Spotting drug-seeking patients

As a moonlighting resident more than 10 years ago, one of my biggest challenges was managing patients who expected to receive prescription pain medications as part of every appointment.

I still find it challenging, although I'm far better now at outsmarting dishonest patients-or, more significantly, finding ways to help them that have nothing to do with handing out a prescription. In fact, if I dismiss a patient whom I suspect of drug-seeking behavior without offering treatment, he'll only show up, trying out the same charade, in someone else's practice. Here are eight lessons I've learned over the past 10 years-lessons I wish I knew about when I started out:

1. If possible, learn how to treat opiate dependence yourself. There's a fairly new medicinal treatment available today that many physicians-not to mention most opiate-dependent patients-don't know about. It's called buprenorphine, and, to prescribe it, a physician must be granted a special federal government waiver (see http://www.buprenorphine.samhsa.gov/bwns/waiver_qualifications.html). But the extra effort is worth it, since the drug is a powerful tool in getting patients off prescription pain medications. If treating opiate dependence is not a practice area you want to get into, identify professionals in your community whom you feel comfortable referring your patients to.

A patient tells you, for example, that he's had his tooth extracted and that his dentist prescribed Tylenol with Codeine No. 3 (T3) to control his pain. But the drug has caused him to vomit, he says, and, showing you his pills, he requests that you prescribe something else. After a phone call to his dentist, his story seems to check out . . . except the fact that he wants you to substitute another narcotic for the one his dentist prescribed for him still troubles you.

3. Identify the pills that patients hand to you. Fortunately, each pill has a unique identifier, which you can read with the help of an ophthalmoscope. In the case of the patient above, I had an office assistant check with our local pharmacy to see if the pills were what the patient said they were. When the pharmacy informed me that they were Robaxin rather than T3, I'd discovered a troubling inconsistency in my patient's story. In fact, it was enough of an inconsistency to deny his request for a new prescription and make him aware of treatment options for opiate dependence.

4. Perform or send out urine drug screens. A 33-year-old female came to see me complaining of monthly migraines. Although she said she hadn't had a migraine for three weeks, she requested a small supply of Norco in anticipation of her next one. If, in fact, she'd had her last migraine three weeks ago and used hydrocodone bitartrate and acetaminophen to treat it, as she claimed, I knew that there shouldn't now be any opiates in her urine. But when I performed a urine analysis on her, she tested positive. I knew then that she was using her claim of migraines to seek drugs. The UA was a critical tool in reaching this evaluation.

It can also help to detect drug-diverting patients. For example, a patient being treated with pain medications for a chronic orthopedic condition should always be positive for the drug you prescribe and negative for all others. If a UA shows the patient is negative on both counts, that's a strong signal that he may be diverting his drugs to a family member-a member who's either opiate-dependent or trafficking.