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

Alicia Ault

Disclosures

June 04, 2019

How an individual practices also plays a big role. Some clinicians would rather give out the medication and risk misuse, as a way of hedging against not giving a therapy to a patient who might truly be in need, Saxon told Medscape. Others might withhold a medication to avoid giving it to someone who has a substance use disorder. "I don't think there's a right or wrong there," he said.

Vega said he tries "to think of the whole patient and their context." He evaluates their source of pain and how it affects them in terms of functioning, and he also looks into whether the patient is experiencing biomedical and psychiatric issues.

If there's a long list with many providers' names…the chances are that this patient has some sort of substance use disorder.

"The most objective and most efficient thing that practitioners can do when they are considering prescribing a controlled substance is to check the state prescription drug monitoring program," said Saxon. If there's a long list with many providers' names, "you pretty much have your answer right there that the chances are that this patient has some sort of substance use disorder," he said.

Physicians can also order a urine drug screen. If the results include one or more illicit substances, "that would suggest that this is not the right patient to be prescribing another controlled substance to," Saxon said.

Part of the "due diligence" that Indiana family physician Will Cooke, MD, conducts on all new patients includes an instant urine screen and an SBIRT (Screening Brief Intervention Referral to Treatment)—both done by a nurse—and he personally checks the state's prescription drug monitoring system. "Right away—before I even walk in the room—I have a wealth of information about this new patient," said Cooke, who practices in Austin, a rural town in Scott County.

Patients Faking Pain to Get Drugs

What kinds of behaviors might be considered "flagrant"? A history of lost or stolen medications. Asking for refills early. Requesting a specific medication.

There may be a constant push to increase the dose or switch to a stronger class of opioids, said Vega. Or there may be clear evidence of misuse. "I've had patients admit to me that they're giving their opioids to relatives," said Vega. "I won't tolerate that."

One patient—whom Vega had never seen before—came in seeking a refill for a high dose of Demerol. "There's no way that's happening," Vega told the patient. The patient claimed that Vega's receptionist had said that the doctor would write the prescription. When Vega still refused, the patient got angry and left, saying she would talk to the city council about Vega's practice.

Sometimes the behavior is more subtle.

"They may not come right out and say, 'I take a Xanax and feel better' or 'I take a Percocet and feel better,'" said Cooke. But when offered alternatives, they'll say nothing else works, he said. "It's like painting you into a corner, so that the only option that's left is an opioid," said Cooke.

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