Recognising signs of drug-seeking and misuse

Many GPs believe they can easily identify drug seekers, but they will not all fit the expected stereotype.
Drug seekers may be known patients or casual attendees to the practice. They may be dependent on the drug or sourcing the drug for black market sale. Drug seekers are not necessarily drug abusers or drug addicts. Anyone regardless of gender, income, ethnicity, health or employment status can be a drug seeker.

In addition, not all drug seekers are faking symptoms. They may have a legitimate complaint and over time have become dependent or tolerant and require larger doses to function in their daily life.(1) Patients with chronic pain, anxiety disorders and attention-deficit disorder are at increased risk of addiction co-morbidity.(2)

Some indicators of drug seeking behaviour are:(1, 2)

• Presenting near closing time without an appointment.


• Reporting a recent move into the area, making validation with a previous practitioner difficult.


• Requesting a specific drug and refusing all other suggestions - the patient may claim that other medications don't work, they have an allergy to them, a high tolerance to drugs or report losing prescriptions.


• Inconsistent symptoms that do not match objective evidence or physical examination.


• Manipulating behaviour which may include comparing one doctor's treatment opinions against another's, offering bribes or making threats.


• Use of multiple doctors.


• Assertive personality, often demanding immediate action.


• Unusual knowledge of medications and symptoms or evasive and vague answers to history questions.


• Reluctance to provide personal information such as address or name of regular doctor.


• Signs and symptoms of intoxication or withdrawal

 

Many drug seekers will target doctors who are new to a practice or doctors who are sympathetic and dislike confrontation. A usual patient/doctor relationship is based on mutual respect, however a drug seeker has a stronger relationship with the prescription than with the doctor. Some doctors who are pressured for time would rather "write than fight".2

Suggested strategies

Behaviours such as dose escalation, medicine hoarding and medicine sharing are suggestive of opioid addiction. However, in some cases, these behaviours occur as a result of under-treatment of pain and ineffective pain coping strategies - termed pseudo-addiction. In contrast to addiction, the behaviours resolve when adequate pain relief is prescribed.(3)

Patients whose reports of pain are not accepted, may resort to behaviours which raise suspicion of opioid misuse.(3) The difference between people with genuine pain and people with opioid misuse problems are that the latter group use opioids in the absence of pain or in an attempt to alter their mood or reduce symptoms other than pain.(3)

It is important to prescribe medicine for breakthrough pain in addition to the usual daily opioid dose and regularly enquire about pain levels, and adjust the dose accordingly, whether the pain is increasing or decreasing.

If you suspect that a patient is seeking opioids for reasons other than legitimate pain relief, some suggested strategies are:(2)

• Outright refusal to prescribe


• Prescribing for a limited time, e.g. two to three days


• Supervised daily dosing


• Prescribing a medicine appropriate for the reported symptoms but different from the one requested by the patient


• Seeking a second opinion from a colleague

 

Which prescription drugs are commonly misused?
Benzodiazepines and opioids are the most commonly misused prescription drugs.
Benzodiazepine misuse frequently occurs when multiple drugs are misused, with the highest correlation between concurrent addiction to opioids and alcohol. Benzodiazepines are used to enhance the euphoriant effects of opioids, enhance cocaine highs and increase the effects of alcohol. They are also used to alleviate withdrawal effects from other drugs.2
Stimulants may be taken to prevent fatigue (e.g. shift workers) or for their euphoric effects. Anticholinergics are taken for their hallucinogenic effects. (4)
Prescription drugs most commonly misused in Australia and New Zealand:(5, 6)

• Amphetamines e.g. dexamphetamine


• Anticholinergics e.g. procyclidine, benztropine


• Benzodiazepines e.g. clonazepam, diazepam


• Dextropropoxyphene


• Pseudoephedrine (also sourced directly from pharmacies)


• Ketamine


• Methylphenidate


• Opioids e.g. morphine, methadone, codeine, tramadol


• Zopiclone


•  

Most prescription drugs that are misused trigger dopamine release in the "reward pathway". They are all also habit forming and cause a state of physiological dependence if they are taken in large enough quantities for long enough periods of time.2

Managing the risk of prescribing controlled drugs(5)

Knowledge Ð review the pharmacology of controlled substances, drug interactions and signs of intoxication or withdrawal. Become familiar with alcohol and drug addiction screening assessments.
Documentation - this is essential, note the diagnosis, indications, expected symptom end points and the treatment time course. A medication flow chart may be useful to monitor refills, symptoms and prescribing.
Tamper proof prescriptions Ð prescribe the exact amount to carry through to the next appointment, write out the number dispensed in words not numerals, consider implementing a one doctor/one pharmacy treatment plan with the patient where only one doctor in the practice prescribes to them and prescriptions are only phoned through to one pharmacy.

Don't be hesitant to refer to peers, supervisors or those with specialised expertise such as addiction specialists, pain management clinics or psychiatrists.2

References

1. Friese G, Wojciehoski R, Friese A. Drug seekers: do you recognise the signs? Emerg Med Serv 2005;34(10):64-7.


2. Longo L, Parran T, Johnson B, Kinsey W. Addiction: Part II. Identification and management of the drug-seeking patient. Am Fam Physician 2000;61(8):2401-8.


3. Elander J, Lusher J, Bevan D, et al. Understanding the causes of problematic pain management in sickle cell disease: evidence that pseudoaddiction plays a more important role than genuine analgesic dependence. J Pain Symptom Manage 2004;27(2):156-69.


4. White J, Taverner D. Drug-seeking behaviour. Aust Prescr 1997;20:68-70.


5. McCormick R. Treating drug addiction in general practice. NZ Fam Pract 2000;27(4).


6. Ministry of Health. National drug policy 2007 - 2012. Wellington, 2007.








 
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Many GPs believe they can easily identify drug seekers, but they will not all fit the expected stereotype. Drug seekers may be known patients or casual attendees to the practice. They may be dependent on the drug or sourcing the drug for black market sale. Drug seekers are not necessarily drug abusers or drug addicts. Anyone regardless of gender, income, ethnicity, health or employment status can be a drug seeker.