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4 Articles in Volume 2, Issue #6
A Conceptual Model of Pain: Measurement and Diagnosis
Carpal Tunnel Syndrome as a Neuropathic Condition
Chronic Insomnia and Pain
Identifying Pain-Drug Abusers and Addicts

Identifying Pain-Drug Abusers and Addicts

Characterization and profiling of patients with deviant addictive behaviors helps weed out abusers from pain practices.

There is nothing more disheartening and disrupting to a pain practitioner than a drug abuser or addict who manages to gain entry into the practice and subsequently exhibits noticeable addictive or deviant behaviors.1-3 The national drive to eliminate under-treatment of pain and relieve the suffering of thousands of bed and house-bound pain patients has given the abuser and addict an opportunity to enter many new and embryonic pain practices. To date, little was known about the profile of abusers and addicts who prey upon pain practices.4-6 In contrast to the heroin addict who is relatively easy to identify by criminal records, presence of needle marks, and morphine in body fluids, most abusers and addicts who frequent pain practices use oral opioids and may have few obvious characteristics to identify them.5-7 Fortunately, the movement to provide opioid treatment to legitimate, non-abusers in pain has now matured enough to allow profiling of oral, opioid abusers and addicts so that some guidance in spotting these individuals can be provided. To assist in preparation of this article, the authors reviewed twenty patients in their practices who entered pain treatment and later demonstrated deviant, addictive behaviors and had to be forcibly discharged.

Drug Abuser and Addict Defined

There appears to be a general consensus on definitions utilized in the practice of pain management.8,9 Fundamentally, a legitimate pain patient uses opioids and other medications to relieve pain while abusers and addicts use the drugs for psychologic, ill-defined reasons other than pain relief. Table 1 lists the definitions used by the Federation of State Medical Boards which are similar to those used in a joint consensus statement of the American Pain Society and the American Society of Addiction Medicine.8 Of special significance to pain practitioners is the definition of “pseudo-addict” who is a patient who frequents emergency rooms and multiple physicians to obtain additional pain relief medication, because their primary pain practitioner is under-treating them.

Definitions utilized by The Federation of State Medical Boards of the United States, Inc.

Substance Abuse: Substance abuse is the use of any substances(s) for non-therapeutic purposes or use of medication for purposes other than those for which it is prescribed.

Pseudo-Addiction: Pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that can be mistaken for addiction.

Addiction: Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm. Addiction may also be referred to by terms such as “drug dependence” and psychological dependence”. Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction.

Physical Dependence: Physical dependence on a controlled substance is a physiologic state of neuro-adaptation which is characterized by the emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself, does not equate with addiction.

Table 1.

The authors recommend the use of the term “addictive characteristics and behaviors” because the pain practitioner needs a checklist or set of specific behaviors and characteristics to help methodically identify the abuser or addict. These behaviors are known to occur in abusers and addicts, and when enough deviant behaviors occur, it is a signal to refer, discharge, or take other measures to control and/or eliminate the behaviors.1,3,5,7 The authors recommend the use of an “Addictive Characteristics and Behaviors Checklist”3 (see Table 2) which is initiated when a patient enters treatment. As addictive characteristics or behaviors are observed over time they can also be noted on the checklist.

Table 2.

It is highly recommended that every pain practitioner establish a set of criteria for admission that will disqualify many abusers and addicts.

Identifying Abusers and Addicts Prior to Treatment

Clinical experience shows that some abusers and addicts can be identified and rejected prior to admission to pain treatment.1,5 Some others may be suspected but admitted to pain treatment to be observed for characteristics and addictive behaviors that will identify them later and render them unsuitable for the pain practitioner’s practice. It is highly recommended that every pain practitioner establish a set of criteria for admission that will disqualify many abusers and addicts. For example, the authors’ practice requires patients to be referred from a physician, be accompanied by a family member, and produce previous medical records that document prior pain treatment and outcomes of the treatment. Typically abusers and addicts, individuals seeking pain-relieving drugs only for abuse purposes, simply “drop in” the practitioner’s office without an appointment, referral, family member, or previous medical records (see Tables 3 and 4).

Recommended Screening and Admission Measures to Identify Legitimate Pain Patients
  • Accompanied by family member of caretaker
  • Stable living quarters
  • Past medical records
  • Source of primary medical care
  • Drivers license and social security number
  • Objective physical signs on physical examination
  • Biologic markers of severe pain


Common Profile of Abuser or Addict Who Seeks Pain Treatment
  • Attends without a family member
  • Drops in for visit; no regular appointment
  • Smoker
  • Vague medical history
  • Frequent changes of residence and employment
  • Few, or no, medical records
  • No physician referral
  • Requests a specific abusable drug
  • No demonstrable biologic markers for pain
  • No ongoing primary care physician
  • Does not follow thru with referrals or diagnostic tests
  • Urine contains illegal drugs
  • Frequently runs out of medications before scheduled appointments

Table 4.

The profile of many abusers and addicts is characteristic.5-7 They attend a practice alone without family, smoke cigarettes, give a vague medical history, possess few, if any, past medical records, give a history of frequent moves and employment, and often lack a valid driver’s license.3-7 Often they request a specific, abusable drug such as hydrocodone (Vicodin®, Norco®, Lortab®) or sustained release oxycodone (Oxycontin®), and they may be resistant to suggestions to try other medications.

In a review of our 20 patients who had to be discharged from pain treatment for addictive behavior after admission to treatment, essentially all had been admitted without the accompaniment of a family member to validate a legitimate pain history and provide assurances that prescribed medication will be properly taken. Few had a primary care physician who cared for their general medical needs. It is consequently recommended that opioid medication not be prescribed to patients seeking pain treatment unless the patient clearly demonstrates responsible family involvement, a source of primary medical care, and a stable residential and transportation situation.

Objective Physical Signs and Biologic Markers

With the possible exception of headache patients, all pain patients with chronic pain severe enough to require opioid medication will demonstrate objective findings on physical examination. Even many chronic, severe headache cases will show facial furrows from recurrent squinting of the eyes and grimacing of the face. A patient with severe, chronic pain that results from neurologic, arthritic, or muscular degeneration invariably demonstrates one or more abnormalities in motor, neurologic or joint function. Gait may be abnormal in that the patient may walk slowly, drag a foot, walk in a bent position or ambulate with a wide gait. Patients with severe fibromyalgia or a neuropathic condition often resist palpation since even the lightest touch produces pain discomfort.

Severe, chronic pain is a stress stimulator to the autonomic nervous system and the pituitary-adrenal axis.10,11 Unless medicated, a patient in severe pain will usually demonstrate a dilated, reactive pupil and possibly photophobia. Blood pressure and pulse rate are usually elevated. Serum concentrations of cortisol, dehydroepiandrosterone (DHEA), and other adrenal stress hormones may be elevated.11 If the pain state has been severe and under-treated for a considerable time period, serum adrenal hormone concentrations, particularly pregnenolone and cortisol, may be low.10,11 Patients who do not demonstrate objective physical signs or biologic markers may be abusers or addicts who are seeking drugs by feigning pain. Sadly, some patients with legitimate pain and objective physical signs and biologic markers may abuse or even divert some of their pain medications after they are admitted to pain treatment.6,7 Eventually, however, their addictive characteristics and behaviors usually tip off the practitioner.

Identification of the Abuser or Addict in Pain Treatment

The authors recommend that every pain practice develop a checklist of “addictive characteristics and behaviors” similar to the checklist presented in Table 2. The checklist may include very unacceptable behaviors such as diversion or selling of medication which may result in immediate, abrupt discharge. Other items on the checklist give the practitioner a way to sequentially record characteristics and behavior as they become known to the practitioner. Once an excessive number of addictive behaviors has been observed, some action should be taken which may include discharge or referral to an addiction specialist or methadone maintenance program (see Tables 3 and 4).

The classic behaviors that indicate abuse or addiction are loss of medication, early refill requests, visits to an emergency room, and patronage of multiple physicians.5,7 Rather than simply ascribe these behaviors to abuse, however, some investigation is necessary to determine if the behavior represents under-treatment of pain and “psuedo-addiction.”9

A clinically dangerous behavior of an abuser or addict, who may even have legitimate pain but abuses medications for non-pain purposes, is over-medication, sedation, and impairment. When pain treatment medication is appropriate and effective, even in high dosages, there is no evidence of sedation or impairment. Tolerance to the sedating and impairing effects of opioids will occur while the analgesic effects remain. This can and should be documented at regular clinic visits by monitoring speech, gait, blood pressure, and pulse rate. When pain treatment medication is effective but not sedating, blood pressure and pulse rate are normal and the pupil diameter is normal and will react to a light challenge with a penlight. In addition to identifying over-medication at a clinic visit, the practitioner may receive reports from an outside party that a patient is over-medicated and possibly abusing medication. When this repeatedly occurs, the practitioner will have to assume abuse and take some action to prevent or eliminate this behavior, since it may result in an overdose or accident.

The first abuse and addictive behaviors observed may be failure of the patient to keep regular appointments or follow through on diagnostic tests or requests to obtain records. Abusers and addicts will often resist or ignore referrals for ancillary services such as physical therapy or psychologic counseling. Legitimate pain patients want to do about anything they can to improve their condition, but the abuser and addict are focused only on acquiring medication.

Urine testing may be useful in select circumstances. Spot, in-clinic qualitative tests are a quick practical assist. Abusers of prescription drugs often abuse marijuana, methamphetamine, or cocaine. The metabolites of these illegal drugs can easily be detected by in-clinic rapid urine assays. Since the patient is normally taking opioids for therapeutic purposes, opioid urine tests are of little or no value. If the urine test is negative, however, diversion of medication must be suspected.

Quantitative serum opioid testing will reveal detectable concentrations which may be above the normal toxic range if the patient is tolerant to opioids. If the patient demonstrates normal blood pressure, pulse rate, and pupil size and reaction in the presence of therapeutic or even higher serum opioid concentrations, the patient is tolerant to the autonomic suppressant effects of opioids but is simultaneously receiving analgesic benefits which is the goal of treatment.

Summary

Unfortunately, some drug abusers and addicts will attempt to enter a pain treatment program to obtain abusable drugs. The authors have found that an essential measure to prevent admission of an abuser or addict to treatment is to require a family member to accompany the patient at the time of initial evaluation to validate the pain history and assure the practitioner that prescribed medications will be properly taken. After a patient is admitted to ambulatory pain treatment, addictive characteristics and behaviors should be monitored. Patients who divert or sell medication should be summarily discharged. Abusers and addicts in treatment typically resist and fail to comply with recommended therapeutic measures such as diagnostic tests and physical therapy. Over-medication due to excessive drug taking is dangerous and can’t be tolerated by the pain practitioner. As pain treatment continues to emerge, pain practitioners should study ways to identify and eliminate abusers and addicts in their pain practices. This is necessary to enhance the credibility of the overall pain treatment movement and protect the legitimate pain patient from the negative stigma that accompanies abusers and addicts.

...pain practitioners should study ways to identify and eliminate abusers and addicts in their pain practices. This is necessary to enhance the credibility of the overall pain treatment movement and protect the legitimate pain patient from the negative stigma that accompanies abusers and addicts.
Last updated on: May 16, 2011
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