How Frequently Are "Classic" Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department?

Casey A. Grover, MD; Joshua W. Elder, MD, MPH; Reb JH. Close, MD; Sean M. Curry, MD

Disclosures

Western J Emerg Med. 2012;13(5):416-421. 

In This Article

Abstract and Introduction

Abstract

Introduction: Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior.The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication.

Methods: We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as "classic" for DSB in the existing literature.

Results: We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit.

Conclusion: Drug-seeking patients appear to exhibit "classically" described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking.

Introduction

Pain is cited as the most common reason for visits to the emergency department (ED).[1–3] In 1997, 94.9 million ED visits, accounting for 22% of all ED visits, resulted in the administration of pharmacotherapy for pain.[4] Despite the frequent use of pharmacotherapy, many studies have suggested that emergency physicians (EP) undertreat patients' pain in what is termed oligoanalgesia.[5] While there are numerous reasons for which EP are hesitant to provide opiate analgesia, concern for patients seeking medication for non-therapeutic purposes is among the most common.[3,6–9] Such patients are estimated to account for as many as 20% of all ED visits, and are often labeled as "drug-seeking." Furthermore, they often present with conditions that are difficult to evaluate and easily feigned, such as headache, back pain, and dental pain.[8–11]

Despite their prevalence, there is no uniform method established to identify these drug-seeking patients. Some ED have developed habitual patient files and case management programs to track patients with frequent use of emergency care, while others have increased physician education as a means to improving identification of these patients.[8,10,12–16] Additionally, several screening methods (Screener and Opioid Assessment for Patients with Pain - Revised, Opioid Risk Tool, Current Opioid Misuse Measure, Diagnosis, Intractability, Risk, and Efficacy inventory, and Addiction Behaviors Checklis) have been developed to assist in identifying problematic narcotic use in chronic pain patients. However, these screening methods were developed in pain clinics and may be lengthy, making them difficult to use in the ED.[17–24] Uniform among all of these approaches is the reliance on the identification of drug-seeking behavior as a means of identifying problem patients. Such behaviors frequently cited as being present in ED patients include complaining of headache, back pain, dental pain, requesting medication by name, requesting a refill of narcotics, benzodiazepines, or muscle relaxants (high risk medications for abuse[HRM]), reporting HRM as having been lost or stolen, reporting being out of HRM, reporting greater than 10/10 pain, and requesting HRM parenterally. While there is a preponderance of publications on the subject of drug-seeking patients, there is very little literature that quantifies the prevalence of these behaviors.[10,25–29] By identifying the frequency of these drug-seeking behaviors we can begin to understand whether our current approach in identifying these patients is both effective and substantiated.

Previously, we reported what we believe to be an innovative study that provided quantitative data as to the relative frequency of drug-seeking behaviors in patients suspected of non-therapeutic use.[29] This case- control study proved instructive in identifying the most common classic drug-seeking behaviors, which included requesting parenteral medication and reporting greater than 10/10 pain. The study did not, however, assess the prevalence of these classic drug-seeking behaviors among drug-seeking patients. Our goal for this investigation was to assess the frequency with which drug seeking patients in the ED use classic drug-seeking behaviors to obtain prescription medication.

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