Navigation

Ultram Drug Information

Abuse of prescription medications may account for as much as one third of the US drug problem. The primary care clinician may be called on to differentiate between a patient with undertreated pain and one who is attempting to divert prescription medications. This article can help health care providers identify drug-seeking patients, address their medical issues appropriately, uncover any ulterior motives--and avoid becoming part of the problem.

**********

According to estimates from the US Drug Enforcement Administration (DEA), prescription medication abuse accounts for nearly 30% of the drug problem in the nation. (1) In 1999, an estimated 4 million people (about 2% of those 12 and older) were using prescription drugs nonmedically each month (2); this outnumbers users of heroin, crack, and cocaine combined. (3,4)

Addiction disorders affect 20% to 50% of hospitalized patients, 15% to 30% of patients in primary care settings, and as many as 50% of patients with psychiatric illness--yet most remain undiagnosed and untreated. (4) Some 72% of persons with an addiction disorder are believed to have a concomitant psychiatric disorder. (5)

Pain management is the reason people are most likely to seek medical attention (2); health care professionals must balance the concern of under-treated pain with that of a growing drug-seeking population. (6) Providers' compassion often makes them susceptible targets for drug diversion. This article is intended to increase clinicians' understanding regarding chemical dependence and certain patients' "abnormal relationships with scheduled drugs" (6) (see "Controlled Substances" (7,8)).

The risk of addiction or abuse appears low when medication is used appropriately. (2) To support correct use, medical providers must commonly described relationships patients have with their prescription medications (see "Defining the Problem," (9) page 55).

It is up to the medical provider to differentiate between patients with undermanaged pain and those with ulterior motives. Unfortunately, many clinicians compound the problem of medication misuse by overprescribing--possibly assuming one of the roles that the American Medical Association describes as "the four Ds" of overprescribing (4,6,9) (see page 56). Parran (6) urges practitioners to prescribe short therapeutic regimens, refuse to prescribe if pushed, and document prescribing patterns carefully on the patient chart.

PATTERNS OF PRESCRIPTION DRUG ABUSE

Prescription agents are becoming the drugs of choice because they have simple characteristics and properties, with dosing that is regulated and predictable. They cost less than other addictive substances and are more easily obtained.

Hydrocodone (Vicodin[R], Lortab[R], etc), a schedule II antitussive and analgesic, is currently the most widely abused prescription medication in the US. (10) Emergency department (ED) visits for its misuse have increased 500% since 1990. (2,11) Also listed by the DEA among "drugs and chemicals of concern" is the schedule II analgesic oxycodone (Percodan[R], Oxy-Contin[R]). Oxycodone-related ED visits tripled from 1996 to 2000. (11)

Other potentially addictive medications (ranging from muscle relaxers to OTC cough remedies) are not specifically regulated. For example, the muscle relaxer carisoprodol (Soma[R]) contains an active metabolite of meprobamate, a schedule IV controlled substance. (12) Taken with alcohol, carisoprodol produces a stuporous state referred to in many EDs as "Soma coma." Similarly, tramadol (Ultram[R]) is a nonscheduled pain medication with some potential for triggering a euphoric state. (13)

Dextromethorphan, a cough suppressant found in most OTC cough syrups, produces a euphoric state when taken in large quantities and can produce visual hallucinations. (11)

Most drug abusers are polysubstance abusers. An estimated 80% of benzodiazepine abuse occurs in conjunction with other drug abuse--usually opioids and/or alcohol. (5)

It should be noted that name recognition makes trade name prescription drugs more attractive than their generic equivalents. (9) Medications in capsules are also desirable because they can be altered easily.

PATIENT CONFIDENTIALITY

How do patient confidentiality regulations apply to the alleged drug seeker? Health care professionals have the right to consult with other providers (including physicians, PAs, NPs and other nurses, providers of emergency medicine, pharmacists, and dentists) regarding the patient's current visit, complaint, of treatment. (14,15) However, the provider may not call another health care professional's office or an ED to warn staff that a patient may be seeking drugs. This could create bias in the examiner or cause treatment to be altered. By making such calls, providers may place themselves and their facility at risk for legal action, according to the Health Insurance Portability and Accountability Act (HIPAA) and the Emergency Medical Treatment and Active Labor Act (EMTALA). (14,15)

RECOGNIZING THE DRUG SEEKER

Drug seekers often give away their intent, and most are poor actors whose scripts read much the same. An index of suspicion is the best starting point. If something in the patient's history or physical examination does not "feel" right, it probably isn't. The clinician must be attentive to objective findings in the examination that do not match the subjective history.

Emphasis on a specific medication is a potential red flag: The patient may request it by name before the examination, describe it as the only effective treatment (going so far as to argue pathology with the provider), or claim that it is the only choice to which the patient is not allergic. The drug seeker may claim to have developed a tolerance to the medication and to need increased dosing. He or she may intentionally mispronounce the medication's name to appear innocent.

The drug-seeking patient may bring along a friend to validate the history and confirm the patient's distress. Even an infant or a grandparent may be used to make the story more believable.

Attempts to "dupe" can manifest as scams, sympathy seeking, aggression, or outright stealing. Scamming may take the form of a "doctor shopper"--a patient who sees multiple practitioners to obtain adequate supplies of a controlled medication. Doctor shoppers often present to the ED or urgent care clinic after hours with a fictitious scenario, such as rotted teeth, old war wounds, or lower back pain; being from out of town or recently moved to the area; lost, stolen, of ruined prescriptions; or complex insurance problems. (4,6,9,16)

Sympathy is a ploy often used by patients with a history of a significant medical condition who have developed an addiction to their medication. In theatrical fashion, they give a current history fraught with social and subjective terms rather then objective medical facts. One might complain, "I ran out of my pain medication early because my grandmother has cancer and I gave her some," and another might claim, "I have such terrible back pain that I cannot take care of my children."

Some drug seekers are overly friendly, striving to win over the prescriber. Others may become noisy, aggressive, or disruptive, hoping the practitioner will do "whatever it takes to get them out." Those who are refused may curse and slander the office and staff in a last-ditch effort to wear down the provider.

The drug-seeking patient may resort to theft. Clinicians should carefully guard prescription pads, name stamps, and DEA numbers--all highly prized items for the patient who is willing to bypass the system altogether. Drug seekers will use the phone and masquerade as pharmacists, insurance agents, or health claims adjusters to obtain a prescriber's DEA number--or a prescription. (9,16)

The drug seeker's relationship with the medication is clearly much more important than that with the provider. (9) Thus, even when the patient steals, providers must remember not to take drug-seeking behaviors personally.

THE CONFRONTATION

Once the drug seeker has been identified, the greatest obstacle for the clinician is to confront him or her. It must be made clear that no means no. (9) The clinician who gives in to pressure once can count on reliving the scene many times.

At the outset, the patient has all the information, and the provider has little. To regain the advantage, the practitioner must obtain information that either verifies or nullifies the patient's history. Interactions can then be based on facts. Of the many ways to get this information, all take some legwork, but the clinician's decreased anxiety and the potential benefit to the patient are worth it.

The obvious first step is to obtain previous records. If the patient is being seen in an ED or outpatient setting where records are not readily available, ask the patient to sign a consent for nearby facilities to release his/her records, even those where the patient denies having been seen. Explain that you do not feel comfortable prescribing medication without consent to review the patient's records. Often, a person involved in a scam will simply disappear.

Think of the local pharmacist, who is equally responsible for prescriptions filled for any controlled substance, as an ally. With a signed release in hand, call and request a search for recent medications that were prescribed and who filled them. Many pharmacies have national databases to track this information: Call even if the patient claims to be from out of town.

What to Ask the Patient

Three questions asked during the history and physical examination can be useful in determining the legitimacy of a patient's complaint:

* When was the last time you were seen for this condition?

* When was the last time you were seen by any health care provider (including EDs, minor emergency centers, clinics)?

* What was the last medication, including narcotic prescriptions, that you had filled? Where? When?

Document answers in the medical record. Compare them with information you obtain from local phone calls and the review of records. Most likely, discrepancies will reveal a drug-seeking patient. Present any to the patient and ask why they were dishonest. Explain that, since you have lost trust in them, you cannot prescribe any medication with the potential for addiction; rather than refuse to treat them, offer an alternative.

Do not be afraid to ask: Do you think you may have an addiction? Many patients will admit to the problem; others will simply leave. It has been suggested that most drug-seeking patients have an underlying medical issue--if not addictive disease, possibly undertreated pain of a psychiatric disorder. (17) Thus, it is important to consider these possibilities. If addictive disease is apparent, offer to refer the patient to a treatment center.

Drug seekers will sometimes continue the charade, despite the evidence. The next step is to ask whether they would consent to a drug screening; drug seekers may refuse and leave. Otherwise, if results support the patient, the prescriber should feel free to prescribe the scheduled medication. If not, the clinician has the option to inform the DEA or the local prosecutor. (The right to do so must be stated on the consent form.)

CONCLUSION

The health care provider must make every effort to distinguish between a patient with legitimate pain and one who is attempting to divert prescription drugs. If it appears that a scheduled medication is required to manage a patient's condition, the clinician should prescribe it without suspecting abuse or addiction. If not, other options and management plans should be considered.

REFERENCES

(1.) Burke J. Scope of the problem. Available at: www.rxdiversion.com/scope.htm. Accessed January 7, 2004.

(2.) National Institute on Drug Abuse, National Institutes of Health. Pain medications and other prescription drugs. NIDA Infofax 13553. Available at: www.medhelp.org/NIHlib/GF-432.html. Accessed January 7, 2004.

(3.) National Drug Strategy Network. Prescription drug abuse rivals illicit drug abuse, some see double standard in law enforcement. NewsBriefs. October 1996. Available at: www.ndsn.org/oct96/prescrip.html. Accessed January 7, 2004.

(4.) American Medical Association. Balancing the response to prescription drug abuse: report of a national symposium on medicine and public policy: Chicago: American Medical Association, Department of Substance Abuse; 1990.

(5.) Brady KT. Comorbidity of substance use and Axis I psychiatric disorders. Medscape Psychiatry & Mental Health eJournal. 1998:3(4). Available at: www.medscape.com/viewarticle/430610. Accessed January 7, 2004.

(6.) Parran T Jr. Prescription drug abuse: a question of balance. Med Clin North Am. 1997;81:967-978.

(7.) Drug Enforcement Administration, US Department of Justice. The diversion of drugs and chemicals: a descriptive report of the program and activities of the DEA's Office of Diversion Control. Washington, DC: US Department of Justice, DEA; 1996.

(8.) US Department of Justice. Controlled Substance Act of 1971. Washington DC: US Government Printing Office; 1971.

(9.) Longo LP, Parran T Jr, Johnson B, Kinsey W. Addiction: part II: identification and management of the drug-seeking patient Am Fam Physician. 2000;61:2401-2408.

(10.) Mitka M. Abuse of prescription drugs: is a patient ailing or addicted? JAMA. 2000;283:1126, 1129.

(11.) Drug Enforcement Administration, US Department of Justice. Drugs and chemicals of concern. Available at: www.deadiversion.usdoj.gov/drugs_concern/index.html. Accessed January 7, 2004.

(12.) Reeves RR, Carter OS, Pinkofsky HB, et al. Carisoprodol (Soma): abuse potential and physician unawareness. J Addict Dis. 1999:18:51-56.

(13.) Medical Economics Staff, ed. Physicians' Desk Reference 2003. 57th ed. Montvale, NJ: Medical Economics. 2002.

(14.) US Department of Health and Human Services. OCR [Office for Civil Rights] privacy brief: summary of the HIPAA [Health Insurance Portability and Accountability Act] privacy rule. Last revised May 2003.

(15.) Thorne JL. EMTALA: the basic requirements, recent court interpretations, and more HCFA regulations to come. EM Topics. Available at: www.aaem.org/emtala/watch.shtml. Accessed January 7, 2004.

(16.) Gitchel GT. Existing methods to identify retail drug diversion. In: Cooper JR, Czechowicz D J, Molinari SP, Petersen RC, eds. Impact of Prescription Drug Diversion Control Systems on Medical Practice and Patient Care. National Institute on Drug Abuse Research Monograph 131. NIH Publication 93-3507; 1993:132-140.

(17.) Yarborough WH. Drug seeking behavior--a differential approach. J Okla State Med Assoc. 2000;93:242-244.

Controlled Substances (7,8)

The word narcotic was established as a legal term by the 1914 Harrison Narcotic Act, (7) the first law ever passed to attempt to regulate habit-forming substances. In 1971 this legislation was superceded by the Controlled Substance Act, (8) which categorized addictive substances according to their use and potential for abuse. Medications in each of these schedules are governed by specific prescribing regulations. Schedule I drugs have the greatest potential for abuse (and no current medicinal use); schedule V drugs have the least risk. The controlled substance schedules can be reviewed at:

www.deadiversion.usdoj.gov

Defining the Problem (9)

Abuse: The use of medication in a manner other than that for which it was prescribed. This may include recreational use or changing dosing or route of administration. Misuse usually results in adverse consequences.

Addiction: An advanced state of abuse, but more than "just a lot of use." The person loses control and develops obsessive-compulsive patterns regarding the addiction. Increased use may lead to tolerance, withdrawal, or sensitization, and often produces cognitive changes.

Dependence: A physiologic process, often related to dosing, timing, and potency, which may lead to tolerance and/or withdrawal. Physiologic dependence is not necessarily addiction.

Data extracted from Longo et al. Am Fam Physician. 2000. (9)

"The Four Ds" of Overprescribing (4,6,9)

Dated. These providers do not remain current regarding new pharmacology, treatment options, and the differential diagnosis and management of pain, anxiety, insomnia, and addiction disorders. They lack confidence in their prescribing skills.

Duped. These caring medical providers share mutual trust and respect with their patients (as they should, ordinarily). Drug seekers often manipulate these well-meaning practitioners.

Dishonest. These providers knowingly prescribe addictive medications to addicted patients for financial gain. They should be reported to local law enforcement agencies or state medical boards for appropriate investigation.

Disabled. These providers have either a medical or a psychiatric problem (eg, chemical dependency, a personality disorder), making them insufficiently attentive to their prescribing habits and reluctant to confront substance-abusing patients.

Data extracted from American Medical Association, Department of Substance Abuse. 1990 (4); Parran. Med Clin North Am. 1997 (6); and Longo et al. Am Fam Physician. 2000. (9)

F.Y.I.

Blame the Black Widow

Novel ways of securing narcotics for severe pain were reported by a Louisville poison center in 2002. One patient presented to seven different health care facilities on eight occasions. claiming to have been bitten by a black widow spider; another, to four different facilities for seven copperhead snake bites.

A third patient was refused pain medication when he said he had been bitten by a lionfish--but could show no physical signs to corroborate his story.

Source: Spiller HA, Schultz OE. Envenomations as a novel drug-seeking method. Ver Hum Toxicol. 2002:44:297-298.

Michael S. Roscoe is a PA in the Emergency Department at Community Hospital of Anderson, Indiana, and is on the faculty of the Butler University/Clarian Health PA Program in Indianapolis.

COPYRIGHT 2004 Clinicians Publishing Group
COPYRIGHT 2004 Gale Group