Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, July 24, 2007

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)
Two such legitimate pain patients over the years stick in my mind:

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.


At Tue Jul 24, 08:03:00 PM, Blogger Cathy said...

Dr. Dino, I wish you would visit my blog and read a post I did yesterday after visiting my Doctor's office. I still don't know what to think about it. Im so scared of narcotics and I still haven't gotten my script filled. he gave me ultram and from what I can find of it, it might be ok and less likely for me to get addicted. I'm very fearful of my grandkids one day looking at me and thinking I look like a junkie. But, the pain is to the point where I am almost not walking, or standing for any amt. of time at all. I guess for me his little sign gave me the courage I needed to ask for something I put off asking for, for years.

I also agree that after reading some of the ER blogs, I NEVER want to ask for pain control while in their ERS.

Can I link to you at my new blog?

At Tue Jul 24, 08:38:00 PM, Blogger Ambulance Driver said...

I try to reserve my contempt for those who have dubious complaints and seek narcotics, yet show none of the signs of acute pain - they sit calmly, joke around, no tachycardia, no restlessness...yet their pain is always 10/10. Even worse are the ones I have to wake up from a narcotics-induced stupor who still have excruciating pain when asked. I watch people on undisguised security cameras who move around, laugh, chat on their cell phones, dig through the ER cabinets...yet suddenly look deathly ill when I walk into the room.

Despite all that, at all of the places I have worked, I have been known as a Candy Man. I believe in relieving someone's pain.

It is easy for us to say that someone should see their PCP about their chronic pain complaint, but in many doctor's offices, the pathetic reimbursement provided to primary care physicians requires those MDs to take on enormous patient loads and see people in assembly-line fashion, and that personal relationship between MD and patient is not possible. So, you either get doctors prescribing narcotics inappropriately, or at the opposite end of the spectrum, a doctor leery of treating a legitimate pain complaint aggressively for fear of official scrutiny or being played for a fool by a patient he barely knows.

Shady pain management clinics are also a plague in our area. It's epidemic, and it poses a legitimate threat of overreaction by the Feds and draconian governmental controls that will hamper the efforts of the legitimate pain management specialists.

I've heard it said that addictions to prescription narcotics are the hardest to beat - simply because they started due to a legitimate ailment, and the patient doesn't see what they're doing as drug abuse. "It's not like those drugs, it's their medicine."

If someone came into my ER, or called my ambulance (and they have), and told me -honestly - something like, "I'm addicted to narcotics, and I'm withdrawing. I need help," I would make that patient as comfortable as I could. May not be opiates, but liberal benzos for the withdrawal symptoms for sure.

I don't know what the solution is, but if I had to sum it up in one sentence, I'd say "more reimbursement for primary care."

More reimbursement will result in more med students choosing primary care as a specialty. More PCPs equals lower patient loads, and more personal relationships with patients. More personal relationships equal less trips to the ER, and better education as to what constitutes an emergency. Less trips to the ER equals less harried EMS and ER staff, and perhaps a little more empathy and compassion as a result. Everybody wins.

So how do we make it happen, short of a complete overhaul of our reimbursement system?

At Tue Jul 24, 10:05:00 PM, Blogger Sevesteen said...

If there were no legal, licensing or malpractice repercussions in prescribing narcotics to known drug seekers, would you handle your narcotics cases differently? I'm curious whether your caution is based on proper medical care, concern for legal and license problems, or something else.

At Wed Jul 25, 11:13:00 AM, Blogger beajerry said...

Eloquent post, doc.

At Wed Jul 25, 12:40:00 PM, Blogger RoseAG said...

When my FIL died, knowing that MIL had drinking problems, we had a senior relative (a physician himself) go through the house and collect all the meds.

A month or so later we did a secret "sweep" and found that the sleeping pills, formerly in his name, had returned - under her name.

Shortly after that we had an intervention and MIL went to Rehab where she had a rough week coming off of sleeping pills and alcohol. Happily she's been sober 12 years now.

We spoke to MIL and FIL's PCPs when MIL went into rehab. Neither had any idea that drug or concurrent alcohol abuse was happening -- despite prescriptions for Halcion over the years. Whether that's what they thought privately we don't know - or care. Ultimately it was our Minister who pushed us to get help for MIL and for that he deserves a place in heaven.

My guess is that there are some academy award winning performances played out in exam rooms.

At Wed Jul 25, 12:43:00 PM, Anonymous Anonymous said...

I never understood why people would deliberately take narcotic pain meds. As a teenager I was prescribed percodan after my wisdom teeth were removed. I spent the bulk of that weekend sick to my stomach and unable to keep anything down.

I was also prescribed some other narcotic after breaking my ankle... only to have to hobble to the bathroom to vomit.

Pain meds make me sick, literally (I read somewhere that 10% of the population suffers like I do with narcotics). Fortunately I am not in pain often, and when I do ibuprofen is sufficient.

I just don't get why anyone would want to take narcotics without needing thm. Wow, I'm feeling a little woozy just thinking about them now!

At Wed Jul 25, 01:01:00 PM, Anonymous Anonymous said...


One of the theories is that some people's brains are simply hard-wired for addiction. They respond more intensely to the rush they get from whatever drug they're taking, be it alcohol or Percocet. So they seek to repeat the experience... and pretty soon they can't stop because they are physically and psychologically dependent. I don't say "addicted" because there is a difference between addiction and habituation; it's not always easy to distinguish between the two but important to keep in mind that narcotic use does not automatically = addiction.

At Thu Jul 26, 02:44:00 AM, Blogger BillyBob said...

I have the nausea that HCN described, but when I can no longer chat on my cell phone, or smile,or move around or crack a joke like ambulance driver describes, then I'll be ready to eat a bullet rather than an oxy.

At Thu Jul 26, 09:14:00 AM, Blogger William the Coroner said...

I see a lot of pain patients. Some docs throw around methadone like it's water. I don't know. Adequate pain control is important. So is not losing your medical license. I think, though, the problem isn't the drug seeking, it's the lying, the manipulation, and the scamming that gets up people's noses.

At Thu Jul 26, 09:55:00 AM, Blogger P said...

Interesting post and perspective. I do have to disagree that most EMS providers view their patients as lazy drug seekers.

While some of our patients complaining of pain may be drug seekers, it is not our job, as acute care providers, to be judge and jury over someone's pain. Studies show one person cannot rate another's pain nor can vital signs be used as a guage of another's pain. I would rather provide a drug seeker making a good case for kidney stone pain, with a temporary fix than deny a person with legitimate pain relief from their suffering. Besides many people who are drug seeking are seeking drugs because they are in pain, and our job is to take care of that pain, while delievering them to a facility that can either further treat their pain or counsel their addiction.

As you know, pain management in medicine is undergoing a sea change in an attempt to end the years of failure to treat it adequately. Newsweek had a recent cover story on this. Our prehospital pain management protocols have grown more liberal with each passing year. We have been taught to no longer view pain as a symptom, but as a disease. Failure to treat acute pain promptly may in fact lead to chronic pain, which if then undertreated may legitimately turn a previously normal person into a drug seeker.

Sure, I get annoyed when I learn I've been scammed, but on the other hand, they are sick and I'm not. I hope eventually they get the long term help they need.

Keep up the blog. It's excellent.

judge people about all EMS bloggers thinking

At Sat Jul 28, 09:35:00 PM, Anonymous Anonymous said...

Three things to share:

1) A "white flag" (opposite of red flag) for the primary or specialist provider who Rx opiates long term is to Rx enough to last until next visit and then another few days. The patient is asked to bring pill bottle to each visit. IF enough pills are still there for next few days, very unlikely they are addicted or diverting. If not enough or no pills are brought, requires further discussion/investigation. This also has the advantage that patients are less likely to call with early refill request if using more in a given month as a buffer exists. Too few pills brought need to be explained but in context of ongoing relationship, may be ok.

2) Providers need to be clear and educate patient to be clear on definitions: "addiction" is not the same as requiring ongoing use of opiates for managing pain. Addiction is when a person is inappropriately seeking drug for its psychic effect not pain relief. There is a term "pseudo-addiction" for when a pain patient is seeking drug to relieve pain only but behaves in same way an addict would (including lying, stealing, seeing multiple providers)but only to relieve pain--not craving drug for it's psychic effect. Pseudo-addiction is cured when pain is adequately managed (by use of opiates or other methods). Physical dependence,i.e., withdrawl symptoms if drug stopped appruptly (or weaned too fast) is also not addiction and occurs almost universally with people on significant dose of opiates (or beta blockers for that matter).

3) Better to use the term opiate or controlled substance as the word "narcotic" has two meanings depending on context: a legal definition that the drug is controlled as it has potential for abuse and a medical definition that it makes you sleepy (narcosis). By the legal definition, cocaine is a narcotic but by medical definition it is not (makes you anything but sleepy). By medical definition, Benadryl is a narcotic but legally it is not as low potential for abuse. (Soap-box issue by my instructors when I was in pain management fellowship, so please forgive if sounds like hair splitting.)

Hope these comments are helpful!

-PDAPC-Pain Doc appreciative of primary care.

At Sat Jul 28, 11:08:00 PM, Anonymous Anonymous said...

Hat tip to you, PC. In all the time I've been reading various medical blogs, you are literally the first doctor I have read who acknowledges that people often "drug seek" for perfectly legitimate reasons. You are also the first I have read who would prefer to err on the side of giving a drug addict a free high than risk a legitimate patient enduring severe pain, and who recognizes that failure to treat acute pain aggressively can lead to chronic pain. I wish that there were more docs like you out there and that more had your attitude.

I can tell you as a chronic pain patient for 15 years and a contact person for CP support groups that your attitude is the exception, and not the rule, and most docs have an extremely poor understanding of CP or how to treat it and an even worse attitude to its victims. Even many so-called "pain specialists" can be remarkably ignorant, judgemental and indifferent to the suffering caused by severe pain. The norm is for people with CP to be treated with suspicion, derision and contempt and to walk out the door with a hefty bill and no treatment. It can take *years* to find someone willing to treat pain to an appropriate degree, and ERs are the bottom of the barrel for acute pain treatment unless you have an observable problem like a gunshot wound or broken leg. If it's a "subjective" problem like fibromyalgia and you are going to the ER to avoid sticking a gun in your mouth, good luck. Because of the danger of being falsely blacklisted as a drug seeker, I would advise anyone with chronic pain to avoid going to an ER for an acute exacerbation of their usual pain unless they absolutely couldn't take the pain or it's not their usual pain, and make damn sure they get a copy of their med records afterwards if they do.

At Tue Jul 31, 01:33:00 AM, Anonymous Anonymous said...

love your blog Dino Dr. I wonder what you would think of me if I presented myself in your office. I have had migraines since I was 2 years old. Occasionally they are so severe that I have actually wanted to die. Twice I’ve been so incapacitated that I wanted to call an ambulance, but couldn’t get to a phone. I have had 2 completely unmedicated childbirths and would take labor over a migraine in a heartbeat if that choice were presented to me.

Because of this, I have an incredibly high pain tolerance. Often I have to work and take care of children and generally live life while in pain. I can totally imagine sitting in a Dr’s office and truthfully answering the painscale question with a 8 or 9 and still being able to talk and occasionally joke…in between throwing up.

Though my migraines are hormonally triggered, I would never consider hormone birth control because I had severe depression for 5 years while on the pill (no, no one ever mentioned to me that these things might be related…I only found out that my OBC was related to my depression after receiving a diagnosis of psychotic post partum depression after the birth of my second child. A nice Dr finally put 2 and 2 together for me, and I’m fine now)

I also am allergic to aspirin, although I react to it with a blood pressure drop so severe it causes blindness and uncontrollable diarrhea, but not true anaphylaxis. I have never lost consciousness or stopped breathing when taking it.

Usually imitrex saves the day, but when it doesn’t, or I’ve taken all I have without success, I end up in a med clinic or ER.

Now imagine you are the ER doc who wins me on the night when I drag myself out of bed after having taken lots of imitrex (which makes me talk a bit thickly), I have to drive myself because no one else is going to and the alternative is letting it get to the “I don’t care if I die” stage. When I get there, I sit with my hand over my eyes and when you talk to me I tell you I want Darvoset and lots of it because I know that’s what works and by this point I’m in no condition to beat around the bush and I also have so much imitrex onboard that I feel like my eyeballs are going to pop out of my head.

Though I answer questions honestly, I’ve been insulted and generally treated like a drug addict more than once. I’ve been given a shot of stadol and sent home…where I promptly passed out in my entry way…and came too with a worse headache. I’ve been told I’m not allergic to aspirin and told to go buy some (really buddy? well just give me a couple and stick around…bring a bedpan and a mop.)

What would you suggest I say? I’m not being sarcastic. I really would like a suggestion.

At Tue Jul 31, 03:44:00 PM, Blogger #1 Dinosaur said...

Linda: What would you think of me if I presented myself in your office?

After listening to the story you just told and examining you, (presuming your neuro exam was normal) first I'd ask you to sign a record release from your old doc.

I'd ask if you've considered DepoProvera (continuous progestin-only contraception), trying to determine whether it might have been the estrogen component of the OC pill that gave you depression problems.

I'd ask/offer a daily prophylactic medication, perhaps Topamax, to see if that would cut down on the frequency and/or severity of your headaches.

I'd ask if it was just aspirin or all non-steroidal agents that produce the severe reaction you describe.

If you answered "no", "no", "I don't want to", and "all" to those requests, I'd furrow my brow at you and ask what you wanted me to do (and if the answer was simply to write narcotics, I'd refuse as politely as I could.)

On the other hand, as you can see, I have several other suggestions for you to help deal with your problem. Your response to those suggestions is my information.

As to what you can say to *another doctor* to be treated appropriately, I think you know I have no answer. Yes, some (ok, perhaps many) other docs are A-holes. Unfortunately, there isn't a whole lot I can do about it. Sorry.

At Tue Jul 31, 04:46:00 PM, Anonymous Anonymous said...

I am curious why you would prefer a host of dangerous drugs like topamax to something far safer like a narcotic, particularly if the patient says it works for her. If patients could treat themselves, I doubt there's a one who'd try 50 different things before reaching for the thing they know that works. Only once they were stabilized and could be assured of quick relief would they be willing to experiment with other, perhaps better options. (Note that Linda usually goes the distance with her Imitrex before considering an emergency room visit for something else). This is just common sense. Time may be on the doctor's side, but when you're in unspeakable agony, can't function and are contemplating suicide, you want relief immediately with something that works, not to play trial and error games.

As for signing a release, what if her previous doc unjustly labeled her a drug addict? Would it be unreasonable for her to not want to sign a release for this guy, knowing that it would prejudice any further care she might receive? There are often valid reasons why patients might not want to sign releases that have nothing to do with drug-seeking, and everything to do with previous experience of abuse. Similarly, patients may be opposed to taking certain kinds of drugs based on what they've read, and adverse reactions to drugs are hardly rare given they injure over 2.2 million people a year in this country and effect God only knows how many more with intolerable side effects. Why any of this should be seen a a sign of drug addiction is beyond me.

At Sat Aug 04, 12:35:00 AM, Anonymous Anonymous said...

really appreciate the thoughtful response. A couple of things I should clarify I guess. These experiences have happened in ER/Med Centers where I only end up if I run really stuck. Weekend night, on vacation, out of Imitrex at 2AM, etc. My OB is my only real doctor because I rarely get sick other than the migraines and the occasional sinus infection and he prescribes the Imitrex.

If I was sitting in your office as a new patient, my answers to your questions would be:

Depo? Well, I’m 36, have an IUD (non hormonal) and am 35lbs overweight already so that would not really be my first choice. I was on the minipill when I had all the depression problems because I was told that estrogen would make my migraines worse and also increase my stroke risk. My understanding is that the minipill and Depo are both progestin-only, so I’d be doubly hesitant.

“Is it just aspirin or all non-steroidal agents that produce the severe reaction you describe?” I honestly don’t know. For the last 15 years I have not taken anything aspirin like. I have never taken ibuprofen. My reaction is unpleasant enough that I stick with Tylenol. I’d be willing to give it a try if a doctor was willing to supervise.

I had forgotten, but my OB did put me on Inderal as a prophylactic and I tried it for a month, but rather than feel terrible one day a month with a migraine, I felt terrible every single day of that month, so I quit taking it. That was a long time ago and I certainly would consider another try with another drug.

If I was seeing you in the ER…yeah, I’d just want the drugs.

I appreciate the time you took to answer my question. I guess I want to know how not to look like a crazy drug addict in those situations, which as redhawk pointed out, are not times when I am looking to discuss treatment plans and not even really capable of niceties. I don’t even like the feeling narcotics bring. Vicodin makes me feel all woozy and awful. It’s especially frustrating to be treated with suspicion when I don’t even have the slightest interest in taking anything once my headache is gone, but I don’t know how to present myself in those circumstances in a way that doesn’t raise alarms.

Thank you again, it helps to understand the physician’s side of things.

At Sat Aug 04, 07:22:00 AM, Blogger #1 Dinosaur said...

My OB is my only real doctor because I rarely get sick other than the migraines and the occasional sinus infection and he prescribes the Imitrex.

Another of my pet peeves: specialists practicing outside their areas of expertise. OB-GYNs are surgical specialists. Although many advertise (and think they can do) "primary care for women" because they order mammograms and treat sinus infections, migraine treatment is beyond their training. Seek out either a good FP or a neurologist (preferably the former, of course.) *grin*

FWIW I get a lot of people referred from their OBs for things like this.

At Sat Aug 04, 07:28:00 AM, Blogger #1 Dinosaur said...

Linda: Another thing: your willingness to try other NSAIDs and prophylactic meds would label you as legit in my book.

PDAPC: On further contemplation, I think your color choice of "ok" sign could be improved: How about "green flags" instead of red ones for legitimate pain patients? "White flags" makes it sound like I'm giving up on them. (That's when I send them to you.)

At Sun Mar 30, 08:28:00 AM, Anonymous Anonymous said...

hi, I usually buy tramadol here online so I'd like to know if tramadol is addictive drug.

At Mon May 05, 12:43:00 PM, Blogger dr sissy said...

Hi, dr. dino,

any advice for a new fp? The narkies are coming out of the woodworks; I offer referral for counselling, hospitalization, pain management, and physical therapy along with NSAID's, tramadol, and other lower risk meds and watch them leave in a huff.


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