Every day in this country more than 130 people die from an opioid overdose. Sadly, that number continues to rise each year. According to the American Society of Addiction Medicine (ASAM), prescription painkillers are a major contributor to heroin addiction. In fact, four in five new heroin users start out by misusing prescription painkillers. Heroin, like prescription opioid drugs, is highly addictive, with the result that nearly one in four heroin users will develop an addiction to the illicit drug, the same ASAM report noted.
What do these statistics about prescription painkiller addiction mean for doctors?
The fact that prescription painkillers are the leading cause of drug overdose in this country and the most common and direct route to heroin addiction is striking for at least two reasons:
1. Prescription drugs from hospitals and doctors offices are a major contributor to the opiate epidemic
The deadly opiate epidemic has become a national public health crisis in this country largely due to prescriptions from hospitals and doctors’ offices. Pharmaceutical companies fueled the problem by falsely marketing and downplaying the addictive potential of these opioid pain medication. They convinced doctors that these drugs were safe for acute and chronic pain. Consequently, for millions of unknowing patients, the introduction to these potent medications became a eureka moment of sorts: the final solution to not just physical pain but the psychological and emotional dimensions of that pain as well.
2. Doctors can play an important role in addressing prescription drug addiction
We as doctors play an important role in more adequately addressing the human tragedy of addiction. More specifically, there are concrete things that we as doctors can do to protect patients who may be vulnerable to prescription drug addictions of any kind— not just opioid use disorders.
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Protecting patients from prescription drug abuse: Signs that doctors can look for
How, then, can doctors help to protect their patients from prescription drug abuse? One of the most important things you can do is to be familiar with the various “drug-seeking behaviors” that can occur in patients with a developing prescription drug problem. In that way, you can intervene if and when you see these behaviors occurring. When you know what signs of addiction to look for, you can address these behaviors with authority, compassion and your patients’ best interests in mind.
What Is “drug-seeking behavior”?
By using the term “drug-seeking behavior,” I want to be careful not to further compound the already pervasive stigma around the disease of addiction. “Drug-seeking behavior” is merely a hallmark feature of the disease of addiction which is widely understood today as a chronic brain disease. What that means is that someone with an addiction may display certain compulsive or “drug-seeking” behaviors that are symptomatic of that underlying chronic brain disease.
In these cases, as in any other, doctors have an obligation to uphold the Hippocratic Oath: to help and not hurt these patients. Our #1 priority is therefore not to police drug-seeking behaviors, but rather to identify, care for and treat the people who exhibit these behaviors. We must always keep in mind that we have a duty to our patients and also to the general public.
Drug-seeking behaviors to watch for when working with patients
With that overriding imperative as a backdrop, here are eight drug-seeking behaviors to watch for when caring for patients who have a prescription for any controlled substance, not just opioid medications:
1. Escalated use of a controlled prescription
If you’re prescribing a med for anxiety and notice that every time you see the patient, they say that the prescribed dose no longer works, that is an example of escalated use that may indicate more than just drug tolerance. Cases of escalated use can be quite common. When they occur, I address the issue, explain how it can harm the patient and then discuss other alternatives.
2. Increasing the dose without speaking to you
If you prescribed a certain dose and the patient doubles it without consulting you, that patient is engaging in a similar form of escalating drug use.
3. Using a prescribed medication to self-medicate for another condition
This sort of scenario can also be very common. Say, for example, I prescribe a pain med for someone and they start using it for sleep, anxiety or stress. That’s a big thing because those other symptoms might be signs of withdrawal and/or they may be developing a psychological and physical dependence on the drug.
4. Self-reported use of illicit drugs
When a patient is using illicit drugs, this, too, qualifies as drug-seeking behavior that can be a risk factor for addiction. If a patient opens up to you saying they smoke marijuana on the weekends, and meanwhile they have a prescription for Xanax, that is a red flag. In instances where you suspect that a patient is using illicit drugs or a drug test confirms it, the important thing is to have a relationship with the patient, so that they are more likely to trust you when you make treatment recommendations.
5. Insisting on only one particular pain/controlled medication
Patients with an addiction to an opioid such as Percocet or to other controlled medications may specifically ask for their one “drug of choice” when you’re suggesting another prescription. Someone with an addiction to Percocet, for example, may become very stirred-up at the prospect of being prescribed another non-habit-forming pain relief option. They may insist that they have allergies to other drugs and that only Percocet works for them. Or, they may start acting erratically if they don’t get the medication they requested.
6. Reporting symptoms that could be signs of withdrawal
A patient may report that they are experiencing new symptoms, such as insomnia, diarrhea, or headaches, which could be an indication of drug withdrawal. If they are in fact having withdrawal symptoms, this could mean they are already misusing their prescription or are at risk of doing so in an effort to self-medicate withdrawal symptoms.
7. “Doctor shopping” and or being dishonest about it
Doctor shopping is an obvious red flag. In our practice, we always check the state of Florida’s eForcse system when prescribing. This lets us know whether a patient may be seeing other doctors who are prescribing them the same controlled substance. If a patient is being treated for pain, they should only be seeing one doctor. With the help of eForcse, we are able to identify patients who have an addiction and their options for outpatient or inpatient treatment.
In more extreme cases, we have come across patients who are doctor shopping and who have lied to us about the fact that they’ve seen five other doctors in the last week or month. My job is to care for this person, so I tell them, “I can’t prescribe this for you and I’m concerned for you. This is a sign of potential addiction and I want you to know how harmful this is.” The best approach here is to be firm and show compassion, recognizing that any drug-seeking behavior is a manifestation of a treatable brain disorder.
8. Forging prescriptions
An even more extreme drug-seeking behavior that I’ve had to deal with has involved a patient actually forging a doctor’s prescription. In one particular instance that comes to mind, when I realized that a patient had forged another doctor’s prescription, I had to alert that doctor. In such cases, we also had to alert law enforcement, because forging prescriptions is also illegal.
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How to intervene when you notice these drug-seeking behaviors
Doctor shopping and forging prescriptions are obvious signs of addiction. However, some of the other drug-seeking behaviors listed above can be harder to spot. If you notice that a patient you’re treating is displaying at least two or three of the behaviors on this list, then it is time to have a gentle but direct conversation with the patient:
- Address the behaviors you’re observing.
- Explain your concerns as well as the nature of addiction and its dangers.
- Discuss and prescribe safer medication options.
- Invite the patient to consider whether they need inpatient or outpatient treatment. You may also choose to take a more prescriptive approach, by referring the patient to an addiction treatment program.
Yes, prescription drug addiction is a public health crisis of epic proportions, but we can help to stop it. The way we do it is by truly caring for one patient at a time.
Ahmed Howeedy, MD
Dr. Ahmed Howeedy is Chief Medical Officer at FHE Health, a Florida-based behavioral health provider. Dr. Howeedy completed his undergraduate studies in Microbiology and Immunology at the University of Miami as an Honors Cum Laude Graduate. He went on to obtain his medical degree from the University of South Florida in Tampa as a USF College of Medicine Scholarship Recipient, and inducted into the College of Medicine Gold Humanism Honor Society. Dr. Howeedy pursued his Family Medicine training in Michigan, and served as a Clinical Resident Instructor with the College of Human Medicine at MSU.
He currently trains and supervises many Nurse Practitioners and Physician Assistants in the area, as he has a love and passion for teaching.
Dr. Howeedy is a member of the American Medical Association, Florida Medical Association, American Academy of Family Practitioners, American College of Occupational and Environmental Medicine, American Academy of Anti-Aging Medicine, and the American Society of Addiction Medicine.
Since joining FHEM in October of 2015, Dr. Howeedy's focus has been implementing a Collaborative Care Model here at FHEM that integrates Medicine and Behavioral Health, from the time when the patient is admitted, through outpatient treatment, and ensuring continuity of care as they transition back into the community.