Dr. Raskin: First, it’s important to exclude the possibility that someone may have an unrecognized or undertreated medical condition. In an addiction treatment setting, this has often been done before the patient sees you, but in other settings it can be more challenging. Once I’ve ruled out an underlying condition like severe pain, I like to begin by reviewing a prescription drug monitoring program (PDMP) database report to see if they’ve gotten prescriptions from other doctors, when, and how often. [Editor’s note: See the lead article for more information on PDMPs.] After that, I sit down with the patient and say, “Let’s look and see if these prescriptions are something that you really need for a medical condition, or if this has more to do with a possible addiction issue.” And I always screen for alcohol metabolites in the urine tox screen that I perform on all patients.
CATR: What do you do after you’ve explored all these alternatives and concluded addiction is the main issue?
Dr. Raskin: I tell the patient my opinion in the most gentle, straightforward way I can. I will say, “Look, for medical purposes, I think that you do have a true problem, and it’s called addiction.” I don’t just say, “Get off these drugs,” or, “I’m not going to give you these drugs.” If patients are ready to accept they might have a substance use disorder, then I will offer to help them. I will say, “Look, I have the knowledge and the ability to help you get off these medications. If you are willing to work with me, I can help you—whether that means an inpatient program or an outpatient program or medication-assisted therapy with drugs like buprenorphine, which I’m certified to give.”
CATR: What about patients who don’t agree they have a problem with addiction?
Dr. Raskin: If a patient isn’t ready to explore that possibility and just insists on a prescription, then unfortunately I can’t have that in my practice, and I have to let them go. Usually, I don’t have to actually fire them or send them a letter of dismissal—they leave when they realize they aren’t going to get what they want. But again, I don’t just tell patients, “I’m not giving this to you.” I want to offer them real solutions for the problem they have, and they can always come back when they are ready.
CATR: That sounds like good advice. Let’s talk about some common scenarios. Do you have any strategies that could help our readers decide when a patient who is requesting opioids is endorsing more pain than they actually have?
Dr. Raskin: It’s tricky. The fact is there is no great measure or marker of pain, and even after 20 years as a practicing internist, I often rely on my gut instinct. But I’ll also look carefully at the patient’s history and exam. For example, clues like elevated blood pressure and body language can indicate when someone is in pain. Talking to family members can occasionally be helpful. One very useful clue is whether someone is willing to explore alternative therapies for pain. For example, if it’s back pain, is the patient willing to see someone for an epidural injection, consider physical therapy, or try a mindfulness group? If they are, they are much more likely to have a legitimate pain problem. On the other end of the spectrum, there are patients who reject alternatives and say, “This is what I have to have—my 8 Percocet a day.” In that case I’m going to say, “I’m not comfortable with that, although I can help you detox and I can help you in other ways.”
CATR: Interesting. What about sedative-hypnotics? For example, what do you say to patients who complain of severe anxiety and insist benzodiazepines are the only thing that help them?
Dr. Raskin: This happens a lot, and I usually start by educating patients. I explain to them that benzodiazepines are indicated for short-term use and for acute panic attacks once in a while, but that they are addictive and have serious side effects like memory impairment, fatigue, and sedation. And I say, “Look, this is a situation where we have to get to the root of the problem. Benzodiazepines are like a Band-Aid for a wound, a wound that needs actual treatment.” I explain, “If there is a true anxiety disorder, then we need to look at a treatment that will not just cover it up. We need to consider an SSRI or an SNRI, or maybe cognitive behavioral therapy if we don’t want to deal with medications.” If I get the sense that there is a benzodiazepine addiction issue—if a patient is getting them from multiple sources, asking to fill prescriptions earlier, etc—sometimes I’ll just confront the patient.
CATR: What do you say?
Dr. Raskin: Something along the lines of, “Look, I think you might be addicted to this type of medication, and I’m qualified to help you get off of it.” And if they continue to insist that benzos are the only thing that works, I’m going to say, “Well, that’s not something that I feel comfortable with.” You have to sort of set boundaries with these patients.