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Just say 'no' (responding to the drug seeker)

Clinical Features

Patients seeking prescribed drugs for non-medical use:

often approach emergency departments of major hospitals or general practitioners’ surgeries at busy times or shortly before closing
may choose a general practitioner who does not know them or who are known to prescribe drugs very readily

Drug seeking patients are usually:

polydrug using
males
aged in their twenties or thirties

The drugs sought are usually:

opioid analgesics
benzodiazepines

Analgesics

Presentations for analgesics:

usually involve painful conditions where there are few physical signs, i.e.
- headache
- renal colic
- backache
the names of analgesics which have proved effective on previous occasions are often referred to with familiarity
the most frequently requested opioid is pethidine by injection
commonly, patients will claim that analgesics, other than the one preferred, have:
- previously proved ineffective and / or
- resulted in severe side effects including an allergic reaction

Diagnosis and Management Plan

a careful history plus physical examination contributes substantially to the diagnosis and management plan
suspicion of illicit drug use is supported by a history of common complications of drug use (such as hepatitis C, endocarditis or previous incarceration)
physical examination should include inspection for track marks
it is often helpful to have a patient discretely observed by an experienced nurse for signs of variability in the severity of signs of pain

As special tests usually cannot prove if the patient’s symptoms result from organic disease, the final clinical decision depends on the doctor’s judgment and experience. In most cases, decisions are relatively easy. When uncertain, the choice has to be made between:

possibly withholding analgesia from a patient in severe pain or
possibly prescribing an opioid analgesic to a malingering patient

The former is a far more serious error.

Prescribing

injections of ketorolac (Toradol®), a non-steroidal anti-inflammatory drug (NSAID), is a safe way of providing a potent analgesic without prescribing an opioid
buprenorphine is a potent analgesic which provides minimal euphoria but can precipitate opioid withdrawal if the patient has withheld a history of recent opioid use

Benzodiazepines

Presentations for benzodiazepines:

often involve a history of anxiety or insomnia due to a recent bereavement

Diagnosis and Management Plan

short-acting benzodiazepines should only be prescribed in very special circumstances and then only in small quantities
if benzodiazepines have to be prescribed, it is better to select long-acting forms but in small quantities
doctors who consider that a patient is seeking drugs should gently advise the patient that they are concerned about this possibility and offer relevant assistance or referral

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