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

Alicia Ault

Disclosures

June 04, 2019

Drug-seeking is often easier to spot in the emergency department—and is more common in that setting—but it's ill-advised to "walk into a patient's room and automatically assume they are drug-seeking," said Rebecca Loveless, a physician assistant in the emergency department at Washington University School of Medicine, St Louis, who also practices at a private orthopedic group. Some patients are legitimately in acute or chronic pain, but some are looking for pills to sell outside the hospital, Loveless tells Medscape.

Loveless begins with a history and chart review to determine how many times a patient has visited her emergency department or others connected to the Washington University electronic medical record. She also looks for inconsistencies in exams. If someone with "belly pain" doesn't react when she palpates with force, it heightens her awareness. Patients who cry without producing tears, or rate their pain a "10" but have normal vital signs, also warrant a closer look.

One patient said he'd fallen off a ladder and hurt his back. But the bruises looked fairly old, and when pressed, the man admitted he'd run himself up against a countertop to feign injury.

In December, a woman came in looking for painkillers. It was her 78th visit to the emergency department over the previous 12 months. Loveless explained that she would not be giving her a prescription. After the patient threatened to kill her, Loveless summoned the police, who arrested the woman.

Getting to the Root Cause

To Earley, calling a patient's behavior "drug-seeking" is somewhat pejorative. "If this was another illness, we wouldn't be calling it that; we would call it signs and symptoms of the disease," he said.

This isn't about drug-seeking; this is about a really rich and difficult illness.

"This isn't about drug-seeking; this is about a really rich and difficult illness," said Earley. He and other experts say stigma about substance use disorders still prevents clinicians from addressing the signs and symptoms.

Earley said it took a decade for him to overcome his own prejudice about dealing with people with addiction, "even though it was my day-in, day-out job." He advises clinicians to be "sensitive to your attitude but not judgmental about it," and to not be surprised if it takes a while to lessen or disappear.

The people who really want opioids or other drugs with misuse potential "have brains that are different," and "certainly when they've had extensive exposure to those controlled substances, their brains then have changed," said Saxon.

The key to addressing the underlying condition—and to relieve the patient's suffering—is to get their backstory, "and that backstory sometimes is messy," Cooke said. He acknowledges, "that takes a little time and effort to interview and investigate and examine and look into things and find the underlying reason for the symptom and treat that, so that they don't need the symptomatic treatment."

He will ask drug-seeking patients whether they've had the medications before; what they got out of the therapies; and then try to parse addiction risk and whether the medications might be treating underlying issues, such as adverse childhood experiences or chronic toxic stress.

For instance, he cites the case of a 60-year-old man who came to the office seeking Percocet for "back pain." "We could have just treated his pain with Percocet," said Cooke, but instead, he asked questions. As it turned out, the patient was going through a divorce and was already taking Percocet. He confessed that taking the drug in the past had helped with stressful episodes. Cooke referred the patient to the behavioral health specialist linked with his family practice. The patient did not take Percocet, "and he did better," said Cooke.

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