American College of Physicians: Internal Medicine — Doctors for Adults ®


Dealing with drug-seeking behavior

How to handle opioids and some of the patients who take them

From the February ACP Hospitalist, copyright © 2014 by the American College of Physicians

By Stacey Butterfield

One patient says that only a specific IV dose of a specific opioid works for her. Another complains of “10 out of 10” pain while gobbling down his breakfast.

“The problem of people seeking drugs who are not really in pain has become more common than it was 10 or 15 years ago,” said Leonard J. Paulozzi, MD, MPH, a medical epidemiologist in the division of unintentional injury prevention at the CDC's National Center for Injury Prevention and Control.

Image by Thinkstock.

Image by Thinkstock.

Recent statistics—such as a more than 34-fold increase in fatal opioid overdoses since 1999, according to the CDC—give hospitalists reason for caution in prescribing pain medication.

On the other hand, physicians are routinely warned about the prevalence and consequences of undertreatment of pain. “It would be a tragedy if somebody with real pain suffers just because we're trying to crack down on prescription misuse,” said Casey Grover, MD, an emergency physician in Monterey, Calif.

Balancing these concerns is a dilemma even for experts. “It's really difficult to distinguish between those patients attempting to get relief from true pain and those who truly just enjoy the intoxicating effects of the opiates,” said Dr. Grover. He and other researchers have found that the factors physicians often use to make this distinction are not very accurate.

“If there was a question that said, ‘Are they telling the truth or not?’ that would be great, but there isn't,” said Jeffrey H. Samet, MD, MA, MPH, FACP, chief of general internal medicine at Boston Medical Center.

Thankfully, there are some tools and tips that can ease hospitalists' interactions with patients they suspect of drug-seeking behavior.

Where to start

First, try not to call them drug-seekers. “Sometimes it's an appropriate descriptor of what's going on with the patient, but a lot of times it's very stigmatizing and it causes a patient's actual pain or other issues to be undertreated,” said Catherine Whiting, PhD, a clinical health psychologist at Seton Medical Center in Austin, Texas. “Staff picks up on it.”

To help figure out what is going on with such patients, the best and simplest tool is a state prescription drug monitoring system. Forty-seven states currently have systems up and running, and 2 more have them in the works (Missouri is the lone holdout). Hospitalists should make sure they have access to these systems, which track prescriptions for drugs controlled under federal schedules, the experts recommended.

“I use that almost every day in my practice,” said Dr. Grover. “Use it if somebody makes you think twice when you go to write the orders for an opiate pain medication.” He's been surprised by the system's results in both directions, he said, from a patient with relatively normal behavior who turned out to have 85 scripts in 3 months to a suspicious-acting patient who had an empty record.

“There are problems with those registries, though,” said Carlos Tirado, MD, a psychiatrist who focuses on chemical dependency at Seton Medical Center. “A lot of the data are not real-time, and also people who get prescriptions through the federal system, like the [Veterans Administration] or the military, don't fall into those registries. Also people who get mail order [prescriptions] sometimes don't get reported.”

The state-by-state nature of the system is a problem too, according to Scott Weiner, MD, MPH, an emergency physician and researcher at Tufts Medical Center in Boston. “If you went to New Hampshire and got your prescription filled there, and then you drove 45 minutes to Boston, that prescription wouldn't show up in my database,” he said.

The state databases also differ in the information provided. “In New York they gave you 2 months of data, in Colorado they gave you 6 months of data, and [Massachusetts has] 12 months of data. Some of them just collect schedule II narcotics, and some of them collect schedules II to V and other potential drugs of abuse,” said Dr. Weiner.

Other methods

These gaps leave physicians, even in states that have registries, with dilemmas about prescribing pain medication. A number of factors observable during treatment have been traditionally used by physicians as red flags of opioid use, and Dr. Weiner recently published a study assessing their accuracy.

He compared emergency physicians' identification of drug-seeking behavior with data from a prescription drug monitoring program and found that looking at registry data after making their own guesses caused physicians to change their prescriptions almost 10% of the time. “The clinicians were not that great at determining doctor-shopping behavior,” Dr. Weiner said.

The study, published in Annals of Emergency Medicine in October 2013, did identify a few traditional red flags that were associated with suspicious registry data, including asking for opioid medications by name (odds ratio [OR], 1.91), multiple visits for the same complaint (OR, 2.5), a suspicious history (OR, 1.88) and reported symptoms out of proportion to the examination (OR, 1.83).

It also found, however, that physicians were more likely to suspect men of drug-seeking, while the registries turned up more problematic data on women, and that the single most predictive factor was which of the studied hospitals a patient presented to, rather than any patient-specific factor.

There is a patient factor that can be highly predictive, noted Dr. Tirado. “Most of the evidence suggests that people who are complaining of pain for the purposes of acquiring opioids had a premorbid history of chemical dependence,” he said, noting that a urine drug screen can be helpful in identifying these patients.

Complicating the issue, however, is the fact that being in pain and misusing opioids are not mutually exclusive patient categories. “It may be 50% addiction, 50% chronic pain. It may be 80% pain. It may be 90% addiction,” said Dr. Grover.

This is one reason some of the experts recommend not fixating on whether or not you believe a patient. “There is no definitive way to parse through who is a drug-seeker, who is a non-drug-seeker. Trying to engage in that negative process of discovery typically leads to a more unconstructive and negative clinical interaction,” said Dr. Tirado. “They may be way off base in terms of why they think they're suffering, but nevertheless, they need a provider who is willing to help them solve a problem and not a provider who is going to stand in judgment.”

The conversation

Dr. Tirado was speaking figuratively, but physicians should literally avoid standing when talking to a patient about opiate use issues. “Walk in and sit down with the patient. Actually being face-to-face with them helps with a lot of defensiveness,” said Dr. Whiting.

Then, be honest about your concerns. If you've got evidence of drug-seeking, present it. “I'll print the form out from the [prescription drug monitoring program] website,” said Dr. Weiner. “I'll say, ‘What's going on here? You've seen 40 providers in 1 year. This is excessive.’”

Explain why the prescription pattern is a problem. Dr. Grover described a recent approach to a patient complaining of back pain who was already getting opioids from 2 different physicians: “Ma’am, I'm really concerned about you. I don't want to prescribe any more of these medicines for you, because they're so unhealthy for you and I'm really concerned about how much you're using them.”

“Truly, there was nothing false about that statement,” Dr. Grover explained. “There's very good evidence that opiate use over time increases perception of pain and can even lead to specific syndromes, such as narcotic bowel syndrome [and] opiate-induced hyperanalgesia.”

Patients, even those who are heavy users of opioids, may be surprised by this information. “A lot of times patients don't realize that the medications they're using are really putting their health at risk, whether it be from [acetaminophen] toxicity or respiratory sedation,” said Dr. Whiting.

For some patients, including the woman Dr. Grover saw, this may be enough to change their perspective. “I gave her a lidocaine patch and at the end of the encounter—I found this very surprising—she said, ‘Gosh, I would like to get off these medicines. Tell me how I can do it,’” he said.

Others won't respond so well. “They often do get frustrated and storm out or call you names,” said Dr. Grover. “What I've found very helpful is you tell people you're just trying to do your job as a physician and provide them with good care and you're concerned about them.”

It's important to be honest but also to avoid expressing disbelief of a patient's claims of pain. “Patients who sense that typically become more insistent and more resistant about their complaint because they feel like they're not being heard or taken seriously,” said Dr. Tirado.

Focus instead on a treatment plan. “Clarify from the get-go: We want to do the best to help you with your pain. Pain medicines may or may not achieve that goal,” said Dr. Samet. “We'll try plan A. We'll look for measures of improvement and we'll base the direction we go with medications on the functional outcome that we get.”

Treat pain and other problems

In choosing a treatment plan, consider what problems other than physical pain may be causing the patient to overuse opioids. “They may be using pain medication for sleep or control of anxiety,” said Dr. Whiting. “Look at the psychiatric functioning of the patient.”

If necessary, call for a psych consult to assess and treat these problems. Palliative care and pain management specialists may also be helpful in developing a treatment plan. “Ask for help. There are more specialists out there than people realize in terms of pain management,” said Dr. Whiting.

To treat patients' pain, the many non-opioid pain treatments should be considered first, of course. But in some cases, treatment may need to include opioids, even in patients whose history causes concerns regarding the drugs. “I would never support the prohibition of opioids to people who have a known opioid use disorder,” said Dr. Tirado. “We have to be able to still treat those patients with opioids if it's obvious that's the most effective treatment.”

In fact, it's important to remember that patients who are taking chronic opioids and those on opioid-agonist treatment for dependence will require higher doses of opioids to treat acute pain problems, such as an injury. “That's a little tricky and sometimes underappreciated by hospitalists,” said Dr. Samet.

Physicians tend to have very individual positions on the prescribing of opioids, but when in doubt, they should err on the side of treatment, advised Dr. Grover. “From a humanitarian standpoint, if you don't know if someone's truly in pain or not—even if you're suspicious—you should presumptively treat their pain as though they have real pain,” he said.

Fears of abuse may affect the method of administering medication, though. “If we have concerns, as much as it's medically appropriate, we try to get patients off IV pain medications as quickly as possible and switch over to [oral], because there's not as much of a rush that goes with it,” said Dr. Whiting.

When admitting patients that are strongly suspected of opioid abuse, her hospital takes additional precautions, she said, such as searching their belongings and ensuring that they aren't bringing in medications. “If you have a known overuser, being able to go through their medications is really, really important in making sure they don't kill themselves on accident in the hospital,” she said. Such searches should only be conducted after consultation with a hospital's risk management team, she noted.

Hospitalists should do their best to provide such patients with access to treatment for their opioid problems, whether it's an inpatient consultation or a referral to outpatient care. “Make sure there is a warm handoff to resources in the community,” said Dr. Paulozzi.

Planning for discharge

For any patient who is leaving the hospital with a script for opioids, the handoff should be particularly close.

“[Hospitalists] certainly need to coordinate with community physicians when the patient is discharged…their assessment of the need for the opioid, how long they think the patient might require it postdischarge and any observations they've made about the patient during hospitalization,” said Dr. Paulozzi. “It might be wise also for the hospitalist to limit the number of days' supply of an opioid analgesic on discharge.”

Hospitalists can take a couple of additional steps before discharge that may reduce the risk of seeing the patient with the same problem again soon. “We have a case management group to try to divert their place of care from inpatient and the emergency room to outpatient,” said Dr. Grover. “Say, ‘We feel your case is best served and best provided to you in a pain management clinic setting and we'd like to provide you with this referral. Here's an appointment for next week.’”

If such focused resources are not available, simply urge patients to choose some kind of outpatient care. “A lot of times people are bouncing from hospital system to hospital system and I encourage them to pick one,” said Dr. Weiner. “Have your primary care doctor and maybe your pain doctor, but it's a lot less suspicious for clinicians when we see that you're all in the same system.”

In addition to these individual efforts, systemic changes underway now should eventually reduce the number of suspicious opiate-related hospital visits.

“Collectively, what we did in the 1990s was problematic. There was a push to treat nonmalignant pain, chronic pain, with opioids. It probably helped some people but others who were probably just biologically predisposed had problems,” Dr. Samet said. “Now, in the face of all these overdose deaths, people are backing off the use of chronic opioids….That's being done better now.”



ACP releases new recommendations on prescription drug abuse

In light of the serious public health problem posed by prescription drug abuse, the College recently issued a position paper offering guidance to prescribers and policymakers on the issue. The paper, published in Annals of Internal Medicine on Dec. 10, 2013, included the following recommendations:

  1. ACP supports appropriate and effective efforts to reduce all substance abuse. These include educational, prevention, diagnostic, and treatment efforts. As physicians dealing with the health effects of this condition, we also support medical research on addiction and its causes and treatment.
  2. ACP supports a comprehensive national policy on prescription drug abuse containing education, monitoring, proper disposal, and enforcement elements.
  3. ACP supports the consideration by physicians of the full array of treatments available for the effective treatment and management of pain.
  4. ACP supports the establishment of a national Prescription Drug Monitoring Program (PDMP). Until such a program is implemented, ACP supports efforts to standardize state PDMPs through the federal National All Schedules Prescription Electronic Reporting (NASPER) program. Prescribers and dispensers should check PDMPs in their own and neighboring states (as permitted) prior to writing or filling prescriptions for medications containing controlled substances. All PDMPs should maintain strong protections to assure confidentiality and privacy.
  5. ACP supports efforts to educate physicians, patients, and the public on the appropriate medical uses of controlled drugs and the dangers of both medical and nonmedical use of prescription drugs.
  6. ACP favors a balanced approach to permit safe and effective medical treatment utilizing controlled substances and efforts to reduce prescription drug abuse. However, educational, documentation, and treatment requirements toward this goal should not impose excessive administrative burdens on prescribers or dispensers.
  7. ACP recognizes that defined maximum dosage (i.e., morphine equivalent) and duration of therapy limitations are not applicable to every clinical encounter. ACP favors establishment of evidence-based, nonbinding guidelines regarding recommended maximum dosage and duration of therapy that a patient taking controlled substance medications may receive.
  8. Patients identified by Medicare, Medicaid, private insurance plans, or law enforcement authorities as being at significant risk of prescription drug abuse may be required to participate in a drug monitoring program and undergo random drug testing. Physicians may be required to report suspected cases of drug abuse, but should not be mandated to conduct random drug testing without the patient's consent. The financial cost of mandatory drug testing should be borne by the authority requiring the testing; neither the patient nor the physician should bear the financial cost of random drug testing mandated by a third-party authority.
  9. ACP recommends the consideration of patient-provider treatment agreements between physician and patients as a tool for the treatment of pain.
  10. ACP recommends the passage of legislation by all 50 states permitting electronic prescription for controlled substances.


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