'My Parrot Ate My Pain Pills': Dealing With Drug-Seeking Patients

Batya Swift Yasgur, MA, LMSW

Disclosures

August 10, 2012

In This Article

Introduction

Two patients show up in your office complaining of severe pain and requesting opioid painkillers. How can you distinguish between the one who's suffering from genuine pain and the one who's abusing or diverting the medication?

Some stories are giveaways. "I've heard patients say that their pills fell into the toilet," reported Daniel Kane, PA, PsyD, a physician assistant in Buford, Georgia. "And I actually had a patient claim that his parrot ate the pills."

Some tall tales are equally absurd but more complex. "I had a patient whose urine tested positive for hydromorphone. When confronted, he claimed that he laid out his father's hydromorphone tablets every morning and the medication had been absorbed through his skin," recounted Steven D. Passik, PhD, Professor of Psychiatry and Professor of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.

Relief-Seeking vs Drug-Seeking Behavior

Some patient's stories are harder to gauge. Patients may be exhibiting behaviors associated with abuse or diversion but may be doing so because their pain is undertreated. "Even the best of us don't always understand how to interpret these behaviors, which are distressing but not necessarily indicative of abuse," said Bill McCarberg, MD, founder of the Chronic Pain Program at Kaiser Permanente, San Diego, and Adjunct Assistant Clinical Professor, University of California, San Diego.

Patients who engage in aberrant behaviors are not necessarily abusing their medication. "They may appear to be drug seekers," said Yvonne D'Arcy, MS, CRNP, CNS, pain management and palliative care nurse practitioner, Suburban Hospital, Johns Hopkins Medicine, Bethesda, Maryland. "But I prefer to call them 'relief seekers' because their pain is significantly undertreated."

Dr. McCarberg described a patient who was arrested at the Mexican border for trying to bring unprescribed acetaminophen with codeine into the country. "Her doctor prescribed a limited number of pills, but she had breast cancer that had metastasized to her spine and was in terrible pain from compression fractures."

This may be an extreme example, but it has far-reaching ramifications. "You can't always tell by the surface presentation whether the patient's 'suspicious' behavior is due to undertreated pain or to abuse or diversion," says Dr. McCarberg.

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