Thursday, April 08, 2010

Shopping Spree

CNN recently had a story entitled How physicians try to prevent 'doctor shopping', about states' efforts to control and prevent prescription drug abuse. While it's a good story, it's unfortunate that we only tend to talk about this issue after the overdose death of a celebrity. Here at Shrink Rap we've talked before about our concerns and challenges related to this issue in a series of blog posts and one podcast which we've collectively referred to as "the Benzo Wars".

The Shrink Rappers have seen both sides of the prescription drug abuse issue and so we have different opinions about it. Neither opinion is all right or all wrong, we just differ on the degree of the problem and to some degree how it should be handled. Our opinions are shaped by the patients we treat: Dinah has a private practice and (I'm guessing here) probably doesn't have many patients with active addictions or legal problems related to this. I work in prison, and nearly 80% of my patients are locked up for crimes related to substance abuse.

First, the things we agree about (and that the CNN story also addresses): we agree that doctors can't be detectives and that we aren't lie detectors. We have no special ability to figure out who is or isn't lying to us about their pain and anxiety or exaggerating problems to obtain medication. We agree that most doctors have certain 'red flags' that raise a concern about abuse. We agree (although Dinah thinks I don't believe this) that patients with real pain and panic disorder deserve care that is delivered in an empathic, sensitive fashion and that questioning or doubting these patients can cause serious problems with the doctor-patient relationship.

That was the easy part.

What the CNN article doesn't address is this: what do you do when you find out that your patient is, in fact, receiving multiple controlled substances from more than one doctor? The CNN article implies that whenever this happens it means the patient must be "doctor-shopping" and that there's a problem.

This situation is going to be more of a challenge for Dinah than it is for me, because in correctional facilities controlled substances are rarely prescribed. When they are ordered, they are dispensed in a tightly supervised manner and generally for a limited time. If an inmate is caught with pills in his cell---whether or not they were prescribed for him---you know the medication is not being used as prescribed. Easy enough.

But what about free society? What if the patient tells you, "I have chronic pain and I get medication from Dr. So-and-So." Truthfulness is a good indicator that the patient probably isn't out to snooker you. True drug addicts rarely give you an avenue to check up on them easily. Nevertheless, physiologic dependence can happen even in the absence of abuse. If the patient is coming to see you for anxiety, I probably still wouldn't choose a benzodiazepine as a first-choice medication because I wouldn't want to cause yet one more dependency issue. There are non-habit-forming alternatives and SSRI's have been shown to have anxiolytic effects.

But what if the patient comes to you already on a benzodiazepine? This is where the benzo war started on the podcast, and where Dinah and I may differ. In this case I think you have to consider what the goal of treatment is going to be and physicians are going to differ with regard to their comfort levels in this situation. Presumably the patient has been referred to you because the previous prescriber either was unable or unwilling to continue the prescription. Unless the prescriber was dead or retiring, to me this could indicate a clinician's concern about the patient's pattern of use and I'd be reluctant to merely continue the status quo. A reasonable treatment goal would be to build coping skills to the extent that either the patient would no longer need medication, or could function with a non-controlled alternative. As strange as it may sound coming from a psychiatrist who mainly does medication-management, I do believe that psychotherapy can help with this.

What if you find out that the patient actually is selling, trading or giving away your controlled substances?

Most free society docs don't find out about this until the patient gets arrested. But say the patient is released on bail---do you accept them back in treatment? Do you continue to prescribe for them? Or what if the other doctor is prescribing unusual combinations of meds, or meds in doses that would raise the eyebrows of even the most liberal psychiatrist? Do you assume the doctor is over-prescribing or do you assume the patient must really 'need' the medication?

It's a complicated situation, made more complicated by the fact that even non-controlled psychiatric medications have street value. And don't even get me started on legalized marijuana.

I'm not trying to start Benzo War Part II, but it's an issue that doctors struggle with. I await your thoughts.