Recognizing Drug Seeking Behaviors

1. Recognizing Drug Seeking Behaviors Meaghan Johnson SN

2. Objective • To enhance the nurses ability to identify and respond professionally to drug seeking patients.

3. What’s the Problem? • In 2010 the DEA reported more than one in forty five Americans abuse prescription drugs. • A federal report released last December showed that Maine has the highest rate of prescription drug abuse in the nation. • Pharmaceutical over dose deaths in Maine outnumber motor vehicle deaths. • More than 500 babies have suffered opiate withdrawal at birth in the last year.

4. Understanding Addiction • Addiction : A chronic, relapsing, yet treatable disease that is characterized by both denial and compulsivity in a constant search for the psychological effects of mood-altering substances. • One of the surest signs of addiction is lack of improvement or worsening in psychological well-being ,despite the best pain control attempts. • Addicts sometimes use medications prescribed to them in ways to intensify their effects, such as taking them on an empty stomach, with alcohol or other drugs, or at dosages or frequencies exceeding what was prescribed. Consequently, addicts often run out of medication before expected

5. Understanding Addiction • Pseudo addiction is a behavioral manifestation of inadequate pain control. • Unrelieved pain can cause so much anxiety and distress that some patients develop the mindset of an addict. • They try to procure more medications as a result of unrelieved pain or in anticipation or fear of running out of analgesics. • The resulting drug-seeking behavior may lead healthcare personnel to inappropriately identify these patients as addicts. It is important to remember that pain management is the most common force driving patients to seek prescription medications

6. Understanding Addiction • Tolerance is the need for an increased drug dosage to produce the same effect or level of previously experienced analgesia. • Recent research indicates that opioid tolerance may induce abnormal pain sensitivity and can actually render the medications less effective or even enhance the sensation of pain. • Tolerance, a neurobiological response common in pain management, isn’t always obvious and doesn’t necessarily signal addiction

7. A Taxonomy of Drug Seekers • Drug seekers can be difficult patients; they require careful observation, interventions, and documentation to remedy their true problems. • Drug seekers are informed people. They know preferred medications by name, strength, color, price, and manufacturer, often better than prescribing practitioners. • The most sought-after substances include narcotic pain medications, benzodiazepines, stimulants, hypnotics, and barbiturates.

8. A Taxonomy of Drug Seekers • Pseudo addicted patients are those who have been legitimately prescribed medications for pain management. As a result of inadequate pain control or in anticipatory fear of running out of medications, pseudo addicted people engage in drug-seeking behaviors to procure an adequate supply of pain medications. • Psychologically disturbed patients obtain prescriptions in association with mental illness, such as dual diagnosis, or a tendency toward suicide or self-injury. They may inflict external trauma upon themselves to create a valid reason for requiring medications. Substance abuse among this group, particularly with amphetamines, sedatives, and hallucinogenic drugs, is much higher than the general population.

9. A Taxonomy of Drug Seekers • Entrepreneurs are “street pharmacists” who obtain prescriptions for medications that can be resold for profit.Their tactics include stealing prescription pads; forging prescriptions; or calling in prescriptions by phone while posing as a prescribing physician. They may also rummage treatment areas for drug paraphernalia having potential street value, such as needles, and syringes. Often refuse diagnostic testing, intramuscular injections, or medications for immediate consumption. Encourage providers to prescribe a maximum amount of pills or ask for a number that is easily converted to a greater one (for example, 30 can become 80 with a stroke of a pen), and also request that prescriptions be written separately . Often entrepreneurs express a preference for brand name drugs over generics because of street recognition as “the real thing.” They know exactly what they want, adamantly refusing alternatives

10. A Taxonomy of Drug Seekers • Professional patients exploit chronic medical conditions to secure drugs. They know the medical aspects of their disease; use resource materials not generally accessed by the general public; and exploit medical jargon or “buzzwords” that are familiar to clinicians. They often refuse workups or leave before treatment is completed if they perceive their drugs of choice will not be given. On the other hand, they can be overly talkative, polite, and friendly with staff, trying to evoke sympathy and manipulating them to dispense the right drugs. When tests are performed, they may try to make the results fit their alleged disease, such as tainting urine specimens with blood or arriving with their own diagnostic reports from prior “workups.”

11. The Nurses Role • Although only nurses with advanced practice status have the authority to prescribe, all nurses are involved in the assessment, medication, and direct care of drug seekers.

12. The Nurses Role • Problems are apt to arise when these patients realize that their search for drugs might not be successful. Some may leave when they realize that they won’t get what they came for, while others may become hostile, threatening suicide or litigation. • Avoid confronting drug seekers alone and maintain your professional boundaries, carefully assessing and intervening appropriately for the safety of the patient, yourself, and other staff. • Don’t hesitate to involve social services, psychiatric support, security, or even the police in extreme circumstances

13. The Nurses Role • Nurses should not remain silent objectors when called upon to medicate patients they believe are drug seekers. • It is important to appropriately voice any suspicions to prescribing providers. • Assessing and identifying substance abuse isn’t only the domain of psychologists and therapists, but the responsibility of every healthcare provider. • Nurses can focus on assessment and clear documentation to aid future referral.

14. The Nurses Role • Clearly and objectively document your concerns and observations on the medical record, using direct patient quotes whenever possible.  For example, inconsistencies in behaviors from the waiting room to the treatment area • Also, be sure to secure prescription pads, sharps containers, and drug paraphernalia from possible theft

15. In Closing… • When dealing with suspected drug seekers, strive for cautious balance. The desire to reduce drug diversion or abuse should not be at the expense of patients who need treatment for addictions or an adjustment to their pain management program. • Be careful not to label patients too quickly, but to identify and document behaviors that support your suspicion of drug seeking. • Documentation and communication!!!