The “What I Wish I Knew” series of articles is a service of AAPP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.
Amy M. VandenBerg, PharmD, BCPP, FAAPP
Clinical Associate Professor
Clinical Pharmacy Specialist, Psychiatry & Neurology
University of Michigan Health System
Ann Arbor, MI
Dr. VandenBerg earned both a BS in Psychology and PharmD from University of Michigan. She completed PGY1 and PGY2 Psychiatry residencies at the Medical University of South Carolina (MUSC). From 2002 to 2016, she served many roles at MUSC and worked closely with Emergency Psychiatry Services as well as the inpatient substance use disorder service and led weekly medication education groups for patients with co-occurring substance use, pain and psychiatric disorders. Currently, Dr. VandenBerg is a Clinical Specialist in Psychiatry (general adult, addictions consult, psychiatry consult and emergency psychiatry) and Neurology, PGY2 Psychiatric Pharmacy RPD at Michigan Medicine and Clinical Associate Professor at UM College of Pharmacy.
How do you safely treat patients who may need pharmacotherapy but may be labeled as “drug seeking?”
It has been my practice to avoid use of the term ‘drug-seeking behavior’ because it is generally used in a negative manner, often in the context of provider frustration. My concern with utilizing the term casually is that we miss the opportunity to have a positive intervention on behalf of the patient if we discount their needs. There are three key questions to ask when concern for ‘drug seeking’ arises.
First, what does the patient history tell us. All patients with chronic use of benzodiazepines or opioids, whether prescribed or not, will develop a degree of physical dependence and may be fearful of reducing doses or stopping due to risk of or history of withdrawal symptoms. Patient interviews should attempt to obtain a thorough history of use and an assessment for current or past withdrawal symptoms with assurance that the information will be used to help optimize treatment. Patients sometimes worry that reporting use or misuse will have consequences ranging from lack of treatment to legal ramifications. With informed consent from the patient, urine drug screens may help clarify what substances a patient has been using recently and be used to validate patient self-reported use. Many substances (eg, some benzodiazepines, synthetic opioids) are not detected by standard screens. Substance use history should not automatically discount current medication requests as ‘drug seeking’.
Second, does the patient have an indication for the requested medication? History of substance use and medical indication for controlled substances are not mutually exclusive. The patient should be objectively evaluated, without judgment, for medical need regardless of history of substance use. When acute symptoms may benefit from medication treatment with controlled substances (eg, opioids for acute injury or benzodiazepines for acute anxiety exacerbation), it is important to set expectations from the start. These may include duration of treatment, dose limits, and participation in concurrent non-pharmacologic interventions (eg, stress management, deep breathing, mindfulness, exercise, stretching, physical therapy).
Finally, what is the rationale for treatment change or restricting access to controlled substances? Has this patient used controlled substances chronically? Are we decreasing doses or discontinuing medications for an alternative therapeutic approach or because of acute risk of harm to patient? If substances are abruptly discontinued or tapered too quickly, the patient may experience withdrawal, rebound anxiety or hyperalgesia. Patients must be included in the decision-making process and be aware of the rationale for treatment change and the risks and benefits of continuing or changing treatment.
What are some objective ways to assess for potentially inappropriate controlled substance requests?
Objectivity can be difficult because patients are typically requesting medications for subjective symptoms of pain and anxiety which have great inter-patient variability in outward presentation. A nurse may report “patient requested lorazepam for anxiety but didn’t look anxious at all.” It is important to consider psychiatric symptoms of anxiety as well as somatic symptoms. A patient does not have to be flushed, diaphoretic, and tremulous to be anxious nor writhing in bed to have significant pain.
When possible, observe patients in a variety of settings and/or obtain input from family. How do they behave when not interacting with health professionals? This can be easier to implement in inpatient settings. Is the patient interactive and gregarious with peers, but endorsing incapacitating anxiety to the provider and requesting PRNs for anxiety throughout the day? Is the patient reporting a pain of 10 and wincing in the presence of the provider, but behaving differently throughout the day with no restriction in activity?
A thorough initial assessment when working with a patient who has a history of anxiety or pain can go a long way in objectively assessing symptoms as well as expectations for treatment. How does this patient experience anxiety? How do they usually try to alleviate anxiety? For pain, it is important to obtain a description of the quality of pain. Is it musculoskeletal, visceral, or neuropathic in nature? What non-pharmacologic interventions have they tried? How do symptoms impact daily activities? Is anxiety/pain impairing their ability to work, engage in social activities or function within their family?
A concern separate from patient misuse or substance use disorder is diversion. When medication utilization is inconsistent with patient history it may be time to consider diversion. Is the patient receiving larger quantities than you would expect for the underlying condition? Does the urine drug screen vary from reported use? Based on controlled substance prescription database, is the patient using more than one prescriber and more than one pharmacy? Whether diversion or over-use is a concern, clear expectations should be provided to the patient such as, only one provider will prescribe a controlled substance and prescription database monitoring will be utilized to assess for other prescribers. If discontinuation is indicated based on concerns for misuse, it is best to taper to avoid acute withdrawal. Keep in mind, patients may see more than one provider within a medical practice, especially those with medical residents.
What are some tips for communicating concerns about potentially inappropriate controlled substance use to the patient and their providers?
Patient education is key. Reduction/restriction of controlled substances is most often based on concerns for patient safety. Clearly informing patients of risks and potential benefits of alternatives is a key starting point.
For anxiety – Be sure to review non-pharmacologic approaches and enforce that, like any skill, they must be practiced when patients are feeling well to be most effective in crisis. Explain, in patient-friendly terms, why the current treatment is not ideal – specifically for the individual. I often use lightbulb analogies for patients. Anxiety is like a light on a dimmer switch. Benzodiazepines turn the dimmer all the way down, but after a few hours the dimmer changes directions and the anxiety comes back. With chronic use, rebound anxiety can become more severe (analogy: brighter lightbulb). Antidepressants work to very slowly dim the light of anxiety. The effects are so slow that you don’t notice day to day but rather have to wait weeks to months to notice. Medications like gabapentin, pregabalin and hydroxyzine, have more rapid effect than antidepressants, but they only partially dim the anxiety rather than completely shut it off like benzodiazepines. There is much less rebound anxiety with chronic use of these agents, although they still should be tapered off rather than abruptly discontinued. With this description of medication effects, I have actually had patients previously labeled as “drug-seeking” ask the team to change their long-term benzodiazepine to an alternative agent.
For pain - Determine source and nature of pain. Explain the mechanism of opioids and the impact on chronic pain (blocking recognition of pain does not alter the source of pain and may lead to hyperalgesia over time). The lamp analogy works for pain as well. Discuss optimal treatment options based on source of pain (eg, gabapentin, antidepressants for neuropathic pain; acetaminophen +/- nonsteroidal anti-inflammatory agents for chronic musculoskeletal and joint pain; exercise/physical therapy for musculoskeletal pain).
Communication between providers must be as objective as possible. I have been on both sides of this recommendation – on the one hand suggesting that patient has an objective source of pain (recent surgery) which warrants temporary opioid pain management and on the other hand, recommending taper of opioids in patient with significant substance use history and rebound migraines worsened by opioids.