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

Alicia Ault

Disclosures

June 04, 2019

Sometimes patients appear to be drug-seeking but may not understand the instructions for use. Vega has found that his patients—who have low health literacy—can make mistakes, which is why he tries as often as possible to have a conversation. "I use my judgement," as to whether a patient's misuse was intentional or potentially harmful to others, or an innocent mistake, said Vega. In addition, "some people really do get their meds stolen," he said.

Saxon said these conversations are "challenging in the context of a busy practice." Trying to get a thorough life, medical, and substance use history is almost impossible in the 15- or 20-minute appointment slot. "So in many ways, clinicians are almost in an untenable situation," said Saxon.

It may be difficult to tell when to have that conversation, also, said Earley. Patients may only have a small window of receptivity, and, in a busy practice, "it's really hard to notice when the window opens up," he said.

A clinician can invite discussion by asking whether a patient would like to talk about how it's going with the tramadol they take for a back issue. If the patient shuts that down, the clinician can then invite them to think about talking about the back problem at the next visit, instead of insisting that something has to be done immediately. "It's all about aligning with the patient and you being clear about concern for their welfare," said Earley.

Should You Fire a Drug-Seeking Patient?

Drug-seeking behavior can be persistent and annoying. Is letting a patient go the answer?

"I don't think firing is the proper course," said Saxon. "If the patient is exhibiting a lot of drug-seeking behavior, the chances are very great that the patient has a use disorder," he said. Instead, the clinician should try to arrange some sort of treatment for the substance use disorder.

Vega has not "fired" a patient, but he has discontinued opioid therapy for some patients and requested that they get them from another source. He said he tries not to send patients away. "I always try to hold on to them, because I know their stories and I know that person and can try to make it more of a therapeutic relationship," he said.

But, he added, "Every practitioner needs to set her or his limits." Vega requires pain management patients to sign a contract. That "gives you standing such that you can have those difficult conversations," Vega said.

Cooke believes in setting boundaries, but also keeping his door open. "I may not agree with their lifestyle or how they're living or even how they treat the people around them, but that doesn't mean I give up on them as a healthcare provider," he said.

He described one patient whom he helped by addressing her addiction, rather than dismissing her for drug-seeking. The patient had been taking high doses of opioids for chronic pain over a long period, but her clinician believed she was misusing the medication and dismissed her from the practice, without any directions on how to taper or wean herself off the therapy.

At a crossroads and hoping to secure more medication, she showed up in Cooke's office. She had come to him at a crucial moment. If he did not help her, she might go into withdrawal, and then possibly look for opioids from friends or family or from illicit sources.

In a situation like this, "this is maybe one of the few opportunities we have maybe to literally save that person's life," said Cooke.

He has seen every aspect of the opioid crisis. In 2015, Scott County was the epicenter of an HIV and hepatitis C epidemic driven by intravenous opioid use.[1] Cooke was on the front lines then and continues to treat patients who struggle with chronic pain, poverty, and hopelessness.

To Cooke, finding the underlying cause is not just a goal; it is a mission. Every patient is "a human life with an intrinsic value"—a person who has a ripple effect on family, friends, and community, he said.

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