"Drug-seeking" label is sometimes wrongly applied

Some patients suffer unnecessarily

Is there clear and convincing evidence that an individual has no pain that would justify a prescription analgesic and is, therefore, seeking medication solely because of an addictive disorder, recreational use, or with the intent of diverting it to others? If so, then the provider may have a legitimate factual basis for identifying a patient as "drug-seeking" and denying requests for medication, says Ben A. Rich, JD, PhD, professor and School of Medicine Alumni Association Endowed Chair of Bioethics at University of California — Davis Health System.

"The implication of the label is that the patient has no legitimate medical need for the medication which they seek," says Rich. Nevertheless, even some patients legitimately labeled as drug-seeking may have other medical issues, including mental health issues, that explain their behavior and require further attention. "Simply showing the patient the door is not an ethical response," says Rich. "The key ethical problem posed is the facility with which the label is used without adequate factual justification. Doing so has profoundly negative implications."

Rich notes that the "drug-seeking" label is almost exclusively applied to individuals who present to medical institutions or providers seeking an opioid analgesic, and rarely to patients seeking antibiotics or other non-opioid medications. "There is nothing intrinsically wrong with seeking something for which one has a legitimate need," says Rich. "When we are hungry, we engage in food-seeking behavior. When we are in pain, we seek pain relief, which, in many instances, requires some form of analgesic."

Clinical judgment

Some drug-seeking patients are "very convincing," acknowledges Kenneth W. Goodman, PhD, professor and director of the Bioethics Program at the University of Miami and director of the World Health Organization's Collaborating Center in Ethics and Global Health Policy. "From migraines to backaches to kidney stones, patients will adopt all kinds of stratagems to try to convince busy clinicians to part with prescriptions for controlled substances," he says. "In some cities, emergency departments are frequent targets of such drug scammers."

It can be a very difficult judgment call when, in a busy emergency department, a patient seems disabled by pain and is requesting a drug known to be abused, says Goodman. The line between appropriate and inappropriate prescribing will not always be clear in this scenario, and busy clinicians must rely on their diagnostic acumen to make these decisions, he adds. "One could argue that it is better to give a controlled substance to an abuser than not to give one to someone in actual pain," he adds. "Telling the difference can be a challenge. Trying to tell the difference is an obligation."

Ethical use of prescribing authority and privileges requires a scientific basis for each prescription, says Goodman. "This does not mean a physician must know in advance that a particular drug will work in a specific case — only that there be some evidence or other good reason," he adds. "Proper prescription of drugs that can be habituating requires an appropriate clinical workup, and mindfulness of the possibility that a patient is malingering."

Red flags might mislead

There are a wide range of screening instruments that can assist prescribers in determining whether opioids are being used as prescribed and are addressing a legitimate medical purpose, says Rich, but most non-pain medicine specialists lack the basic knowledge and skills necessary to administer these instruments effectively. In addition, providers might wrongly suspect drug seeking simply because patients demonstrate a familiarity with analgesic medications and dosages. "If the person has been taking pain medications for a chronic condition, it should be neither surprising nor sinister that they have some familiarity with such medications and experience in which medications have helped them and which have not," says Rich.

Providers might suspect drug seeking simply because the patient is insistent or demanding in their demeanor, but this might be reasonable if patients want relief for pain and feel their truthfulness is being questioned. "There is a recognized phenomenon of 'pseudo-addiction,' in which patients whose efforts to achieve pain relief have been so frustrated by encounters with opiophobic physicians that they are driven to behaviors that mimic a drug-dependent patient in withdrawal," he says. "Such patients suffer unnecessarily, and are victims of untreated or undertreated pain and the negligent infliction of emotional distress." (See related story, below, on ethical practices for providers.)

Sources

Kenneth W. Goodman, PhD, Professor and Director, Bioethics Program, , University of Miami (FL). Phone: (305) 243-5723. E-mail: [email protected].
Peter Koo, PharmD, Clinical Professor of Pharmacy, University of California — San Francisco. Phone: (415) 476-3055. E-mail: [email protected].
Ben A. Rich, JD, PhD, Professor and School of Medicine, University of California — Davis Health System. Phone: (916) 734-6135. E-mail: [email protected].

Uneasy providers can utilize these options

Thorough evaluation is key

Peter Koo, PharmD, a clinical professor of pharmacy and a pharmacist specialist in pain management at University of California — San Francisco, says that sometimes patients are doctor shopping because they are addicted, but often they are doing it because they are actually under-treated. Sometimes, it's a combination of the two. "Often, a patient really does need better pain management and isn't able to address it through the medications they've been prescribed," he says.

For example, patients with nerve pain after a surgical procedure might be prescribed opiates, which the provider knows might not adequately address nerve pain in the long term. "They may have successfully used opiates after the initial surgery, but the cause of their pain has changed to something that no longer responds to the medication they're on," says Koo. "So the patient keeps going back to the doctor to seek more pain control."

One compounding factor is that many physicians aren't trained in pharmacological pain management, or are only focused on interventional procedures, such as nerve blocks or local injections. "Sometimes, a simple shift in medications might actually be more effective in controlling the pain in the long run," says Koo. "In fact, some atypical analgesics, such as antidepressants and seizure medications, actually work very well for nerve pain — much better, in fact, than opiates."

Providers need to conduct a thorough evaluation with any patient before they prescribe medications, especially opiates, underscores Koo. "You really have to assess the patient. If you feel like you are running a circle around yourself in trying to treat a patient's pain, that's a good time to refer them to a pain specialist," he says. "If you truly believe a patient is playing you for medication, you also have several options." Koo gives these examples:

Providers should ask, "Is the opiate indicated?" "Is the patient being followed regularly to assess their progress?" and "Are regulations on opiate prescriptions being followed?"
Providers can offer treatment with the condition that they have the right to conduct a urine test, and conduct periodic reviews of drug-monitoring reports, which track every controlled prescription patients receive.
If providers don't feel comfortable writing the prescription, they can recommend instead that the patient receive an evaluation from an expert.
Providers can identify co-morbidities, such as depression or anxiety, indicating that patients may benefit from psychotherapy as well.
Providers can set up a treatment agreement with the patient, which spells out that they will provide the medications under the condition that the patient may not receive medications from another provider without consulting with you first. "If they do, you reserve the right to terminate their care," says Koo.
Providers can make it an office policy that they do not write for prescriptions for opiates on initial new patient visits. "This will prevent traveling prescription shoppers," says Koo.