The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.
Amy M. VandenBerg, PharmD, BCPP
Clinical Pharmacy Specialist, Psychiatry & Neurology
University of Michigan Health System
Ann Arbor, MI
Dr. VandenBerg earned both a BS in Psychology and PharmD from University of Michigan. She completed PGY1 and PGY2 Psychiatry residencies at the Medical University of South Carolina (MUSC). From 2002 to 2016, she served many roles at MUSC including Psychiatry Clinical Specialist, Coordinator of Psychiatric Pharmacy Services, Residency Program Director (RPD), and Adjunct Assistant Professor. Dr. VandenBerg worked closely with Emergency Department Psychiatry Services as well as the inpatient substance use disorder service at MUSC and led weekly patient education groups involving patients with co-occurring substance use, pain and psychiatric disorders. Currently, Dr. VandenBerg is a Clinical Specialist in Psychiatry and Neurology and PGY2 Pyschiatric Pharmacy RPD at Michigan Medicine.
It has been my practice to avoid use of the term ‘drug-seeking behavior’ because it is generally used in a negative manner, often out of provider frustration. My concern with throwing the term around casually is that we miss the opportunity to have a positive intervention on behalf of the patient if we discount their needs. There are two key questions to ask when concern for ‘drug seeking’ comes up.
First, is this patient actually attempting to get ‘high’ or are they trying to treat/prevent symptoms of acute withdrawal or rebound pain/anxiety? Patient interviews should attempt to obtain a thorough history of use and an assessment for current or past withdrawal symptoms with assurance that the information will be used to help optimize treatment. Patients sometimes worry that reporting use or misuse will have consequences ranging from lack of treatment to legal ramifications. Urine drug screens may help verify what substances a patient has been using recently and be used to validate patient self-reported use. Substance use history should not automatically discount current medication requests as ‘drug seeking’.
Second, does the patient have a legitimate reason to need the medication? The patient should be objectively evaluated, without judgment, for legitimate medical need regardless of history of substance use. If opioids are identified as a means to manage daily stress, the patient should be educated otherwise. However, when acute circumstances may benefit from medication treatment (e.g., acute injury, extreme psychosocial stressors), it is important to set expectations from the start. These may include duration of treatment, dose limits, or participation in non-pharmacologic interventions (e.g., stress management, deep breathing, mindfulness, exercise/stretching/physical therapy).
Finally, what is the impetus for change? Has this patient used controlled substances chronically? Are we decreasing doses or discontinuing medications because of difference in therapeutic approach or because of acute risk of harm to patient? If controlled substances are discontinued in a patient with no desire to quit, they are likely to continue to request medications. If substances are abruptly discontinued, then the patient may be experiencing rebound anxiety or hyperalgesia.
Objectivity can be difficult because patients are typically seeking medications for subjective symptoms of pain and anxiety which have great inter-patient variability in outward presentation. A nurse may report “patient requested lorazepam for anxiety, but didn’t look anxious at all.” It is important to consider psychiatric symptoms of anxiety as well as somatic symptoms. A patient does not have to be flushed, diaphoretic, and tremulous to be anxious nor writhing in bed to have significant pain.
When possible, observe patients in a variety of settings and/or obtain input from family. How do they behave when not interacting with health professionals? Is the patient interactive and gregarious with peers, but endorsing incapacitating anxiety to the provider and requesting PRNs for anxiety throughout the day? Is the patient reporting a pain of 10 and wincing in the presence of the provider, but behaving differently throughout the day with no restriction in activity? How does the patient function in everyday life? Is anxiety/pain impairing their ability to work, function socially or function within their family?
A thorough initial assessment when working with a patient who has a history of anxiety or pain can go a long way in objectively assessing them in the future. How does this patient experience anxiety? How do they usually try to alleviate anxiety? For pain, it is important to obtain a description of the quality of pain. Is it musculoskeletal, visceral, or neuropathic in nature? What non-pharmacologic interventions have they tried?
Lastly, consider diversion. Is the patient receiving larger quantities than you would expect for the underlying condition? Is there a prescription database in your state? Are they using more than one prescriber and more than one pharmacy? Whether diversion or over-use is a concern, a treatment contract is appropriate. This may include having only one provider who prescribes the controlled substances, prescription database monitoring for controlled substances, and/or a scheduled taper.
Patient education is key.
For anxiety – Be sure to review non-pharmacologic approaches and enforce that, like any skill, they must be practiced when patients are feeling well to be most effective in crisis. Explain, in patient-friendly terms, why the current treatment is not ideal. I often use lightbulb analogies for patients. Anxiety is like a light on a dimmer switch. Benzodiazepines turn the dimmer all the way down, but after a few hours the dimmer switches directions and the anxiety comes back. With chronic use, rebound anxiety can become more severe (analogy: brighter lightbulb). Antidepressants work to very slowly dim the light of anxiety. The effects are so slow that you don’t notice day to day, but rather have to wait weeks to months to notice. Medications like gabapentin, pregabalin and hydroxyzine, have more rapid effect than antidepressants, but they still only dim the anxiety rather than totally shut it down like benzodiazepines. There is much less rebound anxiety with chronic use of these agents, although they still should be tapered off rather than abruptly stopped. With this description of medication effects, I have actually had “drug-seeking” patients ask the team to change their long-term benzodiazepine to an alternative agent.
For pain - Determine source and nature of pain. It is really frustrating when a patient clearly has neuropathic pain and is only on narcotic analgesics. Again, it helps to explain how the medications work when explaining why medications are being changed. The dimmer switch analogy works for pain as well when comparing narcotic analgesics to other treatment options (gabapentin, antidepressants for neuropathic pain; acetaminophen +/- nonsteroidal anti-inflammatory agents for chronic pain; exercise for musculoskeletal pain).
Communication between providers must be as objective as possible. I have been on both sides of this recommendation – on the one hand suggesting that patient has a legitimate source of pain (recent surgery) which warrants temporary narcotic pain management and on the other hand, recommending taper of opioids in patient with significant substance use history and rebound migraines.