Modules

Mental health

Substance abuse disorders: The drug seeker

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

  • Physician: Hi, are you Elizabeth Tessier?

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

    Physician: May I call you Elizabeth?

    Patient: Yeah that’s fine?

    Physician: What seems to be going on?

    Patient: I’m in so much pain that I can hardly even get through a day let alone go to work.

    Physician: What kind of work do you do?

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

    Physician: Let’s find out a bit more about the pain and then we can talk about what we can do to help you.

    Patient: Okay as long as you give me something to get through this.

    Physician: Sure, sure, sure. First off could you show me where the pain is exactly?

    Patient: Yeah it’s right here.

    Physician: Okay, does it ever go anywhere else?

    Patient: Yeah it goes into my legs. It’s really exhausting.

    Physician: Okay, describe the pain for me please.

    Patient: It’s sharp, it’s stabbing, it’s unbearable look I already know all this stuff. It’s probably just sciatica from a pinched L4-L5, so what I need from you is Percocet.

    Physician: You’ve been taking Percocet for this?

    Patient: Yeah it’s the only thing that can take some of the pain away.

    Physician: How long you’ve been in this pain?

    Patient: 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. Look, I know what you’re thinking ok, but I’m a nurse and the only thing that can help get me through this is either some Percocet or Demerol that’s it.

    Physician: You’ve been taking Demerol as well?

    Patient: Yes. No, I mean I took a couple of them when my back pain first started but I couldn’t even function.

    Physician: Okay, I can clearly see that you’re in a lot of pain right now Elizabeth but I can’t possibly just prescribe a narcotic without knowing the full situation I think you know that.

    Patient: Okay but the full situation is I’m in a lot of pain. Right? I mean, I know there’s exceptions but I want to do the right thing but I’m just in so much pain.

    Physician: It seems very serious.

    Patient: It is. I mean, I can lose my job even if I miss another shift.

    Physician: Cranky. Okay, so… can I ask, how many on average of Percocet you take in a day?

    Patient: I don’t know like maybe six or eight but I’m in a lot of pain.

    Physician: Yeah but 8 a day, that’s a lot.

    Patient: I know.

    Physician: And who prescribe you those Percocet?

    Patient: The last time was in the emergency room. I want to do the right thing but I can sometimes barely even keep my head above water, sometimes I can’t even stand.

    Physician: And what do you mean by that? keeping your head above water?

    Patient: I don’t know. I mean, everything is just such a mess. I’m in pain and I can’t function and I’m broke, and…

    Physician: Okay, well clearly if I understand this correctly you seem to be going through a very, very difficult time right now Elizabeth. If you don’t mind my asking, do you happen to maybe drink alcohol on top of your Percocet sometimes?

    Patient: Oh my God, you’re just like the rest. Why doesn’t anybody want to help me? Why does no doctor want to help me?

    Physician: You’ve seen other doctors for this?

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

    Physician: I’m sorry that you’re going through a very difficult time right now.

    Patient: This is a very difficult time. I don’t understand how I can be in such pain and nobody wants to help me.

    Physician: Listen, I do want to help you Elizabeth but it’s not as easy as simply just prescribing you a prescription or narcotic.

    Patient: Yeah, right.

    Physician: Okay, so tell me something, when was the last time you had your full physical?

    Patient: I don’t know.

    Physician: So how about this, we’ll have you come back and we’ll run some tests.

    Patient: Don’t you think I’ve already done all the tests? like okay how about if you just give me a few, just to get me through my next shift and then I’ll come back and then we could talk about the test. I won’t tell anybody, I promise.

    Physician: Elizabeth, giving you Percocet is not going to help you long term.

    Patient: How about if you just give me just one.

    Physician: No. What I suggest is this, I’ll have you come back we’ll run some tests and do a full physical. If we have to talk about Percocet we’ll talk about that then.

    Patient: What am I supposed to do until then? You’re supposed to be the doctor.

    Physician: Listen until then what we can do is I’ll prescribe you for an anti-inflammatory that’s recommended for your back pain.

    Patient: Great, that’s it then, so you’re not going to help me at all. Thanks a lot.

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. 


 

Next: Substance abuse disorders: Alcohol

Continue