bones Posted February 10, 2007 Report Share Posted February 10, 2007 You have a patient who continually makes regular appointments to meet with you so that he/she can get a refill of a painkiller. You strongly suspect they are addicted to the drug and don't actually need it. If you refuse to give them the drug, the patient may even forcefully demand it and/or get aggressive with you. What's the proper course of action in this case? In practical terms, what does the physician in the room with this patient do? Link to comment Share on other sites More sharing options...
The Law Posted February 10, 2007 Report Share Posted February 10, 2007 I would not give the patient drugs if I had a strong conviction that they were addicted to it. Instead, I would end up telling them that I would not be able to give them the pain killer. I would first, however, listen to their complaint... and if I could tell that they weren't really telling the truth, and had been coming all the time to get this prescription refilled, I would approach them about the possibility of rehab/drug addiction councilling. I would not really expect it to go well right away, but I definitely would not prescribe the drug to them. Link to comment Share on other sites More sharing options...
ph123 Posted February 18, 2007 Report Share Posted February 18, 2007 I will suggest to refer him to a pain management clinic and see how he will react. If he refused then he made his choice not to proceed with the treatment or at least it is not serious enough for strong pain killers (usually narcotics). If he accepts then they will be able to provide proper help. Link to comment Share on other sites More sharing options...
Madz25 Posted February 18, 2007 Report Share Posted February 18, 2007 I wouldnt prescribe the drug. This scenario, or a similiar one, is in "doing right" by philip c. hebert...followed by an ethical discussion. Link to comment Share on other sites More sharing options...
Rock* Posted February 18, 2007 Report Share Posted February 18, 2007 This is why in an interview or when your in an examination room, they always teach you to be between the person and the door. If there is any possibility for harassment, you have easy access to an escape route. I also wouldn't prescribe the drug and I may also let him go as a patient if he continues to try to abuse the system. There are hundreds of other people who need real medical help next in line for him to tie up the healthcare system with nontherapeutic requests. Link to comment Share on other sites More sharing options...
Satsuma Posted February 18, 2007 Report Share Posted February 18, 2007 I also wouldn't prescribe the drug and I may also let him go as a patient if he continues to try to abuse the system. There are hundreds of other people who need real medical help next in line for him to tie up the healthcare system with nontherapeutic requests. Drug addiction is a real medical problem that requires real medical care. So I am not sure why would think others are more deserving of medical attention. Link to comment Share on other sites More sharing options...
Rock* Posted February 20, 2007 Report Share Posted February 20, 2007 There's idealism, and then there's pragmatism. While I don't disagree with you that drug addicts need help and that they need support to turn their life around, when you actually work as a GP (which is where you're most likely to see these kinds of cases), you'll notice that sometimes you have waiting lists with 2-3 hours worth of people suffering through their ailments to see you. The only thing that should be used to discriminate amongst patients should be medical need. It's unfair to the rest of the equally deserving patients to waste time that would have allowed you to see 3 regular or even more needy patients on one demanding addict who often throws tantrums and in some cases go around destroying clinic property (I know because I'm currently working as a medical assistant). Link to comment Share on other sites More sharing options...
med84 Posted February 20, 2007 Report Share Posted February 20, 2007 By you, as a physician, refusing to give this patient drugs that you suspect he is addicted to, you might think that your helping him because its a step towards prevention. However, lacking such drugs might cause this patient to become really agressive and cause harm to himself and others if he becomes unstable..So as a physician you have to assess his condition, and assuming all methods of you trying to convince him/her to get help to stop using drugs fail... you might want to have some sort of comprimise with him and maby give in the demands for a limited quantity on the basis that he considers rehabitilation or assessment by other professionals. Obviously if you have a hunch he/she is lying to you or can't keep with such a deal then you proceed with a more aggressive attitude towards her/his treatment and at that point the patient knows your justified at doing what you do. Basically have a smart negotiation with this patient and try to 'give and take' to help him out over the long run, not necessarly right away. What does everyone think about this approach? Link to comment Share on other sites More sharing options...
Rock* Posted February 21, 2007 Report Share Posted February 21, 2007 I think you should obviously be careful if you are going to categorize a patient as a drug abuser. Categorizing would involve knowing the patient for a while, and understanding his/her history and tendencies, which can only be determined after evaluating him/her over a long period of time to notice any patterns in their prescription requests. I think that if you determine the patient to be addicted to the drugs he/she keeps requesting, it would be better to confront them on the issue and refer them to an addiction treatment center of some kind. Giving in and prescribing when a patient gets aggressive or violent is never a good idea because psychological studies have shown that the only way to successfully condition people--in this case conditioning your patient to not see you as a dispenser for his/her drug habits--is to be consistent and assertive in your responses. If you so much as give in once to his/her demands, you will encourage them to throw future tantrums because they'll learn that they can usually get what they want by misbehaving long enough. Also, as a doctor working in an overburdened healthcare system, it would be good practice to use government healthcare funding responsibly. Spending too much time and healthcare money getting a doctor to treat an addict when other similarly if not more effective and cheaper heathcare resources are available is not a good way to distribute quality healthcare to as many people as possible. I think a family doctor should only be using his time to treat addicts if treatment through other methods would be ineffective either because of lack of trust, lack of skills, or whatever. Link to comment Share on other sites More sharing options...
The Law Posted February 21, 2007 Report Share Posted February 21, 2007 Well of course it may seem futile trying to get a drug abuser to seek help, but you can't just give up... there is always the chance that one person actually begins to change their life around. This is not just an idealistic thing, but it can be pragmatic... when someone is a doctor, they've agreed to try to help people to the best of their ability, and giving up is definitely not going to end this vicious cycle of abuse. By you, as a physician, refusing to give this patient drugs that you suspect he is addicted to, you might think that your helping him because its a step towards prevention. However, lacking such drugs might cause this patient to become really agressive and cause harm to himself and others if he becomes unstable.. Yes, but by giving them the drug, you are ensuring that they never break out of their habit. I understand the whole idea, that provide them with the drug... and then try to get them off of it later approach, but I really disagree with it. The line has to end somewhere. Link to comment Share on other sites More sharing options...
Satsuma Posted February 21, 2007 Report Share Posted February 21, 2007 It's unfair to the rest of the equally deserving patients to waste time that would have allowed you to see 3 regular or even more needy patients on one demanding addict who often throws tantrums and in some cases go around destroying clinic property (I know because I'm currently working as a medical assistant). I think what you are trying to say is that in the setting of a family practice you are unable to meet the needs of this patient and provide the care they need. In this case I agree with you. But there is quite a difference between stating that a patient is not deserving of medical care and acknowledging that the care you can provide this patient in inadequate. Link to comment Share on other sites More sharing options...
Sharpie* Posted February 21, 2007 Report Share Posted February 21, 2007 You have a patient who continually makes regular appointments to meet with you so that he/she can get a refill of a painkiller. You strongly suspect they are addicted to the drug and don't actually need it. If you refuse to give them the drug, the patient may even forcefully demand it and/or get aggressive with you. What's the proper course of action in this case? In practical terms, what does the physician in the room with this patient do? If the patient has been consistently trying to refill the prescription much before the prescription was supposed to run out, I would certainly have reason to believe that the patient was abusing the drug. Given that it is a controlled substance (that should be prescribed for specific use) I think that in this case I would have the right to refuse to prescribe a refill. I would feel obligated to tell the patient why I am refusing the prescription (i.e. because I think that he is using it for reasons other than those it was originally prescribed for) and to tell him about the risks of substance abuse. I would make sure that he understands these risks. I would try to discuss with him the different ways to cope with quitting the drug. With good enough bedside manner, it is possible that I might sway him. If he denies that he is abusing the drug, and he will not explain to me why they are running out so quickly, the patient is obviously not looking for my medical advice, but instead, just assuming that I am a pharmaceutical source that will give him whatever he wants. People go to doctors for professional opinions...not to make requests for drugs they don't need. I don't think that doctors should be complicit in their patients' drug abuse. In this case, I would assume that I cannot help the patient, and would refer him to substance abuse services, in case he feels inclined to go. Link to comment Share on other sites More sharing options...
iwonder Posted February 24, 2007 Report Share Posted February 24, 2007 Though it may seem that this patient is an addict looking for his next fix, the physician in this case would have to take into account a detailed history of information, and be fully informed before making this decision. The physician could not simply refuse to treat the patient based on a hunch that he is addicted to painkillers. The possibility remains that this patient could in fact be suffering from chronic pain relieved by these painkillers. Pain is a very individual experience and part of the role of the healthcare provider is to trust the patient and what he is experiencing. The doctor would have to know how often this patient is renewing his prescription. Has enough time surpassed from the last prescription that he is taking it as directed (ie: 2 pills every 6 hours as needed, etc.)?? The doctor should collect a detailed pain history from this patient such as where the pain is, when it occurs, what precipitates the pain, what relieves the pain? A doctor who is thorough should be able to determine if this person is abusing the system. If is appears likely that the patient is only seeking medication due to an addiction, then I would confront him gently with the possibility of referral to rehab. If he still insists that the pain is real, perhaps further assessment by a specialist is needed to determine a better course of action for pain management. A GP would encounter many cases like this in their career but should not be so quick to judge the person as a addict and discontinue pain control. If a person insists they are in pain, there may be times when you have to prescribe them painkillers despite your gut feelings. The fact remains that this person may be living with a lot of pain. Link to comment Share on other sites More sharing options...
The Law Posted February 24, 2007 Report Share Posted February 24, 2007 Though it may seem that this patient in addict looking for his next fix, the physician in this case would have to take into account a detailed history of information and be fully informed before making this decision. The physician could not simply refuse to treat the patient based on a hunch that is addicted to painkillers. The possibility remains that this patient could in fact be suffering from chronic pain relieved by these painkillers. Pain is a very individual experience and part of the role of the healthcare provider is to trust the patient and what he is experiencing. Yes, but often there are clear signs that this person may be addicted to pain killers. Link to comment Share on other sites More sharing options...
quickdraw_mcgraw Posted February 28, 2007 Report Share Posted February 28, 2007 The College of Physicians and Surgeons has ruled on this, it is now a type of case law. The scenario is that he has been making appt's to get painkillers, then one would suppose that you have been giving them to the patient. You can't suddenly stop, you caused the addiction and if the patient complained, it is you that could lose your license for creating the situation. Your responsibility is to form a therapeutic relationship and begin a program of cessation which may include referral to a pain clinic or methadone clinic. But ultimately if you think the patient is addicted, it is you job to treat it. Link to comment Share on other sites More sharing options...
Jochi1543 Posted February 28, 2007 Report Share Posted February 28, 2007 you caused the addiction That's an interesting way to put it, that's for sure. I mean, it's not like with heroine or something, when you give a person painkillers, addiction is not the expected result, though it does happen. I'm not quite sure why the physician is to blame. It's not like you can look at someone and be like "Oh, he'll be addicted, no painkillers post-surgery for this guy!" Link to comment Share on other sites More sharing options...
quickdraw_mcgraw Posted February 28, 2007 Report Share Posted February 28, 2007 I know it doesn't seem fair. But the patient really holds all of the cards, and the college will always say "you should have recognized this before the addiction began." Doctors have been suspended or had their license revoked over this specific issue. And with post op pain meds, there are no refills from the surgeon from what i've seen. Post op surgical pain should subside within two weeks, there is no need for narcotics after that. If they come back asking for more, the policy usually is "Speak with your GP." Link to comment Share on other sites More sharing options...
quickdraw_mcgraw Posted February 28, 2007 Report Share Posted February 28, 2007 I guess my point is that it's not a question without an answer. Most regulatory bodies in North America believe when you prescribe a substance that has the potential to cause addiction then it is your responsibility to monitor for signs of addiction. That's the price of being a doctor, responsibility. Link to comment Share on other sites More sharing options...
The Law Posted February 28, 2007 Report Share Posted February 28, 2007 I guess my point is that it's not a question without an answer. Most regulatory bodies in North America believe when you prescribe a substance that has the potential to cause addiction then it is your responsibility to monitor for signs of addiction. That's the price of being a doctor, responsibility. Yep it is, however it isn't necessarily the case that you caused the addiction... they may have gained access to pain killers through other means. I really don't think you should give it to them, especially not to try to avoid a law suit. If you start recognizing that they are addicted at first sign of addiction, then you've done all you could really - Link to comment Share on other sites More sharing options...
eise Posted March 2, 2007 Report Share Posted March 2, 2007 I agree that it is the duty of the physician to monitor medications, especially when they are addictive ones. I don't think cutting the patient off helps anything. It's not like he/she will say "ok, no more drugs" and that's it. They are addicted and will find a way to get more drugs. Perhaps the next doctor this pt approaches will not be aware of the addiction and just prescribe him drugs. At least if you recognize the problem, you can work on getting him help in subsequent visits (if he does not agree to get help immediately). Link to comment Share on other sites More sharing options...
Footyfanatic Posted March 3, 2007 Report Share Posted March 3, 2007 I'd be like: What do you think I am? A doctor?! and then walk away. Link to comment Share on other sites More sharing options...
The Law Posted March 3, 2007 Report Share Posted March 3, 2007 I agree that it is the duty of the physician to monitor medications, especially when they are addictive ones. I don't think cutting the patient off helps anything. It's not like he/she will say "ok, no more drugs" and that's it. They are addicted and will find a way to get more drugs. Perhaps the next doctor this pt approaches will not be aware of the addiction and just prescribe him drugs. At least if you recognize the problem, you can work on getting him help in subsequent visits (if he does not agree to get help immediately). How likely do you think that once you give them the drugs, that they'll come back to seek help? haha footy Link to comment Share on other sites More sharing options...
eise Posted March 3, 2007 Report Share Posted March 3, 2007 How likely do you think that once you give them the drugs, that they'll come back to seek help? haha footy It all depends on whether this is your regular patient or not (i.e. you're the family doc). If he is, then he will likely come back for more drugs. and perhaps you can persuade him to get further help with his addiction. if this individual was not your regular patient, then i doubt you would notice an addiction problem and even if you did, you wouldn't prescribe the drug then. I think only the family doc can develop the relationship and trust with an addict in order to help with the addiction (as opposed to an ER or clinic doc who sees the patient once and likely never again). Link to comment Share on other sites More sharing options...
illusion Posted March 4, 2007 Report Share Posted March 4, 2007 I think it's important to address the issue: the addiction. First, talk to the patient about your concerns and if he/she legitimately in need of the medication, he/she will agree to undergo a psych (?) assessment or undergo counseling. prescription meds are a controlled substance and that prescription pad comes with a responsibility... not to turn all spidey or anything Hugeo problem: prescription meds' addiction overtaking that of illegal narcotics - read article below I believe it's actually from this week! http://www.cbc.ca/health/story/2007/02/28/prescription-pills.html Link to comment Share on other sites More sharing options...
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