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How to discern drug-seekers from patients really in pain

From the May 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Maureen Glabman

SAN DIEGO—Physicians seeing patients who ask for narcotics face a dilemma: While the medical profession has been accused of undertreating chronic pain, physicians don't want to fall victim to substance abusers faking symptoms of pain.

The gold standard in deciding to prescribe is to determine if the narcotic is helping the patient improve function or is causing negative consequences, said Barry E. Egener, MD, an Oregon internist who conducts one-day physician training seminars on drug-seeking behavior and spoke on that topic at Annual Session.

First, physicians have to realize that they will always miss some abusers who are faking symptoms of pain, Dr. Egener said. "You're not going to catch all of them," he said. "Some will come only one time with a great story and great physical exam."

But all too often, Dr. Egener said, doctors give in to fakers because it's easier than arguing with a patient, because they are unfamiliar with addictive behavior, or because they fear losing patients. "If you give in, you feel like a sucker," he said. "But if you say 'no' and you know you're right, you still feel bad."

Dr. Egener said that there are three types of patients who seek drugs: drug addicts who need to relieve physiologic distress or withdrawal, distressed patients who want to relieve psychosocial or psychiatric distress, and truly ill patients who seek cure or palliation of their disease.

At the session, Dr. Egener offered several strategies for dealing with drug seekers who are either addicted to drugs or looking to relieve psychological or psychiatric distress:

  • Don't be defensive, because it only escalates patient emotions. When a Miami physician refused to give an addicted patient controlled substances, the patient grabbed the doctor around the neck and broke his stethoscope.
  • Help the patient describe how the medical problem is affecting function. Inform the patient that you understand and acknowledge his feelings.
  • Empathize with the patient and present perspective on the situation. Then, identify a common goal.
  • Set limits. Tell the patient what you could do rather than what you refuse to do. Try phrases like: "I can tell you're in pain. Let's work on non-narcotic solutions."

Dr. Egener said physicians need to be alert to non-narcotics that can be habit-forming, such as Ultram and Soma. He also said to be wary of a separate category of addict he described as "little old ladies who ask for drugs like Ativan." These medications often cause falls leading to hospital admissions, he said.

Dr. Egener emphasized that physicians should always try to give substance abusers some help. "Briefly mentioning that a patient should try to cut down on alcohol consumption can produce results," he said.

To identify alcohol abusers, Dr. Egener suggested the following questions: Have you ever felt you should cut down on your drinking? Has anyone criticized your drinking? Have you felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves?

If you're wondering whether it's worth your time to try to get through to these patients, consider the statistics: Dr. Egener said that every dollar invested in substance abuse treatment saves $7 in health care and social services costs. In Minnesota, for example, a statewide treatment program helped recover $40 million of $50 million spent on such efforts.

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