to the editor: In the article1 on the drug-seeking patient, the authors offer instruction on “basic clinical survival skill(s).” These survival skills are for the physician and not for the patient with an addiction. When a depressed patient complains of feeling suicidal or an asthmatic patient presents with wheezing, are these patients deliberately trying to be demanding and manipulative? Then why, when patients with substance abuse problems present with the symptoms of addiction, do physicians view this as a chosen behavior and not as a disease?
Physicians' attitudes toward substance-abusing patients is a major barrier to treatment for the addiction.2 Physicians find caring for substance abusers time consuming and frustrating, and they believe that few will actually recover.3 We often encounter severely affected addicts because we failed to identify them earlier, before the disease progressed. Screening rates for users of alcohol and other substances are poor.4 Physicians' negative attitudes also prevent substance abusers who seek treatment from approaching them for help.5
Preventing the development of an addiction by careful patient management is clearly preferable to treating an addiction. However, once patients are addicted, simply saying “no” to their requests for additional medication does little to help treat this disease.1 We should be trying to keep these patients in our clinics to prevent them from exhibiting drug-seeking behavior that is reinforced by visiting multiple physicians. I realize that this strategy is frequently difficult and at times impossible, but we should be treating all patients with care and concern regardless of the disease. Rather than learning to say “no,” perhaps we should instead learn to say, “How can I help?”
Offering to help does not mean writing a prescription; offering to help does mean listening, discussing concerns and presenting treatment options. If the interaction does not result in the patient beginning structured treatment, the visit was not necessarily a failure. This type of interaction is useful in helping patients advance through the stages of change.6
A mentor in medical school said that it is better to be the doctor than the patient. We should be less concerned with our feelings about being manipulated and be more concerned with how our patients are affected by the disease of addiction.
in reply: We agree with Dr. Fink that addictions are truly biopsychosocial diseases that, unfortunately, are not always given adequate attention by busy physicians who are under increasing time demands and fiscal constraints. In our article “Identification and Management of the Drug-Seeking Patient,”1 we clearly acknowledge that early identification and therapeutic intervention are preferable to having to set limits and boundaries with addicted patients later on. However, candid discussions of one's concerns and expectations may help to tip the scales of ambivalence toward change in a patient who otherwise has been “enabled” by other well-intentioned, but naïve physicians.
With regard to forsaking our own feelings for those of our patients—this is frankly dangerous and often backfires in the form of the psychologic defense mechanism of displacement. Many patients with “real” pain or anxiety are frequently the victims of unreasonable skepticism, anger or resentment brought on by a few “bad apples.” It behooves us all to keep a finger on our own pulse.
Certainly empathy, support and nurture are ideal qualities for physicians who treat all illnesses, including patients with addictions, but one must also be mindful of the pitfall of co-dependence—in which the physician wants the patient to recover and puts forth more effort than he or she does.2
We hope that the take-home point of our article was not misconstrued as a simple and heartless “Just Say No” to treating patients with addictions. Our intent was to reflect on our own experiences managing this difficult patient population and to try to understand the contextual nuances of the doctor-patient relationship, which is fraught with medicolegal liability in addition to clinical challenges.3
We hope that readers find our insights and recommendations to be useful and helpful in de-stigmatizing interactions with patients who manifest behavioral symptoms of the disease of addiction. To witness the dramatic positive life changes that our patients are capable of when in recovery can be a truly rewarding experience.
to the editor: The authors of the article on the identification and management of the drug-seeking patient1 skillfully outline the important and complex issues involved in prescribing opioids; however, some statements are potentially misleading.
1. The statement that “Drugs in … these classes are habit forming, frequently causing … physiologic dependence”1 confuses addiction with physical dependence, defined as the development of an abstinence syndrome on abrupt dose reduction or administration of an antagonist. This differs physiologically from craving and reinforcement. Physical dependence is common with some anticonvulsants, antihypertensives and antidepressants, and is minimal with such abused drugs as LSD, or subtle, as with marijuana. Confusion results from the fact that significant tolerance and abstinence are unlikely with occasional use and suggest addiction to recreational substances, yet are usual in treatment with daily benzodiazepines or opioids.
2. The authors cite drug seeking as evidence of addictive disorder, but similar behaviors can result from inadequate treatment.2 Given an incorrect drug or dosing schedule, the patient may watch the clock and “manipulate” to obtain relief (e.g., when such short-acting drugs as meperidine are prescribed every four to six hours).
3. The authors note that “pressure to prescribe in the face of the physician's feeling of hesitancy is a classic indicator of a scam.”1 Such hesitance may instead reflect changing and ambiguous regulatory policies and standards.
4. It is incorrect that, “It is unlawful to provide maintenance or taper prescriptions … to a patient who is addicted.”1 The regulations address not whether the person is addicted, but whether the purpose of the prescribing is to maintain or detoxify addicts.3 The Controlled Substance Act4 clearly states, and the Drug Enforcement Agency (DEA) has repeatedly held, that the reason for the prescription is the issue. Physicians cannot treat addiction with opioids outside a licensed Narcotic Treatment Program but can treat pain in addicts taking opioids. Authority to prescribe implies authority to reduce (or increase) dosage, with no mandate for abrupt discontinuation should the drugs fail to help.
The DEA emphasizes, “This section is not intended to impose any limitation on a physician to … administer or dispense narcotic drugs to persons with intractable pain in which no relief or cure is possible or none has been found after reasonable efforts.”3
The FDA has not considered physical dependence in a pain patient to constitute addiction and held that such a patient's analgesic needs should be met in a private doctor-patient relationship.
5. While federal regulations do not impede pain treatment in those with addictive disorders, state law and medical board regulations may be more restrictive. This situation has improved in most states, and in May 1998, the Federation of State Medical Boards adopted “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain.” Forty-two state boards have already enacted new policies that provide important protections for physicians treating intractable pain with opioids. The University of Wisconsin Pain and Policy Studies Group provides current information on related medical board policies and state laws at the following Web site:http://www.medsch.wisc.edu/painpolicy/. It is essential that physicians be cognizant of regulations in the states in which they practice.
in reply: We appreciate Dr. Covington's thoughtful response and clarifications regarding regulatory policies and standards. Unfortunately, many physicians are left with a sense of misunderstanding or confusion about these issues, as there is frequently state-to-state variation within the legal and medical board regulations. We agree that to withhold appropriate analgesic treatment from addicted persons with legitimate pain is inhumane; yet, physicians must be very cognizant of the dynamic processes in the doctor-patient relationship in order to both protect themselves from possible sanction and to optimize therapeutic interventions for their patients. We hope that the regulatory boundaries become clearer in the future. There is also the potential for increasing office-based management of opioid addiction on the horizon, as it appears that the FDA may soon approve labeling for buprenorphine (Buprenex) for this indication, thus providing an additional tool to our treatment armamentarium.
We hope that our article was not misleading and agree that physiologic dependence is certainly not synonymous with addiction, whose key features are behavioral and/or psychologic. In our article, we qualified our comments regarding escalating use and drug-seeking behaviors as markers of addiction by the following statements: “Overuse of a prescribed medication can be the result of underprescribing or underestimating the magnitude of the symptoms. Indeed, many individuals are undertreated because of the physician's or patient's misplaced fear of addiction or the physician's lack of knowledge about pharmacokinetic properties such as half-life.”1
We hope that our provocative article helps to increase awareness of the complexities inherent in treating persons with addictions, especially when prescribing controlled substances. Being mindful of the potential for misuse and abuse of these agents is a key to avoiding the paradox of overprescribing them to high-risk patients in need of treatment for addiction, and under-prescribing them to the majority of patients with conditions that would clearly be improved by their rational use.