Modules

Mental health

Substance abuse disorders: The drug seeker

This interview takes place in an urgent care clinic in a downtown hospital.

  • Patient: Hi doctor, I am so glad to see you. My back is killing me.

    Physician: Oh, hi Elisabeth. Um, do you mind if I call you Elisabeth?

    Patient: No, that’s fine.

    Physician: So, what seems to be going on?

    Patient: Uh, I’m in so much pain that I can’t even get through a day, let alone get to work.

    Physician: Oh, okay. What kind of work do you do?

    Patient: I’m a homecare nurse, so I know what I need to get through this.

    Physician: Oh, okay. Well, let me find out a little bit more about the pain, and then we can talk about what we can do to help you.

    Patient: Yeah, fine, fine, fine. As long as you give me something to get through this.

    Physician: True. So, first of all can you point to exactly where the pain is?

    Patient: Yeah. It’s it’s right, it’s there. (points)

    Physician: Okay, and does it ever go anywhere else?

    Patient: Yeah, it goes into my legs and it’s just exhausting.

    Physician: Alright. And can you describe the pain for me?

    Patient: Oh, it’s sharp, it’s stabbing, it’s unbearable. Look, I know all this stuff. It’s probably sciatic from a pinched L4-5, so what I need from you is Percocet.

    Physician: Oh, so you’ve been taking Percocet for this?

    Patient: Yes. It’s the only thing that gets me through this.

    Physician: Okay, and how long have you had the pain?

    Patient: Oh, a long time.

    Physician: And do you have the pain every day?

    Patient: Are you listening to me? I need your help. Yes, I have the pain every day. (she sighs) I know what you’re thinking. Look, I’m a nurse but the only thing that can take some of this pain away is Percocet or Demerol. That’s it.

    Physician: So, you’ve been taking Demerol as well?

    Patient: Well, I … I took it when I first started getting this, but I couldn’t even function. I took it for a couple of days, and I couldn’t even function.

    Physician: Well I, I can tell that you are in a lot of pain right now …

    Patient: Yeah.

    Physician: … but, I can’t prescribe a narcotic unless I know the full situation. I think …

    Patient: The full … !

    Physician: I think you know that.

    Patient: The full situation is that I am in really bad pain. Look, I know, I know that, but I know that there are exceptions. Look, I’m at my wits end! I could lose my job if I miss any more work. I mean sometimes I can hardly even stand up!

    Physician: Alright, well it certainly sounds serious.

    Patient: Yeah.

    Physician: Can I ask you how many, how many Percocet you take on average a day?

    Patient: Oh I don’t know, uh, sometimes six or eight. You know, I’m in a lot of pain.

    Physician: Alright, but you know eight is a lot for one day.

    Patient: Yeah, I know.

    Physician: Uh, who prescribed the Percocet for you?

    Patient: Uh, the last one was in emergency. Look, I want to do the right thing, but sometimes I can hardly keep my head above water. I mean, I’m … I’m just in such pain.

    Physician: What do you mean by that: keep your head above water?

    Patient: Oh, everything is such a mess. I need, I’m in, I’m in such pain and I’m exhausted, I’m broke.

    Physician: Alright, well it sounds like you’re going through a very, very difficult time …

    Patient: Yeah. Yeah.

    Physician: … right now Elisabeth. Can I ask you, do you ever drink alcohol on top of the Percocet?

    Patient: Oh god, you’re just like all the rest. Isn’t anybody going to help me? Nobody, no doctor seems to want to help.

    Physician: Um, so you’ve been to other doctors for this?

    Patient: Yes, I’ve seen other doctors and they don’t believe me because if you believed me, you would do your job.

    Physician: Well, I’m sorry that you are having such a difficult time with this Elisabeth.

    Patient: (sighs) Well, I am having a hard time and I don’t understand why I can be in such pain, and nobody wants to help.

    Physician: Well, I do want to help you.

    (patient scoffs in disbelief)

    Physician: Unfortunately it’s, it’s a little more complicated than just giving you a prescription.

    Patient: Yeah right.

    Physician: Um, can you tell me when was your last full physical?

    Patient: I don’t know.

    Physician: Okay, well maybe what we can do is run some tests, have you come back and we’ll run some tests.

    Patient: Don’t you think that I have done all the tests? Look, why don’t you give me just a few, just so I can get through the next shift. Look, I won’t say anything, and then I promise that I’ll come back and we can talk about all the tests. I promise.

    Physician: Elisabeth, giving you Percocet in the long run is not going to help you.

    Patient: Look, why don’t you give me just one?

    Physician: How about we have you come back and we’ll do a full check-up …

    Patient: Uh …

    Physician: … and then we can discuss this then.

    Patient: Oh, what am I supposed to do until then? I mean you’re supposed to be the doctor.

    Physician: And in the meantime I can prescribe an anti-inflammatory that is recommended for back pain.

    Patient: Uh! Oh good. So, that’s it then. You’re not going to help. (patient snorts) Well, thanks!

Reflective exercise

Communication issues
Think about the interview between the physician and Elisabeth.

  • What techniques or styles does he employ to deal with her manipulative behaviour?
  • What techniques or styles does he employ to deal with her anger?
  • What evidence does he obtain that she is a drug abuser?
  • He remains in control of the interview. How does he do that?
  • What attitudes does the physician exhibit?
  • The patient leaves angry and unsatisfied. Has the physician given good professional care? Why or why not?
  • Is there any harm in giving her one pill?

Legal and ethical issues in narcotic prescription

Read the policy on narcotic prescription in your province or territory then answer the following, based on the scenario you watched:

The physician refuses to provide a prescription for Percocet.

    Select as many as apply.

Prescription drug abuse

The following is excerpted from the policy on Prescribing Drugs of the College of Physicians and Surgeons of Ontario but the broad concepts apply to other provinces and territories, each having a similar policy. Please check with your medical regulatory authority for more information.

Narcotics and controlled substances
Narcotics and controlled substances are important tools in the safe, effective and compassionate treatment of acute and chronic pain, mental illness and addiction. Physicians with the requisite knowledge and experience are advised to prescribe narcotics and controlled substances for these reasons, when clinically appropriate.

One of the risks when prescribing narcotics and controlled substances is the potential for prescription drug abuse. The non-medical use or abuse of prescription drugs is a serious and growing public health problem. Virtually any prescription drug can be consumed for reasons other than its medical purpose however, it is usually drugs with psychoactive properties (e.g., opioids) that are the focus of abuse. 

Physicians may be able to reduce or impede the diversion, misuse and/or abuse of narcotics and controlled substances by: carefully considering whether these drugs are the most appropriate choice for the patient; recognizing patients who may be double doctoring,  diverting, misusing or abusing prescription drugs; sharing information with others, as appropriate; instituting measures to prevent prescription pad theft or tampering; taking measures to prevent the theft of drugs from their offices; and educating patients.

The purpose of this section of the policy, along with the related guidelines, is to clarify for physicians their obligations when prescribing narcotics and controlled substances and their role in preventing and addressing prescription drug abuse. This policy does not attempt to curb the prescribing of narcotics and controlled substances for legitimate reasons (i.e., acute or chronic pain, mental illness or addiction), but does reinforce the requirement that physicians prescribe these drugs in an appropriate manner.

Considerations
In addition to complying with the general requirements set out for prescribing any drug and any applicable legislation, physicians must carefully consider whether the narcotic or controlled substance is the most appropriate choice for the patient, even if the patient has been prescribed these drugs in the past.  Special consideration is necessary given that narcotics and controlled substances are highly susceptible to diversion, misuse and/or abuse because of their psychoactive properties. These drugs are extremely harmful to patients and to society when they are diverted, misused and/or abused, so physicians must first consider whether an alternate treatment or drug is clinically appropriate. If there are no appropriate or reasonably available alternatives, physicians are advised to record this fact in the patient’s medical record. The benefits of prescribing narcotics and controlled substances must be weighed against their potential risks when used long-term.

Before prescribing

Physician-patient relationship
Physicians typically prescribe drugs within the context of a physician-patient relationship. In most cases, this means that an appropriate clinical assessment of the patient has been conducted, the physician has made a diagnosis or differential diagnosis and/or has a clinical indication based on the clinical assessment and other relevant information, and informed consent has been obtained.

Assessment
Before prescribing a drug, physicians must have current knowledge of the patient’s clinical status. This can only be accomplished through an appropriate clinical assessment of the patient. An assessment must include:

  • An appropriate patient history, including the most complete and accurate list possible of drugs the patient is taking and any previous adverse reactions to drugs. A physician may obtain and/or verify this information by checking previous records and databases, when available, to obtain prescription and/or other relevant medical information; and if necessary,
  • An appropriate physical examination and/or any other examinations or investigations.

Diagnosis
If physicians intend to prescribe a drug, they are required to make a diagnosis or differential diagnosis and/or have a clinical indication based on the clinical assessment and other relevant information. There must be a logical connection between the drug prescribed and the diagnosis or differential diagnosis and/or clinical indication.

Physicians must consider the risk/benefit ratio for prescribing that particular drug for that patient. In addition, physicians must consider the combined risk/benefit ratio when prescribing multiple drugs. If using technology to prescribe (e.g., Electronic Medical Record), clinical decision support tools may be helpful in assisting physicians to determine whether the drug(s) are appropriate for the patient.

Physicians are also required to consider the risk/benefit ratio when providing long-term prescriptions. The duration of the prescription must be balanced with the need to re-assess the patient and the potential harm that may result if the patient runs out of the medication. 


 

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