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Toxicology

Approach to the Patient with Drug-Seeking Behavior

Michael Hunihan, MD and Jordan Wolfe, MD
Emergency Medicine Residents
Brown University, Department of Emergency Medicine


Nationally, there is a tremendous amount of attention being paid to the current epidemic of opioid related addiction and deaths. We are told that we should be differentiating who needs opioid pain medications and who doesn’t—that some people are obtaining opioid prescriptions for purposes other that pain. This bulleted primer may assist in your decision—to prescribe or not to prescribe…

 

DRUG SEEKING BEHAVIOR → Obtaining medications for non-therapeutic purposes (“misuse”)

  • Recreation, diversion (selling), dependence


EPIDEMIOLOGY → “This is a really big deal and we can be a part of the solution”

  • Daily, 78 Americans die from opioid rx overdose, which is more than MVCs, or heroin and cocaine combined
  • Deaths have risen with prescriptions; we can play an active role in this epidemic, with every patient, on every shift


RED FLAG BEHAVIORS → Positive correlations with opioid misuse 

  • Requesting IV medications—often asking for IV “push”, refusing infusion
  • Complaining of pain scores “11/10!” or higher
  • >2 visits in 7 days
  • >3 different pain complaints over time
  • Requesting medications by name—“I can’t take the generic”.
  • Requesting “refills” for “lost” or “stolen” medications
  • Headache, back pain, dental pain (un-assessable causes of pain)
  • Stating allergies to non-opioid pain relievers—“I’m allergic to Tylenol, I need Vicodin”
  • “Squeaky wheel” of the department
  • Arrives after doctor’s office closes—“I called the office but the service told me to come here”
  • Disregard for intensely unpleasant side effects such as vomiting, diarrhea, constipation, nausea


RISK FACTORS FOR OPIOID MISUSE → Consider when writing a new opioid prescription

  • Personal or family history of substance abuse (including tobacco) or mental health disorders
  • Legal problems, incarceration
  • White > black
  • Age <40
  • Multiple doctors, including appropriate specialists


EXTERNAL TOOLS AT YOUR DISPOSAL TO INVESTIGATE ABERRANT BEHAVIOR 

  • PDMP (RIPMP: https://rhodeisland.pmpaware.net/login/) (or what is available in your state)
  • Call PCPs, pharmacies
  • Corroborate patient’s functional status with their family/friends, and with your entire care team


TREATING PAIN IN THE CHRONIC OPIOID PATIENT → Difficult, drug-seeking or not 

  • Ddx includes opioid misuse, new or progressing disease, opioid tolerance, pseudoaddiction, hyperalgesia
  • NSAIDs, APAP, muscle relaxers, topical, nerve blocks
  • Per ACEP guidelines: short courses of IR opioids are acceptable for non-cancer pain, after you check the PDMP and honor any existing pain contract


PRO TIPS FROM THE PAIN LITERATURE

  • Be aware of your own emotions and countertransference, employ confidence and empathy
  • Maintain a professional, decisive demeanor
  • If you do not think opioids are in your patient’s best interest, communicate that to him/her yourself, and document it



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