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Monday Feb 24, 2014

Caring for Patients With Addiction Problems Takes Practice

It's a Friday afternoon. I walk into the exam room and meet Carl (not his real name) for the first time. Sitting in a chair with his cane next to him, I see that he is middle-aged and morbidly obese.

After we exchange a few pleasantries, he begins to tell me why he is here: His primary care physician recently moved to a new practice, and he does not like the way he is being treated there. He says it is difficult to get an appointment with his physician. Although his diabetes and hypertension have been well controlled, he worries that the care he is getting will negatively impact his health.

After several minutes of discussing his situation, he begins to tell me about his mother recently passing away. With tears streaming down his face, he admits that he has been depressed lately and does not know what to do anymore. His low back pain is severe, he says, and it makes everything about his situation worse.

 Margaux Lazarin, D.O., M.P.H.

A quick check with our state prescription monitoring program and a call to his previous physician's clinic confirm my suspicion that this patient has a history of prescription drug misuse. The clinic warns me that during his most recent visits, he became aggressive when he wasn't given the medications he requested.

We have all had patients who come in with sad and distracting stories that can conceal the red flags indicating that they're attempting to obtain controlled substance prescriptions. As a resident with Friday afternoon clinics, I became accustomed to recognizing these red flags, which include the discovery that the "doctor just moved" (or "passed away"), the alleged allergies to ibuprofen and contrast dye, the tearful story of a loved one who recently died, the bullet that prevents them from being able to get an MRI, the history of a seizure disorder and, of course, the urgency associated with a Friday afternoon appointment. ("But it's the weekend! The clinic will be closed, and I just took my last pill!")

Patient encounters of this sort often make physicians feel frustrated and even angry. Why? Some of the reasons are obvious. These patients can be manipulative and argumentative. At a minimum, these challenging sessions are time-consuming and require a great deal of emotional effort to prevent the possibility of aggression from becoming a reality.

Moreover, inappropriate dispensation of controlled substances threatens our newly acquired medical licenses. On a deeper level, the need to search beyond the chief complaint for ulterior motives, such as diversion and addiction, can cause any physician to become more cynical as time passes. These patients can erode the core of why we became doctors -- to help people. At the end of an emotional visit, when we have told the patient that we will not give him or her the prescription he or she is demanding, it is difficult to feel as though we have helped that patient.

I have found that there are two tactics that help me better manage both these patients and my feelings about them. First, we can reframe our mindset. These patients still need what our original dedication to medicine was all about -- they still need help. They are in our office for medical problems, although their stated problem is typically different from our diagnosis. If we can recognize their addiction, understand their social circumstances and comprehend their psychological needs, we will realize that a family physician is exactly what they need. We can offer to care for all of their medical needs.

As family physicians, this is an area in which we excel. When we are able to see past patients' manipulation, it becomes clear that this attitude has nothing to do with us personally and everything to do with their disease.

The second tactic is to use our support. In residency, we rely on the attending to play "bad cop" with these patients. And although it can feel as though we're are on our own after residency, none of us practices medicine in a vacuum. We can still rely on our clinic's protocols, our medical director and our state laws. Patients cannot argue with "My hands are tied; I am simply not allowed to give you this prescription because of … " And we can impress upon patients that we want to be their primary care physician and that we are committed to being champions for their health.

If your clinic doesn't have a specific protocol for controlled substances, you can help develop one. These protocols typically involve pain contracts, which clearly delineate rules about random drug screens, restrict patients to obtaining a controlled substance from one physician only and allow no early refills.

To better understand the issues involved in balancing appropriate pain management with helping to combat the public health crisis of misuse and diversion of opioid analgesics, review the AAFP's position paper on pain management and opioid abuse

In light of the growing trend for pain management clinics to "fire" patients with substance abuse issues, these patients likely will be turning to the primary care setting. State prescription monitoring programs can significantly improve our ability to objectively identify these patients while strengthening our rationale for declining to prescribe controlled substances, thus lowering the tension surrounding these visits.

Ultimately, successfully caring for these patients takes practice. It can be helpful to view these visits as an opportunity for creative negotiation. It's important to remember that these patients have a legitimate medical problem, often substance abuse combined with difficult psychosocial circumstances, and, as family physicians, we have been trained to help them.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

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