Is Your Patient in Pain or Just Seeking a Pill? What to Do

Alicia Ault

Disclosures

June 04, 2019

Doctors are sometimes caught between a rock and a hard place when it comes to individuals who are in the office, seeking a prescription for a controlled medication.

Some patients may seek opioids and other drugs with abuse potential as a panacea for psychological discomfort. Other patients, who have taken the medications for years, may struggle with physical and emotional dependence that shows up as drug-seeking behavior. Some may have legitimate untreated pain.

Meanwhile, all the pressure is on clinicians to prescribe less.

"It's scary being a primary care physician writing [prescriptions for] opioids because you're worried you're going to get in trouble," said Paul Earley, MD, DFASAM, president of the American Society of Addiction Medicine.

"We really feel as clinicians that we're in a bind," said Charles P. Vega, MD, clinical professor of family medicine at University of California, Irvine. With forces lined up against opioid prescribing, it almost sets up an antagonistic situation with patients who have pain or who may have been using opioids chronically, he said.

"There are clinicians who just won't treat patients with chronic pain at all—and label any small error or misjudgment as drug-seeking behavior and fire them from practice or refuse to continue to give opioid therapy," said Vega.

Beware the 'Drug-Seeking' Patient Label

It's difficult to tease out whether the patient is in legitimate need of the medication, or is just drug-seeking. But, said some doctors, it's overly simplistic—and not good practice—to just label someone as "drug-seeking." The seeking is a symptom of an underlying issue, they said.

"Probably the most difficult symptom to differentiate—to do a differential diagnosis on, if you will—is do they have pain, or do they have addiction? Or do they have both?" said Earley.

Pain is subjective, which makes it hard to tell a patient that his or her pain does not make sense, he said. But "there are times you can know that the amount of the drugs they are requesting or seeking doesn't fit the pathology of the illness," said Earley.

"The flagrant cases are reasonably easy to spot, but there are a lot of cases that are maybe in a gray area, or it's really uncertain and you can't know, and then it comes down to making your best judgement," said Andrew J. Saxon, MD, chairman of the Council on Addiction Psychiatry for the American Psychiatric Association, and professor in the psychiatry and behavioral sciences department at University of Washington School of Medicine, Seattle.

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