Patient or Drug Seeker?

(written by J. Michael Rosenthal - originally published in the June 2008 issue of MD News Magazine)

Several years ago, a friend was hospitalized for congestive heart failure and told me about his first night in the hospital. During the night they placed a post-op patient into his room, following amputation of both legs. Heavily sedated, the patient spent the night crying out about leg pain. The next morning my friend commented to a nurse that caring for such a patient must be extremely difficult and frustrating. The nurse refuted that and said that it was very easy to care for a patient that evoked such empathy. My friend then asked what type of patient was the most difficult. The nurse quickly replied, “Addicts and alcoholics, because once you release them they just go back out and do it again!”

I mention this story because healthcare professionals are frequently besieged by drug-seeking patients; and according to the experts, prescription drug abuse is often coincident to the abuse of alcohol and street drugs. Addiction, regardless of the drug of choice, is a chronic disease characterized by impaired control over drug use, compulsive usage, craving and continued use despite harmful effects. Such addicts will do or say anything to access their “fix”.

Healthcare professionals also indicate that pain is one of the most common patient complaints and one of the most difficult complaints to assess because the pain is not objectively verifiable. Yet the patient often presents quite sympathetically – debilitated by chronic pain and dependent upon the doctor for relief.

Numerous issues come into play with this topic. You have the humanitarian concerns of preventing addiction, helping addicts to recover and misclassifying a legitimate pain patient as a “drug-seeker”. Additionally there are the legal regulations regarding prescription of controlled substances.

On the risk management side, doctors engaged with a drug-seeking patient can find themselves the target of a medical licensing board inquiry or an investigation by the police or DEA. Any such activity can potentially jeopardize a doctor’s practice or license. That is why it is critical that healthcare professionals become knowledgeable in recognizing the signs of a drug-seeking patient.

As with most medical situations, thorough documentation is critical. However, documentation should go beyond patient history, examination results, underlying or coincident conditions, severity and frequency of pain, as well as indicated medication to be prescribed. It should also include detailed notes on the patient’s comments. Often the details of their story will change over subsequent visits and can be indicative of a drug-seeker’s attempted manipulation.

Other indications may include:

1. Escalating need for increased dosage or frequency and requests for early refills.
2. The patient waits until after-hours periods to call for a problem that has existed all day – or demands to be seen immediately.
3. Feigns physical or psychological problems, ranging from various types of pain to anxiety,
   insomnia, fatigue or depression.
4. Indicates that non-narcotic analgesics will not work effectively, or an allergy to them.
5. Alleges to be an out-of-town tourist, unable to get an appointment with their primary
   physician or that a prescription has been lost or stolen.
6. Doesn’t provide insurance information, preferring to pay directly.

In studying reports about addicts, manipulative behavior seems to be a key personality factor. They often exhibit an assertive personality demanding immediate action. They may dress to extremes – either overdressed or slovenly in appearance. They generally have significant knowledge of medications and symptoms, but become vague or evasive when questioned about their personal history. That evasiveness becomes more noticeable when they are reluctant to provide reference information as to address, insurance and regular physician. You may also notice that the patient requests a specific drug or exhibits mood swings while in your office.

Spotting drug seekers is difficult at best. Not all of them are faking their symptoms. They may have a legitimate complaint, but have become physically dependent over time with increased tolerance. Plus, most doctors are concerned about misclassification, thereby denying medication to a legitimate patient.

Every practice should develop procedures for dealing with drug-seeking patients. Determine the best way to communicate your refusal to prescribe for them and what to do if they become confrontational or even violent. Additionally, identify an addiction medication specialist as a resource with whom you can consult and refer patients. If you feel that your practice is confronted with drug-seeking or addicted patients, it might be a good idea to have such a specialist conduct an informative workshop for yourself and your staff.

In conclusion, I must offer the disclaimer that I am not a medical professional. However, as a provider of medical malpractice insurance and risk management resources for the medical industry, this article is based on my personal experiences and research in helping physicians to manage their risks and exposures.