians Practice.
A 2013 study in the Annals of Emergency Medicine also lists such telltale behaviors as multiple visits for the same complaint, suspicious history, and symptoms out of proportion to examination.
"We do try and help the patient through the process," says Dr. Vukmir. Remember, we’re not here to make moral judgments, and we’re treating the condition, not the complaint."
Doctors do have help with complexities of drug-seeking behavior from pharmaceutical databases in some states, he says. The U.S. Department of Justice and Drug Enforcement Administration operate the Diversion Control Diversion State Prescription Drug Monitoring Programs. However, a clever and motivated individual might fill a prescription in one state, and drive to another city in an adjoining state, leaving what doctors describe as wide gaps in the database trail.
Contracts Keep It Clean
In a town of approximately 4,000 people, John Cullen, M.D., 
owns the only doctor’s office in Valdez, Alaska. It’s very isolated, he says, and when a new patient comes to see him and requests a narcotic prescription, that patient is probably really hurting without it.
"Many people really don’t want to go through withdrawal, and, yes, it’s tragic when someone gets behind that eight ball," he says. "We have to determine if they’re really having chronic pain or they have an opioid use disorder, and that takes time. Sometimes we have to use opioids because of a patient’s other health issues. Some patients can do very well long term."
Gut instinct rules here, he says, for "a lot has to do with how you feel about a patient. You develop a sense when people aren’t giving you the full truth. Some are really good at this."
[ Read: Managing Mental Health in Primary Care ]
When he does judiciously dispense them, patients sign his practice’s pain contract. It stipulates they won’t get narcotics from another source, and will obtain them from the specified pharmacy. They’ll be tracked in a database and see the doctor on a regular basis without missing any appointments. They’ll come in when requested for urine screenings and a pill count.
"The same rules apply to everybody," says Dr. Cullen, a spokesperson for the American Academy of Family Physicians. Anyone whose behavior attracts the attention of local law enforcement will be duly noted at the medical practice. It’s not a punitive thing, and we don’t become emotionally invested as a prescriber one way or the other. We can simply say, ‘You didn’t follow up so we can’t prescribe these anymore.’"
Encouraging Opioid Avoidance
If they do stop prescribing, and all medical risks are assessed, the medical team treats the patient appropriately for withdrawal and prescribes long-term follow-up care.
"As family practitioners, we see ourselves as part of the solution," Cullen says. "Many patients on chronic pain medications come in on a lot more meds than they should. If they need to stay on them, our job is to get them down to a safe level. We all try very hard not to prescribe them—unless there is no other option."
He utilizes alternative therapies such as acupuncture, physical therapy, exercise, massage therapy and more. "Plus we have found non-narcotic gabapentin, pregabalin, and anti-inflammatories to be very effective," says Dr. Cullen. "We also try to utilize the opioid buprenorphine more frequently, which is safer than oxycodone and morphine.
Acceptance is a mighty force, Dr. Vukmir says. "When a patient says, ‘I know you’re concerned about me, and yes, I have an issue and am trying to get some help,’ we are ecstatic. We will go to whatever reasonable lengths to get a patient into a supervised treatment program."
"I talk to the patients about their individual risk for addiction and dependence versus the benefit of an opiate prescription," says Aimee Moulin, M.D., FACEP at the University of California at Davis Medical Center. She says she encounters multiple drug-seeking patients every shift, "especially in the lower acuity areas."
"I try to keep the conversation focused on the best treatment options for the patient," says Dr. Moulin. "I’m open about my concerns for addiction and dependence, and hope to engage the patient in that discussion. I also refer patients to an addiction specialist and treatment if necessary. With every patient, I think about the risks of addiction and overdose."
