and the Primary Care Physician
Abuse of Prescription Drugs BONNIE B. WILFORD, Chicago
An estimated 3% of the United States population deliberately misuse or abuse psychoactive medications, with severe consequences. According to the National Institute on Drug Abuse, more than haff of patients who sought treatment or died of drug-related medical problems in 1989 were abusing prescription drugs. Physicians who contribute to this problem have been described by the American Medical Association as dishonest-willfully misprescribing for purposes of abuse, usually for profit; disabled by personal problems with drugs or alcohol; dated in their knowledge ofcurrent pharmacology or therapeutics; or deceived by various patient-initiated fraudulent approaches. Even physicians who do not meet any of these descriptions must guard against contributing to prescription drug abuse through injudicious prescribing, inadequate safeguarding of prescription forms or drug supplies, or acquiescing to the demands or ruses used to obtain drugs for other than medical purposes. (Wilford BB: Abuse of prescription drugs, In Addiction Medicine [Special Issue]. West J Med 1990 May; 152:609-612)
The use of drugs in America is strongly influenced by the social, economic, political, and scientific and technologic environments that define our society. In fact, we are a drug-taking society whose general outlook is that every malady has a treatment and that this solution lies mainly in the use of medicinal agents. We have a social and cultural expectation that there is a "pill for every ill." Medications have come to play such an important role in the interchange between physicians and patients that often the prescription is viewed as an expected medium of exchange between patient and prescriber. A prescriber has not concluded his or her application of skills until a prescription has been written for the cure. The closure of a visit between patient and physician is symbolized by the prescription being handed to the patient. I Recognizing patients who misuse such medications or who seek psychoactive drugs for the purpose of intoxication or resale to others constitutes a clinical problem for which medical school preparation is lacking. Yet the number of such patients is large-3 % of the population, according to federal estimates2-and the consequences of such use severe. In surveys by the National Institute on Drug Abuse, more than half of patients who sought treatment for or died ofdrugrelated medical problems were abusing prescription drugs.3 From the perspective of the health care system and clinicians, there are three variants of prescription drug abuse: * Patients who present with an established dependence on a prescription drug; * Those in whom iatrogenic drug dependence develops as the result of injudicious prescription practices or the use of multiple physicians, or both, or self-medication rather than compliance with a physician's directions; and * Patients who seek drugs to divert them-that is, to acquire drugs to sell.
Despite these differences in motive, the drug-seeking behavior itself has many similarities. The Council on Scientific Affairs of the American Medical Association clearly defined the sources of prescription drug abuse in its 1981 report, "Drug Abuse Related to Prescribing Practices."4 In that report, the Council described as contributing to the problem those practitioners who engage in willful and conscious misprescribing for the purposes of drug abuse, usually for profit; accede to inappropriate demands for medications by patients; prescribe in an uninformed way because they have not kept pace with developments in drug therapy; or whose professional judgment is impaired by virtue of personal problems with drugs or alcohol. The Council also identified patient manipulation of prescription ordersby theft, alteration, or forgery-and theft of drugs as major elements of concern. Having defined the dimensions of the problem, the Council called on physicians to guard against contributing to prescription drug abuse through injudicious prescribing practices or by acquiescing to the demands of certain patients for instant chemical solutions to all their problems. Each physician should convey to patients the concept that all drugs-no matter how helpful-are only part of an overall plan of treatment and management. Even when sound medical indications have been established for using a psychoactive drug, three additional factors should be considered in deciding on the dosage and duration of drug therapy': * The severity of symptoms, in terms of a patient's ability to accommodate them. Relief of symptoms is a legitimate goal of medical practice, but using many psychoactive drugs to achieve complete symptomatic relief requires caution because of the abuse potential and dependence liability of these drugs.
From the Department of Substance Abuse, American Medical Association, Chicago. Reprint requests to Bonnie B. Wilford, Director, Department of Substance Abuse, American Medical Association, 535 N Dearborn St, Chicago, IL 60610.
PRESCRIPTION DRUG ABUSE
610
61.RSRPINDU * A patient's reliability in taking medication, noted through observation and careful history-taking. A physician should assess a patient's susceptibility to drug abuse before prescribing any psychoactive drug and weigh the benefits against the risks. The possible development ofdependence in patients on long-term therapy should be monitored through periodic check-ups and family consultations. * The dependence-producing capability of the drug. Patients should be warned about possible adverse effects caused by interactions with other drugs, including alcohol.
Compliance The question of a patient's compliance with a prescribed drug regimen becomes especially pertinent when the drug in question has potential for abuse. Surveys of patient compliance are not reassuring; as many as half of all patients sampled have deviated from the physician's directions by never obtaining a prescribed drug; never taking the prescribed drug; taking the prescribed drug improperly, which involves taking an incorrect quantity per dose or an incorrect number of doses per day, omitting or "doubling up" doses, or discontinuing the drug prematurely; or taking nonprescribed drugs or discontinued medications in addition to or in place of the prescribed drug.5 The use of alcohol is frequently mentioned in this last category. Patient compliance is enhanced if the flow of information between physician and patient is open and reciprocal. Especially in prescribing psychoactive medication, a physician should carefully describe the purpose and use of the drug, as well as important adverse effects that might be experienced. In situations where a patient's motives are not clear and a history or physical examination indicates that the complaint may be real, the physician should prescribe the smallest possible amount of an appropriate drug pending the results of confirming diagnostic procedures.6
Identifying 'Conning' in a Patient Aside from patients who fail to comply with a prescribed drug regimen through lack of information or insufficient motivation, prescription drug misuse has another face-longterm drug abusers who approach physicians for the specific purpose of securing drugs to support their dependence. In the drug culture, such an approach is known as "working" or "making a doctor." Almost every physician will encounter these "conning" patients, whether in private practice, a clinic setting, a neighborhood health center, a busy emergency department, a rural area, or a large metropolitan hospital. Manipulative approaches used by such patients are outlined in Table 1.7"8
Feigning Physical Problems A variety of physical problems can be convincingly portrayed by drug-seeking patients. These run the gamut from bleeding-often stimulated by the use of anticoagulants-and self-inflicted skin lesions, to gastrointestinal and musculoskeletal disorders. Three of the most common presenting ailments among patients seeking narcotic drugs are renal colic, toothache, and tic douloureux. A patient feigning renal colic complains of pain on the left side of the body (to avoid a diagnosis of appendicitis) and a burning sensation on urination. If the physician asks for a urine specimen, the patient might even prick his or her finger and drop a little blood into the urine.
TABLE 1.-Disorders Feigned by Drug Seekers Migraine headaches Tic douloureux Back pain Colitis Renal colic kAute or chronic pain from orthopedic injury Toothache
Sicide cell crisis Metastatic cancer Bronchitis P i disorders Atention defict syndrome
Narcolepsy Concem over obesity
Patients presenting with toothache often claim to be from another town and to have left at home the medications prescribed by their dentist. Should the physician wish to verify this claim, the telephone number supplied for the hometown dentist often is that of an accomplice. If the person actually has an abscessed tooth, he or she usually makes full use of it by visiting a series of physicians and dentists to ask for pain medication. Tic douloureux is a favorite approach among patient "hustlers" because it has no clinical or pathologic signs. Patients complain of recurring, intense episodes of facial pain lasting several seconds to several minutes. Some patients are able to contort their faces to simulate an attack of pain.
Feigning Psychological Problems Most drug seekers who feign psychological problems are attempting to obtain stimulants or depressants rather than analgesics. The psychological symptoms most often presented include anxiety, insomnia, fatigue, and depression. Deception Manipulative techniques used to deceive physicians include prescription theft, forgery, and alterations, concealing or pretending to take medications, and requesting refills in a shorter period of time than originally prescribed-often with the excuse that the medication was lost or stolen.
Pressuring the Physician Coercive tactics include eliciting sympathy or guilt, such as by suggesting that medical treatment caused the patient's drug dependence, direct threats of physical or financial harm, the offer of bribes, or using the names of family members or friends. Forging Prescriptions Prescriptions are forged in one of the following ways9: Altering a prescription written by a physician. Figure 1 shows three prescriptions, before and after forgery. In each case, the drug seeker used a pen with the same color ink. In the first example, the dispensing number, written only in arabic numberals, is easily altered by the forger. The second example shows that, contrary to popular belief, dispensing numbers written in longhand also can be changed. Some drug seekers alter the number of refills on the prescription. Forging prescriptions from scratch. The forger begins with either a blank piece of paper or a legitimate prescription blank from a practicing physician. In the former case, the forger stencils a physician's name and address (as well as the telephone number of an accomplice) in black lettering onto a blank page and then uses a photocopier to reduce the sheet to the usual size of a prescription. Because the Drug Fnforce-
THE WESTERN JOURNAL OF MEDICINE
-
MAY 1990
e
152
ment Agency registration is now valid for three years, drug seekers are always on the lookout for the names of physicians who have retired, left the state, or died. Some drug seekers use desktop publishing to produce clever forgeries using such assumed identities. To a drug seeker, a blank prescription is like a blank check. Prescription blanks are frequently stolen from emergency departments and clinics, in part because of the carelessness of the medical staff. The Missouri Task Force on the Misuse, Abuse and Diversion of Prescription Drugs has published the following guidelines for the care and use of prescription blanks10'ppl-3): * Store all unused prescription pads in a safe place; * Limit the number of pads in use at one time; * Number prescription blanks so that missing blanks may be detected easily; * Never sign prescription blanks in advance; * Write prescriptions in ink or indelible pencil; * Use a combination of longhand, plus arabic and roman numerals, to indicate the amount of drug precribed; and * Do not use prescription blanks for instructions to patients or memos. Although many "conning" tactics seem obvious when described, they can be used convincingly, especially in the midst of a busy medical office or emergency department. Physicians can protect themselves, however, if they are alert to certain behaviors that are common among drug seek-
clinical intuition will alert the physician that there is a large discrepancy between the patient's report of the severity of the pain and the level of pain actually being experienced. Some patients' manipulativeness can be detected by observation. For example, when a physician has the impression that his or her responses are being studied by the patient as intensely as the physician is studying the patient's situation, the physician should be suspicious that a "doctor shopper" or "conning" patient is at hand. The ordinary patient does not scan the physician for responses in the same way in which those trying to "con" may. This difference is detectable if a physician maintains a reasonable level of awareness.
The 'Spell-Binding' Patient Patients with pseudologica fantastica or Munchhausen's syndrome, or those who are adept at deceit, can be persuasive to a degree that is unusual in comparison to ordinary clinical encounters. When the physician has the feeling that the patient has extraordinary persuasive and dramatic powers, suspicion that a manipulator may be present is justified. The patient who has no interest in diagnosis, fails to keep appointments for x-ray films or laboratory tests, or refuses to see another physician for consultation should be suspected. Most manipulative patients shun real workups and resist attempts to verify history, whereas genuine patients rarely refuse such efforts. The pressure drug seekers can bring to bear on a physician are considerable. A physician who is alert to the tactics employed by these persons usually can avoid being deceived or manipulated, however. When a patient uses such tactics, the physician should maintain control of the physicianpatient relationship, remain professional despite the ploys for sympathy or guilt, and regard the drug seeker as a patient with a serious illness. 4
ers. 3.5.8
The Transient Patient Frequently a patient is from out of town and has lost or had his or her medication stolen. The patient tries to create a sense of urgency and pressures the physician for an immediate response by claiming intense pain. Frequently ordinary la. Original
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Confronting the Drug Seeker It is usually difficult to prove that a patient is a drug seeker from the information obtained during a single visit. Although most of the time the diagnosis is at best a guess, a physician may find the following strategies useful when confronting suspected drug seekers: * Always give advice with reference to the patient's chief complaint. For example, physicians who do not ordinarily prescribe narcotic-containing cough syrups for bronchitis should say so to the patient. * Maintain a professional demeanor throughout the encounter. Drug seekers who are frustrated in their attempts to obtain drugs often become angry. This response is so typical that some clinicians consider it diagnostic of drug-seeking behavior. Frustrated drug seekers may shout obscenities at the staff; others threaten violence, but such threats are seldom carried out. If necessary, security staff or the police should be summoned. * Confront the patient in a gentle, respectful manner. It is important to avoid being judgmental or showing antagonism. A variety of confrontation techniques may be used. Some examples are inquiring as to whether the patient believes that he or she has a problem with prescription drugs, noting the addictive properties of the medications sought, and expressing concern for the patient's welfare. When confronted, some patients admit that they are addicted to prescription drugs and claim that they want to stop taking them. These patients should be referred for formal assessment and treatment. A dilemma commonly encountered is whether to provide a patient with a supply of drugs until he or she can obtain treatment for the underlying dependence. What to do depends in part on which prescription drugs the patient abuses.
PRESCRIPTION DRUG ABUSE
Withdrawal from narcotics can be debilitating, but it is rarely fatal. Withdrawal from barbiturates or benzodiazepines, on the other hand, can be fatal, and patients addicted to these drugs should be held in a medically supervised setting for management of withdrawal. In addition, there are important legal issues to be considered.2 Another dilemma for a physician is whether to believe drug seekers' claims that they wish to stop their drug use. The admission itself may be genuine, but it also may be another ruse. When in doubt, patients should be referred to a specialist in drug rehabilitation for expert consultation. In all cases, patients should be given the benefit of the doubt. It is important to remember that even drug seekers may present with illness not related to their drug addiction and that addiction is a chronic, relapsing disease. REFERENCES
I . Manasse HR: Medication use in an imperfect world: Drug misadventuring as an issue of public policy, part 2. Am J Hosp Pharm 1989; 46:1141-1152 2. Drug Enforcement Administration: Guidelines for Prescribers of Controlled
Substances. Washington, DC, US Dept of Justice, 1987 3. Wilford BB: Prescribing Controlled Drugs. Chicago, American Medical Association, 1987 4. Proceedings of the House of Delegates 269. Chicago, American Medical Association, 1971 5. Cohen S: Drug abuse and the prescribing physician, In Buchwald C, Cohen S, Katz D, et al (Eds): Frequendy Prescribed and Abused Drugs: Their Indications, Efficacy and Rational Prescribing. Nad Inst Drug Abuse Monogr Ser 1980; 2:1-6 6. AMA Department of Drugs: AMA Drug Evaluations, 5th Ed. Chicago, American Medical Association, 1983, pp 5-10 7. Chappel JN: Patient Manipulation ofthe Physician. Workshop on the Ethics and Practice of Prescribing Psychoactive Drugs. San Francisco, Haight Ashbury Training and Education Project, 1980 8. Wilson SJ, Gilmore R: Manipulative tactics of narcotics addicts. Med Times 1974; 102:81-84 9. Goldman G: Frustrating prescription drug seekers. Emerg Med Rep 1988; 9:2632 10. Physician Handbook. Jefferson City, Mo, Missouri Task Force on the Misuse, Abuse and Diversion of Prescription Drugs, 1988
Abuse of Prescription Drugs BONNIE B. WILFORD, Chicago
An estimated 3% of the United States population deliberately misuse or abuse psychoactive medications, with severe consequences. According to the National Institute on Drug Abuse, more than haff of patients who sought treatment or died of drug-related medical problems in 1989 were abusing prescription drugs. Physicians who contribute to this problem have been described by the American Medical Association as dishonest-willfully misprescribing for purposes of abuse, usually for profit; disabled by personal problems with drugs or alcohol; dated in their knowledge ofcurrent pharmacology or therapeutics; or deceived by various patient-initiated fraudulent approaches. Even physicians who do not meet any of these descriptions must guard against contributing to prescription drug abuse through injudicious prescribing, inadequate safeguarding of prescription forms or drug supplies, or acquiescing to the demands or ruses used to obtain drugs for other than medical purposes. (Wilford BB: Abuse of prescription drugs, In Addiction Medicine [Special Issue]. West J Med 1990 May; 152:609-612)
The use of drugs in America is strongly influenced by the social, economic, political, and scientific and technologic environments that define our society. In fact, we are a drug-taking society whose general outlook is that every malady has a treatment and that this solution lies mainly in the use of medicinal agents. We have a social and cultural expectation that there is a "pill for every ill." Medications have come to play such an important role in the interchange between physicians and patients that often the prescription is viewed as an expected medium of exchange between patient and prescriber. A prescriber has not concluded his or her application of skills until a prescription has been written for the cure. The closure of a visit between patient and physician is symbolized by the prescription being handed to the patient. I Recognizing patients who misuse such medications or who seek psychoactive drugs for the purpose of intoxication or resale to others constitutes a clinical problem for which medical school preparation is lacking. Yet the number of such patients is large-3 % of the population, according to federal estimates2-and the consequences of such use severe. In surveys by the National Institute on Drug Abuse, more than half of patients who sought treatment for or died ofdrugrelated medical problems were abusing prescription drugs.3 From the perspective of the health care system and clinicians, there are three variants of prescription drug abuse: * Patients who present with an established dependence on a prescription drug; * Those in whom iatrogenic drug dependence develops as the result of injudicious prescription practices or the use of multiple physicians, or both, or self-medication rather than compliance with a physician's directions; and * Patients who seek drugs to divert them-that is, to acquire drugs to sell.
Despite these differences in motive, the drug-seeking behavior itself has many similarities. The Council on Scientific Affairs of the American Medical Association clearly defined the sources of prescription drug abuse in its 1981 report, "Drug Abuse Related to Prescribing Practices."4 In that report, the Council described as contributing to the problem those practitioners who engage in willful and conscious misprescribing for the purposes of drug abuse, usually for profit; accede to inappropriate demands for medications by patients; prescribe in an uninformed way because they have not kept pace with developments in drug therapy; or whose professional judgment is impaired by virtue of personal problems with drugs or alcohol. The Council also identified patient manipulation of prescription ordersby theft, alteration, or forgery-and theft of drugs as major elements of concern. Having defined the dimensions of the problem, the Council called on physicians to guard against contributing to prescription drug abuse through injudicious prescribing practices or by acquiescing to the demands of certain patients for instant chemical solutions to all their problems. Each physician should convey to patients the concept that all drugs-no matter how helpful-are only part of an overall plan of treatment and management. Even when sound medical indications have been established for using a psychoactive drug, three additional factors should be considered in deciding on the dosage and duration of drug therapy': * The severity of symptoms, in terms of a patient's ability to accommodate them. Relief of symptoms is a legitimate goal of medical practice, but using many psychoactive drugs to achieve complete symptomatic relief requires caution because of the abuse potential and dependence liability of these drugs.
From the Department of Substance Abuse, American Medical Association, Chicago. Reprint requests to Bonnie B. Wilford, Director, Department of Substance Abuse, American Medical Association, 535 N Dearborn St, Chicago, IL 60610.
PRESCRIPTION DRUG ABUSE
610
61.RSRPINDU * A patient's reliability in taking medication, noted through observation and careful history-taking. A physician should assess a patient's susceptibility to drug abuse before prescribing any psychoactive drug and weigh the benefits against the risks. The possible development ofdependence in patients on long-term therapy should be monitored through periodic check-ups and family consultations. * The dependence-producing capability of the drug. Patients should be warned about possible adverse effects caused by interactions with other drugs, including alcohol.
Compliance The question of a patient's compliance with a prescribed drug regimen becomes especially pertinent when the drug in question has potential for abuse. Surveys of patient compliance are not reassuring; as many as half of all patients sampled have deviated from the physician's directions by never obtaining a prescribed drug; never taking the prescribed drug; taking the prescribed drug improperly, which involves taking an incorrect quantity per dose or an incorrect number of doses per day, omitting or "doubling up" doses, or discontinuing the drug prematurely; or taking nonprescribed drugs or discontinued medications in addition to or in place of the prescribed drug.5 The use of alcohol is frequently mentioned in this last category. Patient compliance is enhanced if the flow of information between physician and patient is open and reciprocal. Especially in prescribing psychoactive medication, a physician should carefully describe the purpose and use of the drug, as well as important adverse effects that might be experienced. In situations where a patient's motives are not clear and a history or physical examination indicates that the complaint may be real, the physician should prescribe the smallest possible amount of an appropriate drug pending the results of confirming diagnostic procedures.6
Identifying 'Conning' in a Patient Aside from patients who fail to comply with a prescribed drug regimen through lack of information or insufficient motivation, prescription drug misuse has another face-longterm drug abusers who approach physicians for the specific purpose of securing drugs to support their dependence. In the drug culture, such an approach is known as "working" or "making a doctor." Almost every physician will encounter these "conning" patients, whether in private practice, a clinic setting, a neighborhood health center, a busy emergency department, a rural area, or a large metropolitan hospital. Manipulative approaches used by such patients are outlined in Table 1.7"8
Feigning Physical Problems A variety of physical problems can be convincingly portrayed by drug-seeking patients. These run the gamut from bleeding-often stimulated by the use of anticoagulants-and self-inflicted skin lesions, to gastrointestinal and musculoskeletal disorders. Three of the most common presenting ailments among patients seeking narcotic drugs are renal colic, toothache, and tic douloureux. A patient feigning renal colic complains of pain on the left side of the body (to avoid a diagnosis of appendicitis) and a burning sensation on urination. If the physician asks for a urine specimen, the patient might even prick his or her finger and drop a little blood into the urine.
TABLE 1.-Disorders Feigned by Drug Seekers Migraine headaches Tic douloureux Back pain Colitis Renal colic kAute or chronic pain from orthopedic injury Toothache
Sicide cell crisis Metastatic cancer Bronchitis P i disorders Atention defict syndrome
Narcolepsy Concem over obesity
Patients presenting with toothache often claim to be from another town and to have left at home the medications prescribed by their dentist. Should the physician wish to verify this claim, the telephone number supplied for the hometown dentist often is that of an accomplice. If the person actually has an abscessed tooth, he or she usually makes full use of it by visiting a series of physicians and dentists to ask for pain medication. Tic douloureux is a favorite approach among patient "hustlers" because it has no clinical or pathologic signs. Patients complain of recurring, intense episodes of facial pain lasting several seconds to several minutes. Some patients are able to contort their faces to simulate an attack of pain.
Feigning Psychological Problems Most drug seekers who feign psychological problems are attempting to obtain stimulants or depressants rather than analgesics. The psychological symptoms most often presented include anxiety, insomnia, fatigue, and depression. Deception Manipulative techniques used to deceive physicians include prescription theft, forgery, and alterations, concealing or pretending to take medications, and requesting refills in a shorter period of time than originally prescribed-often with the excuse that the medication was lost or stolen.
Pressuring the Physician Coercive tactics include eliciting sympathy or guilt, such as by suggesting that medical treatment caused the patient's drug dependence, direct threats of physical or financial harm, the offer of bribes, or using the names of family members or friends. Forging Prescriptions Prescriptions are forged in one of the following ways9: Altering a prescription written by a physician. Figure 1 shows three prescriptions, before and after forgery. In each case, the drug seeker used a pen with the same color ink. In the first example, the dispensing number, written only in arabic numberals, is easily altered by the forger. The second example shows that, contrary to popular belief, dispensing numbers written in longhand also can be changed. Some drug seekers alter the number of refills on the prescription. Forging prescriptions from scratch. The forger begins with either a blank piece of paper or a legitimate prescription blank from a practicing physician. In the former case, the forger stencils a physician's name and address (as well as the telephone number of an accomplice) in black lettering onto a blank page and then uses a photocopier to reduce the sheet to the usual size of a prescription. Because the Drug Fnforce-
THE WESTERN JOURNAL OF MEDICINE
-
MAY 1990
e
152
ment Agency registration is now valid for three years, drug seekers are always on the lookout for the names of physicians who have retired, left the state, or died. Some drug seekers use desktop publishing to produce clever forgeries using such assumed identities. To a drug seeker, a blank prescription is like a blank check. Prescription blanks are frequently stolen from emergency departments and clinics, in part because of the carelessness of the medical staff. The Missouri Task Force on the Misuse, Abuse and Diversion of Prescription Drugs has published the following guidelines for the care and use of prescription blanks10'ppl-3): * Store all unused prescription pads in a safe place; * Limit the number of pads in use at one time; * Number prescription blanks so that missing blanks may be detected easily; * Never sign prescription blanks in advance; * Write prescriptions in ink or indelible pencil; * Use a combination of longhand, plus arabic and roman numerals, to indicate the amount of drug precribed; and * Do not use prescription blanks for instructions to patients or memos. Although many "conning" tactics seem obvious when described, they can be used convincingly, especially in the midst of a busy medical office or emergency department. Physicians can protect themselves, however, if they are alert to certain behaviors that are common among drug seek-
clinical intuition will alert the physician that there is a large discrepancy between the patient's report of the severity of the pain and the level of pain actually being experienced. Some patients' manipulativeness can be detected by observation. For example, when a physician has the impression that his or her responses are being studied by the patient as intensely as the physician is studying the patient's situation, the physician should be suspicious that a "doctor shopper" or "conning" patient is at hand. The ordinary patient does not scan the physician for responses in the same way in which those trying to "con" may. This difference is detectable if a physician maintains a reasonable level of awareness.
The 'Spell-Binding' Patient Patients with pseudologica fantastica or Munchhausen's syndrome, or those who are adept at deceit, can be persuasive to a degree that is unusual in comparison to ordinary clinical encounters. When the physician has the feeling that the patient has extraordinary persuasive and dramatic powers, suspicion that a manipulator may be present is justified. The patient who has no interest in diagnosis, fails to keep appointments for x-ray films or laboratory tests, or refuses to see another physician for consultation should be suspected. Most manipulative patients shun real workups and resist attempts to verify history, whereas genuine patients rarely refuse such efforts. The pressure drug seekers can bring to bear on a physician are considerable. A physician who is alert to the tactics employed by these persons usually can avoid being deceived or manipulated, however. When a patient uses such tactics, the physician should maintain control of the physicianpatient relationship, remain professional despite the ploys for sympathy or guilt, and regard the drug seeker as a patient with a serious illness. 4
ers. 3.5.8
The Transient Patient Frequently a patient is from out of town and has lost or had his or her medication stolen. The patient tries to create a sense of urgency and pressures the physician for an immediate response by claiming intense pain. Frequently ordinary la. Original
611
5
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3a. Original
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Emergency Physicians Group Jo Smilk MD
SS N. Fifdt SL
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JoeSmi.MD )C22Z2222
USA (621)333-9087 XL
-
5tmwhm_c USA
(621)333-9067
(on)3333466
Dwre121/r
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55 N. Fii SL
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Joe Sil MD XZ2222222
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0
612
Confronting the Drug Seeker It is usually difficult to prove that a patient is a drug seeker from the information obtained during a single visit. Although most of the time the diagnosis is at best a guess, a physician may find the following strategies useful when confronting suspected drug seekers: * Always give advice with reference to the patient's chief complaint. For example, physicians who do not ordinarily prescribe narcotic-containing cough syrups for bronchitis should say so to the patient. * Maintain a professional demeanor throughout the encounter. Drug seekers who are frustrated in their attempts to obtain drugs often become angry. This response is so typical that some clinicians consider it diagnostic of drug-seeking behavior. Frustrated drug seekers may shout obscenities at the staff; others threaten violence, but such threats are seldom carried out. If necessary, security staff or the police should be summoned. * Confront the patient in a gentle, respectful manner. It is important to avoid being judgmental or showing antagonism. A variety of confrontation techniques may be used. Some examples are inquiring as to whether the patient believes that he or she has a problem with prescription drugs, noting the addictive properties of the medications sought, and expressing concern for the patient's welfare. When confronted, some patients admit that they are addicted to prescription drugs and claim that they want to stop taking them. These patients should be referred for formal assessment and treatment. A dilemma commonly encountered is whether to provide a patient with a supply of drugs until he or she can obtain treatment for the underlying dependence. What to do depends in part on which prescription drugs the patient abuses.
PRESCRIPTION DRUG ABUSE
Withdrawal from narcotics can be debilitating, but it is rarely fatal. Withdrawal from barbiturates or benzodiazepines, on the other hand, can be fatal, and patients addicted to these drugs should be held in a medically supervised setting for management of withdrawal. In addition, there are important legal issues to be considered.2 Another dilemma for a physician is whether to believe drug seekers' claims that they wish to stop their drug use. The admission itself may be genuine, but it also may be another ruse. When in doubt, patients should be referred to a specialist in drug rehabilitation for expert consultation. In all cases, patients should be given the benefit of the doubt. It is important to remember that even drug seekers may present with illness not related to their drug addiction and that addiction is a chronic, relapsing disease. REFERENCES
I . Manasse HR: Medication use in an imperfect world: Drug misadventuring as an issue of public policy, part 2. Am J Hosp Pharm 1989; 46:1141-1152 2. Drug Enforcement Administration: Guidelines for Prescribers of Controlled
Substances. Washington, DC, US Dept of Justice, 1987 3. Wilford BB: Prescribing Controlled Drugs. Chicago, American Medical Association, 1987 4. Proceedings of the House of Delegates 269. Chicago, American Medical Association, 1971 5. Cohen S: Drug abuse and the prescribing physician, In Buchwald C, Cohen S, Katz D, et al (Eds): Frequendy Prescribed and Abused Drugs: Their Indications, Efficacy and Rational Prescribing. Nad Inst Drug Abuse Monogr Ser 1980; 2:1-6 6. AMA Department of Drugs: AMA Drug Evaluations, 5th Ed. Chicago, American Medical Association, 1983, pp 5-10 7. Chappel JN: Patient Manipulation ofthe Physician. Workshop on the Ethics and Practice of Prescribing Psychoactive Drugs. San Francisco, Haight Ashbury Training and Education Project, 1980 8. Wilson SJ, Gilmore R: Manipulative tactics of narcotics addicts. Med Times 1974; 102:81-84 9. Goldman G: Frustrating prescription drug seekers. Emerg Med Rep 1988; 9:2632 10. Physician Handbook. Jefferson City, Mo, Missouri Task Force on the Misuse, Abuse and Diversion of Prescription Drugs, 1988
