drug-seeking patients

[cattledog]

Hi all (especially residents),

I'm a JMS interested in PM&R, specifically TBI and stroke rehabilitation. I identify whole-heartedly with PM&R's emphasis on considering all aspects of a patient's condition when arriving at a treatment plan. I like helping people regain function more than anything I've done in medical school.

The only reservation I have about PM&R involves the extent to which physiatrists deal with patients who seek drugs they don't need. I've found that I have little tolerance for patients who willfully deceive doctors. By this I certainly don't mean someone who I think might be exaggerating his pain, or someone who complains of pain with no apparent organic cause. I give patients who appear to be in pain the benefit of the doubt. I'm talking about the 12 week post-op minor surgical patient who complains of 8/10 pain but appears pain-free, who specifies Lortab 10 instead of Lortab 5, and whose husband has multiple drug charges - in other words, a patient who almost certainly is seeking drugs dishonestly.

Here are my questions for physiatry residents and M4s with more experience in PM&R than me: How frequently do you feel that you have to deal with drug-seeking patients? If you see many drug-seeking patients, does it become less troubling after you've been practicing for some time? And finally, do you feel like you have to deal with drug-seeking patients more frequently than other doctors?

Thanks for any feedback you can offer. I understand that every specialty has its drawbacks. I am looking forward to a career in PM&R but I want to know all I can about the field, warts and all.

Thanks, cd

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[axm397]

Hi all (especially residents),

I'm a JMS interested in PM&R, specifically TBI and stroke rehabilitation. I identify whole-heartedly with PM&R's emphasis on considering all aspects of a patient's condition when arriving at a treatment plan. I like helping people regain function more than anything I've done in medical school.

The only reservation I have about PM&R involves the extent to which physiatrists deal with patients who seek drugs they don't need. I've found that I have little tolerance for patients who willfully deceive doctors. By this I certainly don't mean someone who I think might be exaggerating his pain, or someone who complains of pain with no apparent organic cause. I give patients who appear to be in pain the benefit of the doubt. I'm talking about the 12 week post-op minor surgical patient who complains of 8/10 pain but appears pain-free, who specifies Lortab 10 instead of Lortab 5, and whose husband has multiple drug charges - in other words, a patient who almost certainly is seeking drugs dishonestly.

Here are my questions for physiatry residents and M4s with more experience in PM&R than me: How frequently do you feel that you have to deal with drug-seeking patients? If you see many drug-seeking patients, does it become less troubling after you've been practicing for some time? And finally, do you feel like you have to deal with drug-seeking patients more frequently than other doctors?

Thanks for any feedback you can offer. I understand that every specialty has its drawbacks. I am looking forward to a career in PM&R but I want to know all I can about the field, warts and all.

Thanks, cd

I don't think there are many fields where you don't have to deal with some of that. Ob-Gyn gets pelvic pain, GI gets vague abdominal pain, surgery gets the patient you mentioned with post op pain, primary docs get stuck with them, anesthesia pain, rheumatology gets fibro, neurology gets headache patients, don't even mention ER, etc. etc. Many patients are legit, others do seem to have drug seeking behavior. Then there's the concept of addiction, dependence, and pseudo addiction. Probably about the only field may be radiology or pathology. I think the number of those types of patients you see depends on your practice type and how firm you are about your boundary setting. There are many docs on this forum who will not write opioid Rx during the first visit, etc.

 

[Diamox]

Don't worry about it. Just like people with personality disorders, You can't get away from it; but you can tailor your practice when you start to screen for drug seekers.

 

[PMR 4 MSK]

If you do neuro rehab, like CVA and TBI, you won't get much of it, and can always steer them to the pain guys - PM&R or anesthesia.

If you give out a prescription to one patient for opioids, sooner or later, someone will come to you for express purpose of obtaining opioids to abuse or divert. There is nothing you can do to prevent it and the good ones will keep fooling you for a while. Drug testing helps, but is no where near a complete deterrent. Excellent training in opioids use and misuse combined with expereince will help immensely.

Basically, either don't give out opioids, or be very careful and judicious in their use. And document the hell outta everything.

 

[IpMan1970]

I don't think there are many fields where you don't have to deal with some of that. Ob-Gyn gets pelvic pain, GI gets vague abdominal pain, surgery gets the patient you mentioned with post op pain, primary docs get stuck with them, anesthesia pain, rheumatology gets fibro, neurology gets headache patients, don't even mention ER, etc. etc. Many patients are legit, others do seem to have drug seeking behavior. Then there's the concept of addiction, dependence, and pseudo addiction. Probably about the only field may be radiology or pathology. I think the number of those types of patients you see depends on your practice type and how firm you are about your boundary setting. There are many docs on this forum who will not write opioid Rx during the first visit, etc.

The worst problem with drug seeking is 'it works', plain and simple, most times and it rightfully should in many cases as in most occasions, it is simpler, smarter, and more careful to go ahead and write a 'proper' but limited to FU script and move-on rather than try to dig in deep with someone who presents functional especially. I prefer to just give them a several day dose, and refer FU to specialist concerning their issue, or even have them have a pscyh work-up done as a condition of returning to see me in any setting.

The worst we can do is fear writing 10 tabs of a pain reliever because of what we believe or perceive in a person and have them walk out the ER/Practice door in real pain and suffering more than even a drug addict should. And I do not believe in just passing the buck by doing this, no I really want the FU, psych stuff done and even in such cases, if managed and agreed, I will control pain, anxiety, etc., as long as guidelines and drops are done without issue.

Ethically, morally, etc., we have a responsibility to the patient regardless of their situation and there is a way we can offer to patients where we free ourselves of any guilt when symptoms are simple deception, pseudo, etc., to our ethics, and assuage our self of guilt turning away the truly needful patient with a bad history and a real situation which needs treatment, guarded treatment, but none the less, the right medicine for the right symptoms. I have personally witnessed practitioners cold turkey pts if urine is dirty, which I personally disagree with. In such a case, the person needs an emergency dose of what they've been taking *especially if on med for a long time and withdrawal syndrome is going to be horrid*, one cannot just leave them to hand. Instead, you write the short dose, demand psych work up, put on probation and give them a chance to comply and right their path. Most doctors in my experience are jaded and will not give time and I've even witnessed clinics post signs saying such things as "We do not prescribe drugs like Vicodin and Xanax, so DON'T ASK". Lightly put, I didn't stay long in such clinics and reported them.

I would much rather care for a patient with a known narcotic than throw Celebrex/Abilify and watch them like hawks for the known side effects, unless there is already a liver, involvement, neph issue, etc., then all bets are off. I know for a fact a few Vicodin are going to hurt a person 'globally' than starting a regimen of late century meds with a million interactions and issues to watch for, again unless the context demands such a medication. Sorry if I babbled on this one. I'm a big believer in "Do No Harm" and have seen many people in real suffering turned away without a second thought to what the PT will face for the next week, month, because we have been over-run by liars and cheats. Everyone starts at 10 with me, and really like your answer of tending to be more liberal with dosing even with the notorious meds.

One last note, I don't mind the medication and dosage remarks from a PT. It can change what I write sometimes. I always look at the fact a PT 40 years old has had at least 20 adult years of studying themselves and taking meds to know what has worked and what has had bad effects for them. I balance their remarks, with need, and compromise, along with aforementioned guidelines and agreements to treat such patients on a continued basis.

Again, forgive my ramble, but this is a subject I've fought quite a many times with admins and other doctors about and I've seen some odd things with medications.
Another quick example of last statement is psych friends and colleagues who have had no luck with AD's with mild mood disorders, giving small doses of methadone or morphine and watch lives turn completely around without any increases in dosage and near complete remission of psych symptoms without MANY interaction, effects, level checks, etc., being run. Not saying this is an experiment one should try globally, but on the few where nothing seems to do the trick without changing PT function and to see the drastic positive change from a small dose of an opiate. ( We are talking about 10 to 20 mgs a day of methadone, and 5 to 10 mgs of Morphine - very often the morphine being turned away after trying only to have the methadone be sucessful. I should have started a new thread perhaps.

Bows humbly at rant,

Ip Man
PS - Forgive grammar and typos, I ranted so long I didn't care to edit.

Good Care!

 

[vistaril]

right their path. Most doctors in my experience are jaded and will not give time and I've even witnessed clinics post signs saying such things as "We do not prescribe drugs like Vicodin and Xanax, so DON'T ASK". Lightly put, I didn't stay long in such clinics and reported them.

report them for what? There is nothing reportable about that for most providers.....

 

[RUOkie]

.

I have personally witnessed practitioners cold turkey pts if urine is dirty, which I personally disagree with. In such a case, the person needs an emergency dose of what they've been taking *especially if on med for a long time and withdrawal syndrome is going to be horrid*, one cannot just leave them to hand.

nobody ever died from narcotic withdrawal. But people die of overdoses every day. I have had people come to my office in active withdrawal, and my response was: You have a choice, 1) go to a detox or suboxone clinic (I give them the information, or 2) a 1 week supply of Clonidine and good luck.

My wife was a drug/alcohol addict and ultimately died as a result of it. I learned first hand how duplicitous drug addicts are. I will practice how I like, and how I feel is "ethical". Please do not preach to me on how to practice. I have close to 20 yrs experience, and have consulted my state board on what is legal/ethical. I don't prescribe xanax and VERY rarely prescribe opiates. Go ahead and report me.

 

[bedrock]

Uh guys,
IP man is clearly a drug seeker.

No one else would take the time to write that rant out on an internet forum.

 

[nvrsumr]

I see alot of average physiatrists whose only out-patient option in a competitive market is to be the candyman.

 

[SSdoc33]

I see alot of average physiatrists whose only out-patient option in a competitive market is to be the candyman.

yup

 

[vistaril]

I see alot of average physiatrists whose only out-patient option in a competitive market is to be the candyman.

yup....Im a psychiatrist and this happens ALL the time unfortunately.

 

[bedrock]

I see alot of average physiatrists whose only out-patient option in a competitive market is to be the candyman.

Referencing what I just quoted on another thread about fellowships
http://forums.studentdoctor.net/showthread.php?t=999758

If your goal is outpatient-only PMR in a top 10 market in the country, then you absolutely need to do a sports medicine or pain fellowship. Otherwise the only thing you can find are candyman positions.

If you want to do inpatient, or inpatient + some general rehab clinic, you don't need a fellowship. If you want outpatient-only PMR but don't have to live in a top 10 desirable area, you don't need a fellowship.

 

[Apollyon]

I see alot of average physiatrists whose only out-patient option in a competitive market is to be the candyman.

yup....Im a psychiatrist and this happens ALL the time unfortunately.

Physiatrist and psychiatrist.

 

[vistaril]

Physiatrist and psychiatrist.

just noticed that my bad

I assumed that the comment was in response to someone who said these difficult pain patients without known source should be referred to psych...when I was thinking the downside of that was that many average psychs don't have any such skill set to effectively deal with chronic pain.

 

[IpMan1970]

Uh guys,
IP man is clearly a drug seeker.

No one else would take the time to write that rant out on an internet forum.

I do not NEED to seek drugs, I have had many friends and fellows under me who would write a dose of anything I need or do it the old fashioned way, just chart it on a pt and move on.....working in hospitals most of the past 20 years, I have seen people die from withdrawal. Less than a year ago, in our clinic, a NEW D.O. came along with the 'personal preference' of NOT prescribing certain meds and began a warpath of eliminating any benzo scrips. Didn't matter if it was serious CNS, no benzos and someone else stated on here their wife was a drug addict and for me to report them for not prescribing, also a very junior thing to say. If you can live with it, fine, but don't pretend your choice is one made out of anything but bias.

Sometimes meds just work, and like I said, I would much rather err on the side of a ER visit for a pt who screens dirty and psych refer, but I will not ever cut them off without referral and direction. This was my main point. I do not like clear lines cut for political and other non-clinical based reasons.

And I love the statement made 'no one has ever died from narc withdrawal', apparently you haven't looked up the incidence on deaths from withdrawal for pts who have a true need. One pt this NEW 'doctor' cold turkeyed had chronic stress induced angina and was in and out of a-fib more times than one would believe. They had panic attacks and anxiety along with 3 major cardiac diseases, and along with this, seizure activity. She cut him off, he went into a seizure within 3 days, bit the tip of his tongue off, went into ER, where he went into a massive heart attack, but like you said, he didn't DIE or anything...just went through Hell and is now BACK on the meds he was given at age 20, now age 50+.

And to the rant remark, I apologized a few times and even admitted I would be one to rant. I have a lot more time now in my field of practice.

Too many clinicians these days just see Sqaure, Triangle, Circle, you can live in that world and deal with whatever moves your soul to feeling differently. You should really re-research death from withdrawal and more importantly the cost of those who go through no titration and if they suffer more than they ever really needed? One mentioned at least OPTIONS to the PT, and that is my main point - You must at least refer elsewhere and give them options, you don't just cut them off and leave them to an odds chart of chances. It doesn't take bravery to cut people off and stop meds, it takes bravery to find different routes and ways to help people regardless of their illness, even if the illness IS addiction. I have treated many pts with major, life threatening illnesses who also happen to be addicts from treatment. Most if older, I change very little as it makes no sense to see them suffer the last 6 months of life. Would you stop morphine in a pt with pancreatic cancer with 3 months to live so you could get them good and sober for....well I guess for the wake? Heh....levity helps.

Just my humble opinion. I cannot wait to share this stuff with some of my students - only reason I'm here is to get a feel for the next to come and some of my current students. I am sure with my lectures on drug seeking, most will fall the same way as most of you, but it is my hope some hear the reasons for other options for pts and many times, changing types within a class makes even better sense. Clonaz instead of Alpra for example especially in pts with seizure and other neuro issues is easy and takes away much of the addiction activity and mind set. Not having that chemical spike but still having the safety net of a benzo in their sys has made all the difference for many pts i've treated.

And no I hate revealing my specialties and my board certs - double spec for me with added rotations beyond requirements and over 20 years in the field. No CV's for public boards where people seem to like to argue about anything and just LOVE to get personal such as calling me a drug seeker. Just lovely, and you are here to be educated, educate, or just share hateful statements like this one? Shame on you, hysterics probably, perhaps we should look into fumigation of the vagina?? Oh no, Galen already tried and failed at this 2,000 years ago...although I am sure there was some temporary 'relief' for his female pts.

Yet again, I rant - perhaps it has something to do with the Prozac, or my Celexa, or my Celebrex mixing badly with my Parafon Forte, all great drugs you have to take every day or the side effects of stopping suddenly could be ghastly...then again - screw that, just cold turkey your pts on their nitro as well. Then again, maybe I just have too much time on my hands, and I'm too old and you new docs are just too brilliant for me and know much more. I will never claim to know more than another, unless I come across them (heh), seriously, I don't care much for doctors who mix up their personal life with how they treat patients and all I really ever said in my posts, when boiled down is patients can be treated differently and not all addicts are non-functional. But by many standards most new docs would take them off the new/old drugs of prohibition. Just like the days when OC's were talked about like hand grenades because of stupid kids crushing them and OD'ing. I will not join the mass hysteria of this and change the way I treat. Pinesol and Bleach are also very bad to ingest, perhaps we should put them on a control list as well. Don't tell me all you physicians out there just love being told what is right and wrong by politicians and the media? Every doctor I worked with during the OC Scary Days laughed at and also feared for their pts losing a great medication for those who need it. All my Onc friends were near riotous over it and still have to watch their backs for prescription limits, etc. It's just not such an easy answer as it seems to have been made here.

Okay, on with the laments and shock of my statements, or sheer disregard for any merit. I don't live for your merit either way, but it is good to know how to curve my grades by info I get out of forums like this.

IpMan1970

PS - If my rant wasn't enough to draw a giggle from some of the more elite 'clinicians' out there who were offended by my statements, I also believe in prescribing POT and believe in Psych setting MDMA can be helpful. So, there are some great ones for you. Talk to some older psych's who used it when it was allowed and how mad many of them were when we could no longer use in studies. Fare the well, until next time.

 

[specepic]

Ipman-would not rec rx to someone with dirty urine. what do you think they are going to do with that rx and who will take the blame?

The healthiest thing I did for myself and my practice was to not hate or resent pts 'seeking' opioids inappropriately, either through manipulation or ignorance. The reason we get the training we do is to sort this kind of stuff out. I also depersonalize the discussion with statements like: "I recommend" or "my medical opinion is...". I tell them they are free to disagree with me or get another opinion and I dont claim to be perfect or all knowing, but I do have certain policies and procedures and that is that, we are not negotiating.

The folks who have the toughest time with this are doc's who need to be friends with their pts or have 'pleaser personalities'. Just say no, its that freaking simple. Every opioid pt needs to meet two criteria (I learned this from someone else so I'm not taking credit), do they have the right dx for opioids and are they the right pt for opioids. In other words, you could have a pt with terminal cancer and 'pain', but you find cocaine in their urine and find out from the cops they are selling half their Rx, guess what, they are done getting rx, for personal and public safety reasons. Use logic, use your training, etc.

 

[mulberry]

nobody ever died from narcotic withdrawal. But people die of overdoses every day. I have had people come to my office in active withdrawal, and my response was: You have a choice, 1) go to a detox or suboxone clinic (I give them the information, or 2) a 1 week supply of Clonidine and good luck.

My wife was a drug/alcohol addict and ultimately died as a result of it. I learned first hand how duplicitous drug addicts are. I will practice how I like, and how I feel is "ethical". Please do not preach to me on how to practice. I have close to 20 yrs experience, and have consulted my state board on what is legal/ethical. I don't prescribe xanax and VERY rarely prescribe opiates. Go ahead and report me.

I am prescribed xanax to treat mild anxiety. There is no eurphoria on xanax, it just calms you down a little. Opiates actually give you a euphoria which is why I am confused as to why you would be reluctant to prescribe xanax but not opiates. In any case, patients shouldn't be coming to a physiatrist to get xanax.

 

[vistaril]

I am prescribed xanax to treat mild anxiety. There is no eurphoria on xanax, it just calms you down a little. Opiates actually give you a euphoria which is why I am confused as to why you would be reluctant to prescribe xanax but not opiates. In any case, patients shouldn't be coming to a physiatrist to get xanax.

physiatrists are more than capable of prescribing xanax. And in fact many non-psychiatrists actually do a much better job of not just throwing everyone on xanax than some psychiatrists. Why a physiatrist would bother to r want to rx a pt xanax is another story.

And some people do experience a euphoria to some degree on xanax. Not like opiates, but there is no hard line in the sand to differentiate euphoria from anxiolytic effects.

 

[IpMan1970]

Ipman-would not rec rx to someone with dirty urine. what do you think they are going to do with that rx and who will take the blame?

The healthiest thing I did for myself and my practice was to not hate or resent pts 'seeking' opioids inappropriately, either through manipulation or ignorance. The reason we get the training we do is to sort this kind of stuff out. I also depersonalize the discussion with statements like: "I recommend" or "my medical opinion is...". I tell them they are free to disagree with me or get another opinion and I dont claim to be perfect or all knowing, but I do have certain policies and procedures and that is that, we are not negotiating.

The folks who have the toughest time with this are doc's who need to be friends with their pts or have 'pleaser personalities'. Just say no, its that freaking simple. Every opioid pt needs to meet two criteria (I learned this from someone else so I'm not taking credit), do they have the right dx for opioids and are they the right pt for opioids. In other words, you could have a pt with terminal cancer and 'pain', but you find cocaine in their urine and find out from the cops they are selling half their Rx, guess what, they are done getting rx, for personal and public safety reasons. Use logic, use your training, etc.

As you said, best advice you received with regard to this topic was the 2 criteria you mentioned. And I appreciate both your candor and diplomacy in a debut. Thanks much for the response.
My criticisms often apply to a 'generation' of clinicians I have seen who act like Stepford Doctors and do not think out of the box. Docs who will not even check the body, they just look at the chart and they are done. Flags and Behaviors are not everything is my whole point. I see people globally. I don't just hand out meds left and right as some might presume. Instead, I am more liberal than many as I still would rather hand out meds (again, stressing agreements, and also how I dose regarding quantity, etc., all play a role). I just do not think in a black and white manner, as we ARE dealing with humans who very seldom fall all into a single category. Too many people suffer over drug seekers and I will not punish self-medicators whom I see to be in desperate situations without helping them, even if that is an alternate med to carry them to a place/point where they can get the 'global' healing and help they need.
Very intelligent response doctor and again, I appreciate your tone. I don't care much for trolls or doctors who apply blanket statements to situations. This is what caused much of the upsurge in prescription abuse in middle and upper classes where the under class was profiled much more by physicians in many case back in the 80's - 90's especially. I don't like the attributing status to how I treat a patient and how believable they are, but I digress, and will start another rant.
I am an anti-drug war person politically and have a lot to say about it. This is why I post a rant when it comes to hurting patients with no lifeline, no recourse, no direction. This was always my main point. Thanks again for the informed and wise response.

IpMan

 

[specepic]

As you said, best advice you received with regard to this topic was the 2 criteria you mentioned. And I appreciate both your candor and diplomacy in a debut. Thanks much for the response.
My criticisms often apply to a 'generation' of clinicians I have seen who act like Stepford Doctors and do not think out of the box. Docs who will not even check the body, they just look at the chart and they are done. Flags and Behaviors are not everything is my whole point. I see people globally. I don't just hand out meds left and right as some might presume. Instead, I am more liberal than many as I still would rather hand out meds (again, stressing agreements, and also how I dose regarding quantity, etc., all play a role). I just do not think in a black and white manner, as we ARE dealing with humans who very seldom fall all into a single category. Too many people suffer over drug seekers and I will not punish self-medicators whom I see to be in desperate situations without helping them, even if that is an alternate med to carry them to a place/point where they can get the 'global' healing and help they need.
Very intelligent response doctor and again, I appreciate your tone. I don't care much for trolls or doctors who apply blanket statements to situations. This is what caused much of the upsurge in prescription abuse in middle and upper classes where the under class was profiled much more by physicians in many case back in the 80's - 90's especially. I don't like the attributing status to how I treat a patient and how believable they are, but I digress, and will start another rant.
I am an anti-drug war person politically and have a lot to say about it. This is why I post a rant when it comes to hurting patients with no lifeline, no recourse, no direction. This was always my main point. Thanks again for the informed and wise response.

IpMan

I agree that things are not black and white, and as I tell my pts "pt's bodies rarely follow the textbook". I have seen many pts where after reading the chart and talking with my MA I go in the room thinking, 'there is no way i'm rxing for this pt'. Then I meet them and get the context. I DO think it is important to have certain rules as these pts can manipulate so well.

I see two camps lately:

- the emphatetic trusting doctor--the pts talk them into doing things they should not do

- the my way or the highway doc who wont even rx to appropriate pts with any little risk factor, or just wont rx opioids at all

I follow the 'trust but verify' approach

One of my mentors once said "pain is not an opioid deficient state". This is where docs get into trouble. They see chronic pain and they think opioids, which is the solution in a MINORITY of pts.

It snds like you may be facilitating some chemical coping with your pts or am I way off? Are you psych or primary care, whats your specialty?

 

[IpMan1970]

I really want to answer you clearly, so I will take my time and think about what you've said and I even am going to pull some pt records and some studies I did a decade ago compared to today.

I have a double specialty, which I hate to tell people, as they like to box people in by the name card, labels they see, but I do not feel this from you, just curiosity. Infectious Disease, Pediatric Oncology, currently a part time Hospitalist as I near retirement.

I also teach at an unnamed school, not near my home - for you detectives out there seeing me login from Southeast Ohio. Most of my work has been in New England states as were my studies.
My teaching is pretty much been in the Ohio Valley into New England. I also have given multiple symposiums and was a big voice during the Oxy Scare explaining to the lay aspirin in their cabinet is just as dangerous as a gun, etc. There were also other studies, cultural, epidemiology, I am also a musician/composer, very independent of political and social mores.

I don't care much for fads. I care for what works best, most efficaciously, quickest, and affecting as few systems as possible. I like bulls-eyes in my rxing, I don't like buckshot.

But I want to respond to your lines in the sand...I find them very much the way I operate and I am humbly say I am proud to call you a colleague in the WAY you practice. I use a formula as you do. Others whom I have little respect for believe that X=SAP, ad nauseum, every time when we all know the variables change from moment to moment.

Thanks for your response. I have more to say on this, but as I said I want to look up some incidence first, and more relevant to so many, FDA standards are so much overlooked and yet I find I agree with many of them. We will get back to that. For now, thanks for the response, questions, etc.