Complete Your CE Test Online - Click Here Recognizing the drug abuser [41] Telling the difference between a legitimate patient and a drug abuser is not easy. The drug-seeking individual may be unfamiliar. They could be a person who claims to be from out-of-town and has lost or forgotten a prescription of medication. Or the drug seeker may actually another practitioner, coworker, friend, or relative. Drug abusers (or doctor-shoppers) often possess similar traits and ways of operating. Recognizing these characteristics is the first step to identifying the drug- seeking patient who may be attempting to use manipulation to obtain desired medications. Common characteristics of the drug abuser: ● ● Unusual behavior in the waiting room. ● ● Assertive personality, often demanding immediate action. ● ● Unusual appearance – extremes of either slovenliness or being over- dressed. ● ● May show unusual knowledge of controlled substances and/or gives medical history with textbook symptoms OR gives evasive or vague answers to questions regarding medical history. ● ● Reluctant or unwilling to provide reference information – usually has no regular doctor and often no health insurance. ● ● Will often request a specific controlled drug and is reluctant to try a different drug. ● ● Generally has no interest in diagnosis – fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation. ● ● May exaggerate medical problems and/or simulate symptoms. ● ● May exhibit mood disturbances, suicidal thoughts, lack of impulse control, thought disorders, and/or sexual dysfunction. ● ● Cutaneous signs of drug abuse – skin tracks and related scars on the neck, axilla, forearm, wrist, foot, or ankle. Such marks are usually multiple, hyper-pigmented, and linear. New lesions may be inflamed. Shows signs of pop scars from subcutaneous injections. Nursing consideration: Nurses must be alert to the characteristics of the drug abuser and intervene to help him/her resolve the addiction. General principles of responsible controlled substance prescribing A summary of the key steps generally considered essential for the responsible prescription of all controlled substances follows [32]. 1. Effective patient evaluation [36]. Determining if an opioid medication is appropriate for a patient involves assessing both the condition itself and the patient’s potential for misuse or abuse of the medications. The FDA recommends that providers contemplating prescribing an opioid pain medication complete a “comprehensive history and physical exam, including assessment of psychosocial factors and family history of substance misuse, as well as special considerations for the elderly, women, children, and cultural/ethnic groups.” Regulators expect to see at least a basic physical exam as part of the evaluation that leads to treatment with controlled substances. The exact components of the exam, however, are left to the medical judgment of the clinician, who is expected to have performed an exam proportionate to the diagnosis that justifies treatment. Any basic pain assessment includes: chief complaint; history of present illness; past medical, surgical, and psychosocial history; family history; physical exam; and exam of imaging and other diagnostic studies or tests. As when assessing any patient, clinicians should take the time to look beyond the specific complaint or body part/system and evaluate holistically the broader mental, cultural, and socioeconomic contexts within which the chief complaint is embedded. Evaluating patients for risk of opioid dependence or abuse Whenever a clinician considers treating pain with a controlled substance, such as an opioid, risk of misuse or diversion is always a possibility, no matter how remote, and must be assessed. Prescribers must be vigilant with all patients. The concept of “universal precautions” has been applied to this approach, which means that any patient in pain could have a drug misuse problem – just as any patient requiring a blood draw for a simple lab test could have HIV. Treating everyone with the same screens, diagnostic tests, and administrative procedures can help remove bias and level the playing field so everyone is treated equally and screened thoroughly. Nonetheless, it is also true that some patient characteristics are predictive of a potential for drug abuse, misuse, or other aberrant behaviors. The factor that appears to be most strongly predictive in this regard is a personal or family history of alcohol or drug abuse. Some studies have also shown that younger age and the presence of psychiatric conditions are also associated with aberrant drug-related behaviors. What you should do when confronted by a suspected drug abuser [41]: DO: ■ ■ Perform a thorough exam appropriate to the condition. ■ ■ Document exam results and questions you asked the patient. ■ ■ Request picture ID, or other ID and a Social Security number. Photocopy these documents and include in the patient’s record. ■ ■ Call a previous practitioner, pharmacist, or hospital to confirm patient’s story. ■ ■ Confirm a telephone number, if provided by the patient. ■ ■ Confirm the current address at each visit. ■ ■ Write prescriptions for limited quantities. DO NOT: ■ ■ “Take their word for it” when you are suspicious. ■ ■ Dispense drugs just to get rid of drug-seeking patients. ■ ■ Prescribe, dispense, or administer controlled substances outside the scope of your professional practice or in the absence of a formal practitioner-patient relationship. Nursing consideration: Because of the prevalence of drug abuse, nurses must be prepared to evaluate all patients for the possibility of abuse. 2. Opioid selection [37-38]. Opioids comprise many specific agents available in a wide range of formulations. A given patient might be appropriate for long-acting therapy only, short-acting only, or a combination of an extended-release opioid with a short-acting opioid for breakthrough pain. Short-acting, orally-administered opioids typically have rapid onset of action (10 to 60 minutes) and relatively short duration of action (2 to 4 hours) [33]. They are used for acute or intermittent pain, or breakthrough pain that occurs against a background of a persistent level of pain. Combination products join an opioid with a non-opioid analgesic, such as acetaminophen, usually for use in patients with moderate pain. Using a combination product when dose escalation is required risks increasing adverse effects from the non-opioid co-analgesic, even if an increase of the opioid dose is appropriate. In such cases, using a pure opioid may be preferable. Unfortunately, at this time, no pharmaceutically manufactured single-agent option for hydrocodone is available. Single-agent formulations are available for other types of opioids, such as codeine, morphine, oxycodone, oxymorphone, and hydromorphone. Extended release/long-acting (ER/LA) opioids usually have a relatively slow onset of action (typically between 30 and 90 minutes) and a relatively long duration of action (4 to 72 hours). Such agents are typically used for patients with constant background pain. These agents achieve their extended activity in various ways. Methadone and levorphanol have intrinsic pharmacokinetic properties that make their effects more enduring than many short-acting opioids. ER/LA agents such as controlled- release morphine, oxycodone, or transdermal fentanyl achieve their prolonged time course via a delivery system that is modified to slow absorption or to slow the release of the active ingredient. Clinicians should warn patients that unless specifically instructed otherwise, Page 5