DRUG-SEEKING PATIENTS

The opioid epidemic is a real problem in the U.S. “Drug-seeking” patients visit doctors’ offices quite often in search of the prescriber who will give them what they want. The ever-increasing number of people who are addicted to opioid pain medicines (narcotic analgesics) plague doctors with convincing stories of why they need to be given a narcotic. Not a day goes by when a physician doesn’t have to decide if a patient is legit. Are they really in need of a narcotic? Or are they addicted and a “drug seeker?” This isn’t a problem that impacts my average reader, but it’s still worth knowing about. In a “stable practice” like mine, where I saw the same patients repeatedly, this wasn’t a problem. It’s the ER or urgent care doctor who sees only people he doesn’t know where this is a major problem.

In most cases, based on the results of diagnostic evaluation, a physician knows if the patient’s symptoms are real. The CT that shows a kidney stone, the arteriogram that shows an aneurysm, or the X-ray that shows a rib fracture are all objective findings that prove the patient’s pain is real. Also, a patient’s medical record can inform the doctor of the patient’s terminal illness or chronic pain syndrome. These are all straightforward indications the patient justifiably may need an opioid analgesic.

But what if the doctor doesn’t have objective information about patient X? What if patient X appears to be in pain, but you can’t find a reason? Is there any way the doctor can determine if the patient is a drug seeker? Are there clues or red flags that tell the doctor to beware? It’s very difficult to know sometimes, but there are several things the doctor can look for.

Medical Economics magazine recently published an article providing answers for this dilemma. Titled “Is your patient a drug seeker? 13 red flags to watch for,” it lists 13 items that should make the physician pay closer attention to a patient, as well as unusual circumstances that should increase a physician’s skepticism. Those items are listed below:

1. The patient is from out-of-town or far away. (Their local doctors are on to them)
2. The patient has seen many doctors in a short time for the same reason. (Each doctor prescribed some but not enough)
3. The patient has medical records, but they are from many years ago. (Information is not current)
4. The patient uses multiple pharmacies. (Pharmacies have dispensing limitations)
5. The patient claims an allergy or intolerance to all meds except “X,” a narcotic.
6. The patient is specific about the drug he needs including dose, quantity, and number of refills.
7. The patient is unwilling to consider any other treatment. Only wants drug “X.”
8. The patient calls for a refill at night, on the weekend, or before a holiday, and speaks to a physician who doesn’t know the patient. 
9. The patient’s story is inconsistent, a lie, or nonsensical.
10. The patient cries, moans, or exaggerates symptoms.
11. The patient gets aggressive or belligerent when an alternate drug is suggested.
12. The patient gives a false address, phone number, or other info.
13. The patient takes other controlled substances.

Then, there are the excuses patients gave me at the office:

     My oxycontin was stolen from my purse by some guy on the bus.

     The dog got my pills and ate them.

     I accidentally spilled the bottle down the toilet/down the drain (or my child did)

     The pharmacist shorted me. 

     I have a toothache and can’t get in to see the dentist.

     My insurance allows 50 pills and 3 refills.

Every physician deals with drug-seeking patients in some degree. As I said previously, ER and urgent care docs get the most exposure along with pain clinics and pain specialists. Of the list presented above, I encountered each of those scenarios at least a few times. Getting to know your patient and their family keeps drug seekers at bay. If they have a drug problem, their regular family doctor is usually not their supplier. It’s the occasional new patient or the friend of a patient who is the drug seeker. The doctor has to have a “sixth sense” about this sort of thing and nip it early. If the doctor doesn’t stop it, he becomes known by drug seekers as an easy mark and will attract more and more such patients. The path of least resistance is to just say “yes”, write for a small supply of drug, and send them on their way. But once you start, the problem perpetuates itself. They won’t just come once. Being aware of the items listed reduces a physicians complicity in a patient’s opioid dependence, but it does nothing to correct the overall problem. That’s a much bigger issue!

Reference: https://www.medicaleconomics.com/view/your-patient-drug-seeker.