Strategies for Managing Drug-Seeking Patients

Chronic pain physicians experience significantly worse physician burnout than other physicians,¹ and physician burnout may be a contributing factor to the opioid epidemic². Physicians suffering from physician burnout may not possess enough time or energy to fully explore non-opioid alternatives to chronic pain patients. It is a vicious cycle, but there are strategies physicians can use to break it.

Patients in chronic pain with behavioral health disorders and substance use disorders present a potentially high risk for misuse of prescribed opioids.³ Managing the chronic pain of a drug-seeking, doctor-shopping patient requires a level of vigilance, expertise, and discipline that may seem impossible in a busy practice. Determining why a patient is seeking opioids can help simplify the process of managing the individual’s healthcare in a way that will not increase the risk of burnout. Although there is overlap, there are three main categories of patients who pressure physicians for opioids: opioid dependent chronic pain patients⁴, patients with opioid use disorder⁵, and patients who are diverting their medications.

Following are tools and resources to help identify and manage these drug-seeking patients. There are also increasing numbers of resources for individuals with opioid addiction and for chronic pain patients who have developed opioid dependency that interferes with their medical care. Being prepared with policies and protocols can help alleviate the stress of managing these challenging patients.

Aberrant Drug-Related Behavior

Full participation by all prescribers in prescription drug monitoring programs (PDMPs) is emerging as an effective strategy for mitigated the risks of patient drug diversion. The following patient behaviors may also indicate that your patient has an opioid use disorder or is planning to sell or give opioids to others:

• Requesting a certain drug by name, IV opioids, or stating that non-opioid alternatives do not work
• Seeing multiple physicians (doctor shopping)
• Reciting textbook symptoms
• Failing to obtain prior records or claiming a previous physician’s practice has closed
• Showing up to appointments with imaging results (i.e., MRI)
• Failing to follow through with treatment other than obtaining pain medications
• Failing to comply with a pain treatment agreement
• Calling for early refills (e.g., claiming medications were lost or stolen)
• Testing positive for illegal drugs
• Testing negative for prescribed pain medications (possible diversion)
• Complaining of pain with no objective medical evidence to explain stated levels of pain
• Paying with cash only and not using insurance

Drug-Seeking Behavior Resources

Some patients requesting pain medications may not be in pain. It can be very difficult to determine which patients require pain relief and which patients plan to misuse the medications. Different roles within a practice often necessitate different strategies. The following resources describe strategies for different roles:

• Hospitalist: Today’s Hospitalist article, “Strategies for Dealing with Drug-Seeking Patients”
• Primary Care Physician: Australian Prescriber article, “Dealing with Drug-Seeking Behaviour”
• ED Nurse: Nurse.com article, “Drug-Seeking Behavior is a Challenge for Any ED”

Opioid Use Disorder

Thinking of opioid use disorder as a long-term chronic medical condition like diabetes or cardiovascular disease can reorient the physician to a role as healer. Treatment of opioid use disorder may require referral to other medical, behavioral health, or community and recovery support services. Having a plan in place for assessing, treating, and referring patients with opioid use disorder can help reduce the stress associated with treating these patients.

Opioid Use Disorder Resources

• Centers for Disease Control and Prevention (CDC) training module, “Assessing and Addressing Opioid Use Disorder (OUD)”
• BMJ article, “Predicting Opioid Use Disorder in Patients with Chronic Pain Who Present to the Emergency Department”
• Substance Abuse and Mental Health Services Administration (SAMHSA), “TIP 63: Medications for Opioid Use Disorder”

Opioid Prescribing for Chronic Pain

Without a carefully crafted pain management plan, opioid therapy can be deadly for a patient with an opioid use disorder. Continued prescribing of opioids for a patient should be contingent on assessment and reassessment of the efficacy, risks and benefits of doing so. It is also important to understand and comply with state and federal laws and regulations that control opioid prescribing practices. Policies, protocols, clinical tools, and a clear understanding of the laws and regulations can make decision-making and management of a drug-seeking chronic pain patient easier.

ProAssurance Risk Management Resources on Opioid Prescribing for Chronic Pain

• Case Study: Reducing Opioid Overdose Risk in Patients with Opioid Use Disorder
• Case Study: Optimizing Opioid Therapy for Patients with Behavioral Health Disorders
• Case Study: Strategies for Tapering Patients off Long-Term Opioid Therapy
• Case Study: Pain Management vs. Treating the Underlying Causes of Pain
• Case Study: Increased Overdose Risk When Combining Opioids With Other Medications
• Case Study: Dismissing a Patient with Chronic Pain and Opioid Dependency Leads to Allegation of Abandonment
• Best Practices: Managing the Risks of Treating Chronic Pain with Opioids
• Best Practices: Decreasing Overdose Risk for New Patients on High-Dose Opioid Therapy for Chronic Pain

Additional Resources

• CDC, “Clinical Practice Guideline for Prescribing Opioids for Pain”
• Six Building Blocks, “Policy, Patient Agreement and Workflow”
• National Institute on Drug Abuse sample pain treatment contracts
• Pain Medicine article, “Universal Precautions Revisited: Managing the Inherited Pain Patient”
• Stanford Medicine course, “How to Taper Patients off of Chronic Opioid Therapy”

References

1. Steve A Hyman, et al. “Prevalence of Burnout and Its Relationship to Health Status and Social Support in More than 1000 Subspecialty Anesthesiologists.” Regional Anesthesia & Pain Medicine. 2021;46:381-387. DOI: 10.1136/rapm-2021-102530

2. Steven A. Adelman. “The Opioid Crisis and Physician Burnout: A Tale of Two Epidemics.” Harvard Health Blog. June 8, 2016.

3. Yu-Ping Chang, et al. “Management of Chronic Pain with Chronic Opioid Therapy in Patients with Substance Use Disorders.” Addiction Science & Clinical Practice, 2013, 8(1), 21.

4. J. Kimber Rotchford. “Opioids: Addiction or Physical Dependence?” Practical Pain Management, Updated on: May 13, 2019.

5. American Psychiatric Association. “Opioid Use Disorder.” Reviewed December 2022.