Drug Seeking in Primary Care
Most of the (blog) "literature" on drug seeking comes from the ER and pre-hospital bloggers. To them, seekers are all stupid, lazy, unwilling to confront their demons/addictions, often belligerent and overall pains in the ass.
While I don't dispute the picture painted by those bloggers, I must point out that there are some significant differences between drug seekers in primary care and those encountered in the ER setting. For starters, the smart ones (no, "smart drug seeker" is not an oxymoron) don't usually go to ERs, preferring to form an ongoing relationship with someone they can get drugs from more than just once or twice.
Many patients presenting either with explicit requests or with diagnoses implying the need for controlled substances are not "drug seekers" in the usual sense of the term. There are legitimate patients out there with chronic pain, ADHD and anxiety, among other conditions, who use controlled substances successfully and appropriately, and it is a mistake to assume otherwise. However there is a greater onus on the practitioner to distinguish the legitimate patient from the savvy seeker, a task that usually requires something unique to primary care: the forming of a relationship over multiple encounters.
Another difference between the ER and the office is that patients rarely present to us in acute pain. Sure, I've been burned by the girl with "renal colic" -- complete with blood in her urine -- who got a percocet script off me. But when she wouldn't go for the IVP, and then called after a car crash in which "my meds were towed away in the car", I eventually caught on. There was also the guy carrying the x-ray showing a vertebral body in two pieces who got medicated for his acute fracture pain -- until I saw the report describing the x-ray finding as chronic; a congenital anomaly. By and large, I'd rather err on the side of being fooled than not treating legitimate pain. But I'm generally not fooled for long.
Most drug seekers we see come in with a history of an ongoing chronic or episodic painful condition -- migraines or back pain, for example -- requesting prescriptions for maintenance pain meds. A full history and physical is part of the initial evaluation. Failure to sit still for that ("I don't have time for a full exam today. Just give me the prescription and I'll re-schedule") is a red flag. No script. As always, the history provides clues. "What else have you tried?" usually elicits either "nothing" or "everything," the latter usually with suboptimal relief or intolerable side effects (including "allergies", of course.) The response to my suggestion of alternate therapies is telling: the seeker finds a way to refuse. The patient with, say, legitimate menstrual migraines ought to be open to the idea of continuous contraception.
What are the hallmarks of the patient legitimately seeking to form a new doctor-patient relationship for management of a chronic condition requiring controlled substances?
- Honesty, including a willingness to verify statements (ie, signing a records release)
- Consistency (neither the history nor the requests change over time; not seeing multiple physicians or using multiple pharmacies)
- Recognition that trust takes time; I need time to get to know the patient. Trust goes both ways, too: patients should be willing to try other strategies (anticonvulsants for neuropathic pain, for example)
Once in the early 1990s a patient walked into my office and said, "I'm addicted to narcotics for my chronic back pain from an accident ten years ago. My doctor is retiring, and I need a new one to work with me." I was a bit taken aback; I had only been in practice for a couple of years, but I asked him to ask his previous physician to write me a letter documenting that fact. He did, and she did, sending it along with his records documenting that he never abused them, never called early and used only one pharmacy. In fourteen years with me the pattern has continued. He has better times when he doesn't call as often, and worse times when he calls more regularly. He never waits until the last minute to call for refills, allowing enough time to receive written scripts in the mail. And he always comes in when I ask him to; a model patient.
Another time I took over a patient on massive doses of chronic narcotics because, among other things, he broke ribs just by coughing. The chart was full of fruitless workups for metabolic disorders to explain his fragile ribs, but x-rays always confirmed them. No alcohol either; he had Hep C and didn't drink, generally confirmed by all lab work. He was a big old biker dude covered with tattoos, and when I first met him I confess I was concerned that I was being taken. But I asked him to give me the opportunity to get to know him -- x-ray his ribs a few times rather than just taking his word that he'd broken one again; maybe repeat a few other metabolic tests -- and he wasn't the least bit offended. He did everything I asked: came back regularly for follow-up; tried NSAIDs; never abused pain meds nor asked for early refills. When he started going longer spells without fractures, the refills slowed down. And only once in seven years did he call for a new prescription, having "torn the house apart; I just can't find them. I think the dog knocked the bottle over." That was just this past April, but by now, after all these years, I trust him.
Make no mistake: we certainly see drug seekers in the office. Many of them are charming and have extremely legitimate-sounding stories. Over the years, though, I've discovered something in my own thought processes that flags them unerringly: in the course of the history and exam, in which the long-suffering patient is telling a tale of such woe, such suffering, such angst, the thought occurs to me, Could this patient just be out for drugs? and I say to myself, How could you even THINK that about this nice person! That second thought is the key. More often than not, yes: that nice person is looking for drugs.