On the Meaning of "Drug Seeking"

Margo McCaffery, MS, RN, FAAN; Megan A. Grimm, MPH, CHES; Chris Pasero, MS, RN, FAAN; Betty Ferrell, PhD, FAAN; Gwen C. Uman, PhD

Disclosures

Pain Manag Nurs. 2005;6(4):122-136. 

In This Article

Discussion

Limitations of Study

The sizes of the groups were not equal; the general nurses group was much larger (295) than the emergency nurses group (35) and the pain management nurses group (39). Comparing the responses of groups unequal in size can be regarded only as suggestive of similarities and differences between them. Further study using groups of equal size is indicated.

Content of the Survey

Only a few of the behaviors on our survey were mentioned in the publications that were written primarily by physicians, suggesting that nurses have a different perspective on the term "drug seeking." In the medical literature, Weaver and Schnoll (2002) provide a list of what they consider drug-seeking behaviors, of which only one is included in our survey, multiple episodes of lost prescriptions. In one article the physicians list behaviors that are understood by implication to be drug seeking and may or may not indicate abuse (Mitra & Sinatra, 2004). From this list those behaviors that are included in our survey are multiple lost/stolen/spilled prescriptions and patient obtains opioids from multiple sources such as emergency departments.

In a more current publication by a physician, drug-seeking behaviors are listed as such but include only one that is in our survey, frequent lost prescriptions (Kanner, 2003a). The behaviors were referred to as "red flags" that drug diversion or illicit use may be occurring. Pseudoaddiction was not mentioned as a possibility.

Other behaviors referred to as "aberrant drug-related behaviors that raise concern about the potential for addiction" were developed by Portenoy (1994), a physician. They are often mentioned in current literature but not usually labeled drug seeking. Aberrant drug-related behaviors comprise the above behaviors and one other on our survey, requesting specific drugs. This behavior is listed as one that is less suggestive of addictive disease.

These findings suggest that nurses and physicians may view drug-seeking behaviors from different perspectives. Whatever nurses mean by the term "drug seeking" may be dissimilar from what physicians mean. This is worth further study.

Behaviors Associated With Drug Seeking

The items that would cause the majority of all three groups to refer to a patient as drug seeking were as follows: going to different emergency departments to get opioids (65.8%–85.7%), telling inconsistent stories about pain or medical history (56%–74.3%), and asking for a refill because the prescription was lost or stolen (56.4%–68.6%). On every item emergency nurses were more likely to label behavior as drug seeking than were pain management nurses, and on all but two items (prefers the needle to the pill and clock watching) the emergency nurses were more likely than general nurses to label the patient as drug seeking. All of the items were endorsed by all groups as being at least somewhat likely to cause them to refer to the patient as drug seeking. This suggests that the behaviors listed on the survey are more likely to cause emergency nurses to refer to patients as drug seeking than general nurses or pain management nurses. It is also evident that a variety of patient behaviors cause disagreement among nurses as to whether they indicate drug seeking or not.

Following is a discussion of possible circumstances other than addiction or abuse that might underlie each of the three most frequent behaviors that caused nurses to label a patient as drug seeking. Going to different emergency departments to obtain opioids for pain relief obviously may mean the patient has a chronic pain condition and that the primary physician has not treated it adequately, the previous emergency department failed to provide effective pain relief, or insurance may not pay for office visits. Our troubled health insurance industries result in many patients without insurance having only the emergency department as a source of care.

One study that helps explain some of the frequent use of the emergency departments for pain relief found that more than one third of patients presenting to the emergency department with pain did not have their pain resolved (Johnston, Gagnon, Pepler, & Bourgault, 2005). At follow-up 1 week later, approximately one third of patients still could not return to normal activities. Another study found that 73% of patients who frequently used emergency departments actually had a usual source of health care and that 30% had attempted to seek care elsewhere before their visit to the emergency department (Lucus & Sanford, 2003).

Patients who tell inconsistent stories about pain or medical history may have a number of problems such as cognitive impairment, psychiatric illness, medication side effects, or simple difficulty in recalling or communicating details that occurred recently or some time ago. In their review of the literature, Smith and Safer (1993) found that chronic pain that varies in intensity over weeks and months may be especially difficult to remember accurately. Further, Kanner (2003b) acknowledges that history taking is sometimes difficult because the patient cannot recall or be specific about the time course of a pain syndrome. Or, a patient may have trouble describing the exact distribution of back and leg pain. Trying to communicate in English as a second language also heightens the possibility of patients telling inconsistent stories. In fact, pain has a language of its own, such as various qualities, intensities, and locations with which patients may not be familiar. Without the help of a clinician skilled at history taking, some patients with communication difficulties may tell inconsistent stories about pain to the same or different interviewers.

Other factors may complicate the ability to obtain an accurate and consistent history from patients about their pain. It has been known for some time that present pain intensity affects chronic pain patients' recall of their pain and medication use for 1 day to several weeks previously (Smith & Safer, 1993). Prior pain is recalled as less severe when present pain is at relatively low intensity and as more severe when present pain is at a relatively high intensity. Medication use is recalled as less frequent when the patient's present level of pain is low. Therefore, it should not be too surprising that some patients fail to give consistent pain histories.

Asking for a refill because the prescription has been lost or stolen may be a result of many factors. For example, patients with cognitive impairment may misplace items. Other patients may be unaware of the street value of their prescriptions and fail to protect their supplies, leading to theft by relatives orvisitors to their home. Some patients with breakthrough medications may carry those with them when they leave their residence. These patients need to be cautioned to carefully secure their prescriptions and never carry all of their medications with them when they are going out. It is also possible that patients reporting lost or stolen prescriptions simply ran out of medication because the prescription was insufficient. In their study of patients with chronic pain, Kirsh, Whitcomb, Donaghy, and Passik (2002) found that undertreated pain in patients with cancer resulted in those patients escalating their doses of prescription opioids.

Meanings Associated With Drug Seeking

When the term "drug seeking" is used, all three groups agreed that it was very likely to mean the patient was addicted to opioids (57.9%–64.7%), the patient was abusing pain medicine (61.8%–70.6%), and the patient was manipulative (53.8%–68.8%). Another important finding was that for each item there were responses in each of the categories of not likely, somewhat likely, and very likely. Clearly the term "drug seeking" evokes very different meanings among nurses.

When a patient is referred to as drug seeking, less than one third of the nurses in each group thought it was very likely that the patient found the pain unbearable, the patient had undertreated pain, or the patient was upset. The pain management nurses rather strongly (61.5%) agreed that drug seeking does not mean that the pain is unbearable. Undertreatment of pain is well recognized, but very few nurses in each group thought it was very likely (20.6%–26.2%) that a patient who is referred to as drug seeking has under-treated pain. Despite higher levels of education, their attendance at the ASPMN meeting, and current experience in pain management, only 23.1% of the pain management nurses thought drug seeking was very likely to mean undertreated pain, and only 12.8% thought it was very likely that the patient found the pain unbearable.

Compared with the general nurses group and the emergency nurses group, the pain management nurses group's responses are not very different. One might expect they would give different or stronger responses to survey items. However, this was not the case.

Because there is widespread undertreatment of pain, behaviors that raise concern about drug seeking seem to be best approached initially as potential undertreatment of pain, or pseudoaddiction. Every behavioral item on the survey could be caused by unrelieved pain. A clinician in the field of addiction and pain believes that many patients coming to a physician's office requesting pain medication are accused of drug seeking, when in reality, most of these patients may be undertreated for their pain (Heit, 2001). This may actually result in manipulative behavior.

As pointed out by Fisher (2004)), undertreatment of pain can easily cause the patient to be less than honest with the physician. When patients do not get relief for the pain they report, it is a common observation ( Table 3 ) that some patients will change their behavior, trying to learn what behaviors are likely or not likely to help them get pain relief, causing them to become manipulative. If the patient's report of pain is not accepted and pain relief is not forthcoming, it would be logical for that patient to try to determine what behaviors or information would increase the likelihood of getting pain relief. Patients' actions are actually valid attempts to improve the likelihood of getting pain relief, unless, of course, they are caught doing it. One study showed that patients who reported identical levels of severe pain were more likely to receive high doses of morphine if they were grimacing than if they were smiling (McCaffery, Ferrell & Pasero, 2002).

When the clinician does not respond with attempts to relieve the patient's pain, the clinician should stop to consider, What would the patient have to say or do to make me relieve the pain? Very likely some patients will figure out the answers and begin to act like and say things that would cause the clinician to provide pain relief.

In dealing with the behaviors that may cause nurses to refer to a patient as drug seeking and conclude that this means addictive disease, nurses should examine the behavior for other possible meanings using this strategy: This behavior may mean that the patient has addictive disease, but what else could it mean? Nurses must also recognize that they may not be educated and experienced enough in the science of addiction to make the diagnosis of addictive disease. This diagnosis can only be made over time by a qualified clinician. Furthermore, the use of certain lists of behaviors to establish the presence of addictive disease has not been validated. One clear limitation is that these behaviors are merely a series of anecdotal observations, not necessarily a pattern of behavior (Fisher, 2004).

Portenoy emphasizes that his list of aberrant behaviors is not equated with addiction and requires a differential diagnosis because they may also indicate unrelieved pain or mild encephalopathy with confusion about drug intake (Portenoy, 1996). To rule out pseudoaddiction, improved pain control such as escalation of the opioid dose, is recommended by both Portenoy (1994) and Passik and Kirsh (2004). They also emphasize the need for differential diagnosis of drug-taking behavior as either addiction or not, but note that clinicians need not be correct in their final conclusion as to the presence or absence of addictive disease. In either case the care of the patient can be individualized without necessarily terminating the prescription of opioids. The authors give specific suggestions for doing this.

Others also point out that aberrant drug behaviors are not equated with addiction and their predictive ability is unknown (Kirsh et al., 2004; Michna et al., 2004). On the basis of research data, it seems that only a minority of patients taking opioids for pain engage in these behaviors. More research is needed on the prevalence of licit versus illicit intent behind these behaviors, but some authors (e.g., Ballantyne & Mao, 2003) make unsubstantiated statements that most often the behaviors reflect addiction or noncompliance.

In an effort to improve the usefulness of lists of aberrant or drug seeking behaviors, Fisher (2004) focuses on the issue of undertreatment and suggests dividing the behaviors into two groups that pose different possibilities for the meaning of the behaviors:
(1) drug-related behaviors primarily suggestive of undertreated pain such as requesting specific drugs, and
(2) drug-related behaviors possibly suggesting under-treated pain, such as recurrent prescription losses.

Use of the Term "Drug Seeking"

The majority (82.4%–84.6%) of nurses in all groups agreed that drug seeking has a negative meaning. Looking at behaviors from the perspective of concern or possible undertreated pain instead of viewing them as potential indicators of addictive disease, as suggested above, may help them question their attitudes.

The groups were fairly evenly divided as to whether the term should be used in health care, with the pain management nurses less likely (63.9%) to think the term should be used. The groups were also fairly evenly divided as to whether they used the term in talking about patients, with the emergency nurses more likely (67.6%) to use the term in conversation. A majority of all groups (91.2%–93.2%) denied using the term in charting.

During the piloting period of the survey, the authors began to suspect that completing the survey was influencing the nurses' behavior. Later during the lecture on pain there were fewer concerns expressed about drug seeking. Thus a question was added to the survey to explore how completion of the survey affected the nurses' use of the term "drug seeking." In response, a majority of the general nurses group (59.5%) and pain management nurses group (61.1%) were less inclined to use the term "drug seeking." The emergency nurses group was fairly evenly divided between being less inclined to use the term and being comfortable with their current use of the term. On the basis of the findings addressed above, perhaps this short survey, which takes approximately 10 minutes to complete, would be an efficient way to begin to help nurses examine their attitudes about patients they have been referring to as drug seeking and begin to address the stigma associated with those terms.

Addressing Stigma in Clinical Practice

To get a perspective on the concept of stigma, it is useful to know that describing a patient as difficult is considered a stigmatizing act (McDonald, 2003). The term "drug seeking" is often applied to patients who are considered difficult. McDonald describes characteristics of patients referred to as difficult. One characteristic is a blemish of character, such as chemical dependency, which is one of the meanings nurses ascribed to the term "drug seeking." According to McDonald, one other characteristic of the difficult patient is the nurses' sense of being challenged as to who is in control in the nurse–patient encounter. Many of the items that nurses endorsed on the survey indicate an issue of control, such as the patient telling the nurse how to give the medication.

Our findings indicate that a high level of confusion and stigma are likely to be present in the care of a patient who is labeled drug seeking. The term "drug seeking" is very often used, is ill-defined, is stigmatizing, and conveys no well-established criteria for concluding that the patient does or does not have addictive disease. The term should not be used in discussing patients or be written in patients' medical records. Instead of stigmatizing a patient with the label drug seeking, the behavior should be described and discussed with the patient in a respectful manner to determine meanings and causes of the behavior, seeking to work with the patient for solutions. In the field of pain and addiction considerable stigmatism and undertreatment already exist. The term "drug seeking" seems to be similar to other groups of behaviors such as aberrant drug use, which also carries stigmatism and is frequently used to diagnosis a patient as having an addictive disease when that was not the intent (Portenoy, 1994). We propose at the very least that clinicians either carefully define the term "drug seeking" or eliminate it from their vocabulary in the professional environment. We recognize that sometimes patients who display behaviors commonly called drug seeking may have addictive disease or may be diverters. Regardless, all patients should be treated with respect.

Instead of using terms such as "aberrant drug-taking behavior" or "drug-seeking behavior," it has been suggested that such behaviors be referred to as "concern-raising behaviors" to not prejudge or stigmatize patients (Elander, Lusher, Bevan, Telfer, & Burton, 2004). Using the word concern simply alerts the clinician that something is not going as usual and needs to be examined. Further, it conveys a caring and positive attitude toward the patient. No stigma is attached and no diagnosis such as addictive disease is suggested.

After designating behaviors as concern raising, following Portenoy's (1994; 1996) advice from more than a decade ago, behaviors should be carefully examined by discussion with the patient and accompanied by careful observation over time of the total of that patient's behaviors. The first step to be taken with such behaviors is to rule out pseudoaddiction by thoroughly examining the pain management plan and escalating opioids and other pain-relief methods to determine whether the behaviors are driven by undertreatment of pain.

Quite simply, a differential diagnosis should be done when questionable behaviors occur during the course of pain management. Portenoy (1996) emphasizes that "the diagnosis of an addiction disorder should be made only if the criteria for this diagnosis are met and there is no credible alternative diagnosis" (p. 258).

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