The identification and management of drug-seeking behavior in a medical center

Reducing the health consequences of opioid addiction in primary care

Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.

Differences in the personality profile of medication-overuse headache sufferers and drug addict patients: a comparative study using MMPI-2

BACKGROUND

Medication-overuse headache (MOH) refers to headache attributed to excessive use of acute medications. The role of personality needs studies to explain the shifting from drug use to drug abuse. The main aim of this study is to study personality, according to Minnesota Multiphasic Personality Inventory, comparing MOH, episodic headache, substance addicts (SA) vs healthy controls.

METHODS

Eighty-two MOH patients (mean age 44.5; 20 M, 62 F) and 35 episodic headache (mean age 40.2; 8 M, 27 F), were compared to 37 SA (mean age 32.5; 29 M, 8 F) and 37 healthy controls (mean age: 32.49; 20 M, 17 F). International Classification of Headache Disorders 2nd Edition criteria were employed. Chi-square test, Kruskal-Wallis test, and post hoc comparisons were used for statistics.

RESULTS

MOH patients scored higher on Hypochondriasis, Depression (only females), Hysteria (only females) (P < .000). MOH did not show higher scores than episodic headache or healthy controls in dependency scales, while SA did.

CONCLUSION

The data obtained show that MOH and SA do not share common personality characteristics linked to dependence. Although further studies are needed to understand if such a difference is related to instrumental characteristics or to yet undiscovered psychobiological characteristics of MOH patients; however, we hypothesize that the detected difference may rely on the fact that drug dependence in the 2 groups is promoted by entirely different needs: pleasure seeking in the SA group, pain avoidance in the MOH group.

Prescription drug misuse in New Zealand: challenges for primary health care professionals

BACKGROUND

Prescription drug misuse (PDM) is an international phenomenon. Prescription drugs sought for this purpose are often obtained through the primary health care network.

OBJECTIVES

This study aimed to explore the challenges faced by community pharmacists (CPs) and general practitioners (GPs) when faced with the issue of "drug-seeking" and PDM. This forms part of a larger study of PDM issues for primary health care practitioners.

METHODS

Qualitative interviews were carried out in New Zealand with 17 GPs and 16 CPs, purposively sampled to provide information from a variety of demographic and work environments. Interviews were tape-recorded, transcribed verbatim, and a thematic analysis conducted. Data collection took place between June 2007 and January 2008, and interviewees were offered an NZ$30 voucher in recognition of their contribution to the research.

RESULTS

GPs and CPs faced a series of challenges in managing PDM, including identification of PDM, dealing with requests for inappropriate requests for psychoactive prescription drugs, verifying the legitimacy of requests and managing threatening behaviors. Specific issues were faced by rural practitioners, female practitioners and by locums and part-time staff. In particular, some participants reported feeling emotionally stressed after unpleasant drug-seeking incidents and some acknowledged that they may have missed identifying some drug-seeking because of lack of knowledge, "drug-seekers'" sophisticated strategies, or patients falling outside of their image of the archetypal "drug-seeker."

CONCLUSION

This study demonstrated that PDM can be an issue for primary health care practitioners, and it can cause disruption to their work. Training in how to better manage threatening and escalating incidents may be useful as would increasing the level of awareness of PDM issues among health professional students.

Innocent parties or devious drug users: the views of primary healthcare practitioners with respect to those who misuse prescription drugs

BACKGROUND

Many health professionals engage in providing health services for drug users; however, there is evidence of stigmatisation by some health professionals. Prescription drug misusers as a specific group, may also be subject to such judgment. This study aimed to understand issues for primary care health practitioners in relation to prescription drug misuse (PDM), by exploring the attitudes and experiences of healthcare professionals with respect to PDM.

METHODS

Tape-recorded interviews were conducted with a purposive sample of general practitioners (17), community pharmacists (16) and 'key experts' (18) in New Zealand. Interviews were transcribed verbatim and a thematic analysis undertaken. Participants were offered vouchers to the value of NZ$30 for their participation.

RESULTS

A major theme that was identified was that of two different types of patients involved in PDM, as described by participants - the 'abuser' and the 'overuser'. The 'abuser' was believed to acquire prescription medicines through deception for their own use or for selling on to the illicit market, to use the drugs recreationally, for a 'high' or to stave off withdrawal from illicit drugs. 'Overusers' were characterised as having become 'addicted' through inadvertent overuse and over prescribing, and were generally viewed more sympathetically by practitioners. It also emerged that practitioners' attitudes may have impacted on whether any harm reduction interventions might be offered. Furthermore, whilst practitioners might be more willing to offer help to the 'over-user', it seemed that there is a lack of appropriate services for this group, who may also lack a peer support network.

CONCLUSIONS

A binary view of PDM may not be helpful in understanding the issues surrounding PDM, nor in providing appropriate interventions. There is a need for further exploration of 'over users' whose needs may not be being met by mainstream drug services, and issues of stigma in relation to 'abusers'.

Allopathic, complementary, and alternative medical treatment utilization for pain among methadone-maintained patients

We surveyed 150 methadone maintenance treatment program (MMTP) patients about pain, pain treatment utilization, perceived efficacy of prior pain treatment, and interest in pursuing pain treatment at the MMTP. Respondents with chronic severe pain (CSP) (ie, pain lasting at least six months with moderate to severe pain intensity or significant pain interference) and "some pain" (ie, pain reported in the previous week but not CSP) endorsed similar rates of past-week and lifetime allopathic or standard medical (with the exception of lifetime medical use of non-opiate medication) and complementary and alternative medicine (CAM) utilization for pain reduction. Prior pain treatments were perceived to be less effective by CSP than SP patients but both groups had equivalent high rates of interest in pain treatment associated with the MMTP. These findings may have implications for resource and program planning in MMTPs.

A validation of self-reported substance use with biochemical testing among patients presenting to the emergency department seeking treatment for backache, headache, and toothache

PURPOSE

This study tests the validity of self-reported illicit substance use against biochemical testing among Emergency Department (ED) patients seeking treatment with narcotics for backache, headache, and toothache and to characterize patients who provide false reports.

METHODS

Retrospective chart review comparing the self-reported drug use history obtained during an ED visit during a six-year period (1995-2001) with the results of a biochemical drug screen obtained the same day.

RESULTS

248 patients met screening criteria, 79 (32%) of whom tested positive for unclaimed "drugs of abuse." Patients with a history of "drug abuse" and chronic pain were significantly more likely to test positive for unclaimed drugs than were their counterparts (p=.05 and p<.0001, respectively). No significant difference was found in comparing those with and without multiple ED visits or those requesting a specific narcotic.

CONCLUSION

Self-reported drug use is unreliable in this ED subpopulation. When this knowledge is critical for patient care, biochemical testing may be indicated.

Profiling patients suspected of drug seeking in an adult emergency department

OBJECTIVES

(i) To profile ED consultations where drug seeking is considered; (ii) to clarify if an Australian patient cohort shares the characteristics identified in the literature, that is, high rate of psychiatric, chronic pain and drug dependency problems; and (iii) to quantify the extent of missed organic disease in suspected drug-seeking presentations.

METHODS

Prospective descriptive study with an initial enrolment period of 3 months, follow up at 3 and 5 years. Tertiary hospital ED doctors voluntarily identified suspected drug-seeking behaviour. Patients' demographic information, past history, presenting features, investigations, management and missed diagnoses of organic pathology were collected. Recurrent presentations of drug seeking, self-harming, psychiatric, chronic pain and drug dependency complaints were documented.

RESULTS

Thirty-seven presentations (31 patients) of 10,958 total attendances were analysed. All patients were less than 65 years. Twenty-one patients (68%, 95% confidence interval [CI 49.7-85.8]) were on unemployment or disability pension. Twenty-six presentations (70% [95% CI 54.2-86.3]) described psychiatric problems, whereas three presentations (8% [95% CI 0.0-18.3]) had chronic pain and 10 presentations (27% [95% CI 11.4-42.7]) had drug dependency problems. Twenty-six patients (84% [95% CI 69.3-98.4]) recurrently presented with self-harming and drug-seeking behaviour at 3 years. The risk of missing organic pathology was 8/37 (22% [95% CI 7.0-36.2]).

CONCLUSIONS

Further characterization of this population would help accurate diagnosis of this aberrant behaviour and decrease the risk of missing organic pathology. The management of frequently presenting patients should prompt formulation of departmental plans to effectively assess and manage these people.

Screening for addiction in patients with chronic pain and "problematic" substance use: evaluation of a pilot assessment tool

Assessing for the presence of addiction in the chronic pain patient receiving chronic opioid analgesia is a challenging clinical task. This paper presents a recently developed screening tool for addictive disease in chronic pain patients, and pilot efficacy data describing its ability to do so. In a small sample of patients (n = 52) referred from a multidisciplinary pain center for "problematic" medication use, responses to the screening questionnaire were compared between patients who met combined diagnostic criteria for a substance use disorder and those who did not, as assessed by a trained addiction medicine specialist. Responses of addicted patients significantly differed from those of nonaddicted patients on multiple screening items, with the two groups easily differentiated by total questionnaire score. Further, three key screening indicators were identified as excellent predictors for the presence of addictive disease in this sample of chronic pain patients.

Community-wide emergency department visits by patients suspected of drug-seeking behavior

OBJECTIVE

To measure community-wide ED use by patients at high risk for drug-seeking behavior.

METHODS

A retrospective, observational study was performed to analyze a cohort of university hospital ED patients seen January 1 to June 30, 1990, for specific pain-related diagnoses (i.e., ureteral colic, toothache, back pain, abdominal pain, or headache) and either independently identified on at least one other local hospital's "patient alert" list or having a drug-related death during 1990. Patients with terminal illnesses were excluded. The frequency of ED (and affiliated urgent care clinic) visits and hospital admissions were determined for January 1 to December 31, 1990, at seven local hospitals. Detailed, supplemental chart review was performed for visits to three of these hospitals from 1990 to 1992.

RESULTS

Thirty patients were identified as being at risk for drug-seeking behavior (mean age: 34.3 years; range: 21-55 years; 50% males). We identified 379 visits for this cohort (86% ED visits, 9.8% urgent care visits, 4.7% hospital admissions), for an average of 12.6 visits (range: 2-33) per patient per year. On average, each patient visited 4.1 (range: 1-7) different hospitals and used 2.2 (range: 1-6) different aliases. Two patients died of drug overdose. Supplemental chart review revealed 28 episodes (among 17 different patients) in which a patient was told that he or she "would receive no further 'narcotics'" from that facility; these patients subsequently received controlled substances from another hospital in 93% of these instances and from the same facility in 71%.

CONCLUSIONS

Patients identified as being at high risk for drug-seeking behavior have high community-wide ED visit rates. Improving communication between and within hospitals may help identify patients who could benefit from more consistent community-wide care and appropriate treatment for addiction.

Habitually wandering patients

BACKGROUND

Physicians are sometimes confronted with patients who gain admission to one hospital after another, sometimes referred to as "wandering patients." Little is known about the presenting symptoms of these patients, their use of hospital resources, or the costs of their medical care. We analyzed the demographic and clinical characteristics of wandering patients served by Department of Veterans Affairs medical centers (VAMCs).

METHODS

For each patient they admit, all 159 hospitals in the Veterans Affairs medical system submit demographic and diagnostic information to a central data base at the Data Processing Center in Austin, Texas. We searched these records to identify patients who were admitted to four or more VAMCs within each year from fiscal year 1988 through 1992. Patients so identified in any one year were called "wanderers"; those identified in all five years were designated "habitual wanderers."

RESULTS

We identified 1013 wanderers in 1988. The number gradually declined each year to 729 in 1993. In 1991 there were 810 wandering patients, who averaged about eight admissions per year and over 100 days of inpatient care; they accounted for about $26.5 million in costs for inpatient and outpatient care in that year. Only 35 patients wandered in all five years from 1988 through 1992. The most common discharge diagnoses of these 35 men were related to substance abuse (mostly alcoholism) and mental disorders. Their 2268 admissions and 7832 outpatient visits cost an estimated $6.5 million over the five-year period.

CONCLUSIONS

Patients who are repeatedly admitted to different hospitals--wandering patients--accumulate high numbers of admissions, cause diagnostic confusion, and receive uncoordinated care. Because of the complexity of their disorders, such patients require case management on a regional or national basis.

Educational approaches to prescribing practices and substance abuse

The history of medical education in treating and prescribing for additive disorders is primarily one of omission. This began to change in the 1970s, leading to positive developments in medical education; however, much still remains to be done. Training in writing prescriptions should cover four areas: (1) prescribing to prevent addiction; (2) prescribing for alcohol or other drug dependent patients; (3) prescribing for withdrawal from alcohol or other drugs; and (4) prescribing for patients in recovery from alcohol or other drug addiction. Other areas of importance to medical education are inappropriate prescribing practices, self-prescribing, and prescribing for dual diagnosis patients. Physicians need to know how to avoid becoming duped, dated, impaired or "script doctors." The educational techniques used in attaining these goals emphasize adult, or andragogical, education, sequencing curricula over the years of medical school and residency training, utilizing a variety of instructional techniques, and evaluating the results after each educational unit. The use of clinical vignettes, patient management problems and simulated patients is recommended.