One of the greatest challenges in treating chronic pain is assessing for and monitoring potential overuse of prescribed medications. Most patients complaining of pain are seeking relief from disabling or unbearable discomfort. Some drug-seeking behavior may be a result of under treatment of pain, which should be addressed through an improved pain management plan¹.

However, some individuals will seek drugs to cope with addictions or provide an illicit income from the sale of controlled medications. The National Institute on Drug Abuse reports that over 46.6% of primary care physicians report difficulty discussing the misuse of prescription drugs with patients, yet physicians are in a unique position to identify and address prescription overuse².

Cigna uses pharmacy claim data to identify patterns of narcotic medication use that may require evaluation. One program identifies those receiving medication from multiple providers and filling medication through numerous pharmacies. If you are notified of a patient with such a pattern, we hope it will assist you in intervening as appropriate.

Before prescribing opioid medications to chronic pain patients, it is advised to assess the patient for potential overuse. Assessment includes an evaluation of individual risk factors, such as a personal history of substance use and/or a family history of substance use. Screening tools such as the AUDIT can be used to evaluate addiction in patients³. The assessment of addictive potential should include an evaluation of alcohol, drugs, food, sex, gambling, and spending money. Demonstration of potential addictive behavior does not eliminate the use of narcotics in pain patients, but if used does require close monitoring.

In addition, aberrant behaviors such as increased use, seeking euphoria from opiates, requests for early refills, concurrent use of alcohol, and prescription forgery are associated with drug use³. Three common characteristics observed in the drug-seeking patient are escalated use, doctor shopping, and “scamming”⁴. Escalated use is noticed when the patient is continually running out of drugs before the scheduled follow-up appointment. Or the patient frequently reports losing medications. Doctor shopping may first be identified by the pharmacy or healthcare plan. Patients may make frequent visits to emergency rooms or obtain prescriptions for the same drug from multiple providers. Scamming techniques to procure additional medications may include forging prescriptions, using the prescriptions of others, feigning illness, and requesting a specific controlled substance¹.

Differences Between a Chronic Pain Patient and an Addicted Patient⁵

Chronic Pain	Addicted Patients
1. Not out of control with medications	1. Repeated request for higher doses or more frequent prescriptions
2. Medications improve quality of life	2. Medications cause decreased quality of life
3. Will want to decrease medications if side effects are present	3. Medication continues or increases despite side effects
4. Concern about the physical problem and active in using other forms of treatment	4. Unaware or in denial about problems and singularly focused on drug therapy
5. Follows the agreement for the use of opioids	5. Does not follow the agreement for use of the opioids
6. May have medication left over or request for refills are consistent with schedule.	6. Does not have medicines left over, loses prescriptions, and always has a “story”

Management Tips

Healthcare practitioners can use several strategies to manage the interactions with the drug seeking patient.

1. Contact past providers and pharmacies to confirm the information provided by each new patient. Continue communication and coordination with pharmacies and other providers involved in the patient’s care throughout treatment.
2. Educate patients carefully about their medication including expected effects, dosing schedule, and the potentially addictive properties¹.
3. Use a pain control contract to outline treatment goals and verify the patient’s understanding of the risks, benefits and personal expectations of drug therapy.
4. Schedule regular follow-up office visits to monitor the effectiveness of the treatment regimen and screen for behaviors that may suggest drug use. Write prescriptions for the exact amount needed until the next visit.¹
5. Avoid renewing prescriptions by phone. Be cautious of calls requesting refills after business hours and on weekends.
6. Consider asking patients to bring all medications to each appointment in their pharmacy bottles for a periodic review and pill count.¹
7. Use periodic urine toxicology screens to evaluate treatment compliance.
8. Be clear about the grounds for discontinuing therapy.
9. Use a multidisciplinary treatment approach involving a behavioral health professional for managing substance use in the chronic pain patient.

footnotes

¹ Gerhardt, A.M. (2004). Identifying the drug seeker: The advanced practice nurse’s role in managing prescription drug abuse. Journal of the American Academy of Nurse Practitioner, 16(6), 239-243.
² National Institute on Drug Abuse. (2001). Prescription drugs: Abuse and addiction (NIH Publication No. 01-4881). Washington, DC: U.S. Government Printing Office.
³ Webster, L.R. (2004). Assessing abuse potential in pain patients. Medscape Neurology & Neurosurgery, 6(1). http://www.medscape.com/viewarticle/471663.
⁴ Longo, L.P., Parran, T., Johnson, B., & Kinsey, W. (2000). Addiction: Part II. Identification and management of the drug-seeking patient. American Family Physician, 61, 2401-2408.
⁵ Schnoll, S.H., Finch, J. (1994). Medical education for pain and addiction: Making progress toward answering a need. Journal of Law, Medicine & Ethics, 22(3): 252-256.