Quantifying Drug-seeking Behavior

A Case Control Study

Casey A. Grover, MD; Reb J. H. Close, MD; Erik D. Wiele, BA; Kathy Villarreal, RN; Lee M. Goldman, MD

Disclosures

J Emerg Med. 2012;42(1):15-21. 

In This Article

Abstract and Introduction

Abstract

Background: Drug-seeking behavior (DSB) is common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of anecdotal evidence.
Study Objectives: To perform a casecontrol study examining the relative frequency of DSB in suspected drug-seeking patients as compared to all ED patients.
Methods: We performed a retrospective chart review of 152 drug-seeking patients and of age- and gendermatched controls, noting which of the following behaviors were exhibited during a 1-year period: reporting a nonnarcotic allergy, requesting addictive medications by name, requesting a medication refill, reporting lost or stolen medication, three or more ED visits complaining of pain in different body parts, reporting 10 out of 10 pain, reporting > 10 out of 10 pain, three or more ED visits within 7 days, reporting being out of medication, requesting medications parenterally, and presenting with a chief complaint of headache, back pain, or dental pain.
Results: The odds ratios for each studied behavior being used by drug seeking patients as compared to controls were: non-narcotic allergy: 3.4,medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits in 7 days: 30.8, out of medication: 26.9, headache: 10.9, back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated odds ratio of infinity for these two behaviors.
Conclusions: Requesting parenteral medication and reporting greater than ten out of ten pain were most predictive of drug-seeking, while reporting a non-narcotic allergy was less predictive of drug-seeking than other behaviors.

Introduction

Pain is a common problem for which patients seek care in the emergency department (ED), accounting for up to 42% of all ED visits.[1,2] Despite this, pain control in the ED can be challenging, with inadequate pain control occurring frequently.[2,3] There are many reasons why pain control may be problematic in the ED, such as variability in emergency physician (EP) prescribing practices and difficulty in assessing a patient's level of pain.[3–5] Additionally, EPs may be reluctant to administer analgesia out of concern that a patient complaining of pain may be trying to obtain medications for non-therapeutic purposes.[2–4] These patients, often labeled as "drug seeking," represent a difficult group of patients to manage in the ED. They often present with conditions that may be easily feigned and are difficult to evaluate, such as headache, back pain, and dental pain.[6,7] They also are known to engage in deceptive behavior in an attempt to fool clinicians into giving them additional medication. Such behaviors include prescription forgery, seeking care from multiple providers, reporting allergies to nonopioid analgesics, complaining of lost or stolen medications, requesting refills, exaggerating symptoms, and using multiple aliases.[6–11] These patients are also noted to have an extensive knowledge about pain medication, request to receive medications parenterally, request medication by name, and may exhibit threatening or even violent behavior when denied the medications they want.[6,10–12]

Drug-seeking patients are common in the ED, accounting for as many as 20% of all ED visits, and are also known to consume large amounts of medical resources.[9,12] As a result, many EDs have created habitual patient files and case management programs in an attempt to track the use patterns of these patients and minimize the amount of narcotics and other medications that they receive.[5,7,10,13–15]

Despite the magnitude of the problem and the familiarity of physicians from all specialties with these patients, there is still much to learn about them. A review of the medical literature reveals that there are many publications on the subject, including several screening tools (Screener and Opioid Assessment for Patients with Pain - Revised [SOAPP-R]; Opioid Risk Tool [ORT]; Current Opioid Misuse Measure [COMM]; Diagnosis, Intractability, Risk, and Efficacy score [DIRE]; and Addiction Behaviors Checklist [ABC]) developed by pain management clinicians to assess for problematic medication use in chronic pain patients.[16–23] However, few of these studies present any quantitative data on drug-seeking patients in the ED, and these studies are limited to small numbers of patients.[6,7,24,25] With this in mind, we chose to perform a case-control study on a large number of patients referred to a case management program for suspected narcotic abuse. To the best of our knowledge, this is the first study to date that provides quantitative data as to the relative frequency of drug-seeking behaviors in all patients suspected of non-therapeutic ED use as opposed to controls.

The goal of this investigation was to perform a casecontrol study to determine the relative frequency of drug-seeking behaviors in suspected drug-seeking patients as compared to all ED patients. Given the difficulty in studying this group of patients, we are aware that finding the exact frequency of any given behavior is very unlikely. However, we hope to provide practicing EPs with information as to which drug-seeking behaviors are more commonly used by drug-seeking patients. We feel that, from a clinical standpoint, knowing that one particular behavior is strongly associated with drug-seeking behavior while another is not as strongly associated would be helpful in evaluating a patient suspected of drug seeking.

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