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.
CATR: What about when patients ask for stimulants? How do you weed out true ADHD cases from not-so-true ones?
Dr. Raskin: Well, first of all, there’s no question stimulant medications are overprescribed, and there are a lot of people who claim they have ADHD who really don’t. When patients complain of ADHD symptoms, it’s important to ask how long they’ve had them. If they were diagnosed in childhood and they needed stimulants to get through school—and school records can tell you that—then that’s one thing. But if I have a patient that aced high school, went to Yale, and finished law school, and now just needs some Adderall to help them through a case to impress the senior partner, that’s an illegitimate use of the drug.
CATR: So how do you handle these patients?
Dr. Raskin: If I don’t think a patient has true ADHD, I’ll explain to them the hazards and side effects of stimulant medications, like insomnia, anxiety, heart palpitations, elevated blood pressure, and decreased appetite—those types of things. And I tell them that these medications don’t necessarily help patients without true ADHD. In today’s society, we’re all trying to get so much done in a day, and life is stressful. I’ll ask the patient, “Look, is this something that can be managed with changing some behaviors? Is it something that can be managed with just prioritizing?” For some patients, it may be appropriate to offer a non-stimulant medication like atomoxetine that doesn’t have any addictive properties. Or sometimes I’ll offer a patient bupropion if I think there’s an element of depression that could account for lack of concentration, focus, or motivation. But for those patients who insist they need stimulants for ADHD, but I’m not convinced, I’ll often refer them for cognitive testing.
CATR: Doctors often inherit patients who are already taking high doses or combinations of controlled substances that they’re not comfortable prescribing. How can they get those patients to accept coming back down to safe dosing levels?
Dr. Raskin: This happened to me. There was a doctor who retired a few years back in a town where I used to practice, and he just loved to prescribe big doses of narcotics. I inherited quite a few of his patients, and they were all really happy. And they were not young people looking to get high; they were 70-year-old men and women on 6 or 8 Percocet a day for back pain, fibromyalgia, headaches, and these types of things. With patients like this, I don’t just say, “Hey, I’m going to take you off these drugs” because that doesn’t help them. But I do try to explain the dangers of these drugs—the hazards of confusion, falls, car accidents, and so on. These conversations are especially important with older patients, and especially if we’re combining benzodiazepines, opiates, and other sedating medications.
CATR: That’s true. What’s your usual protocol for reducing levels?
Dr. Raskin: After explaining the rationale, I’ll try to reduce the medications slowly and strategically. I might convert a shortacting narcotic to a long-acting narcotic, for example, and then try to add in some adjunctive therapy. For example, if I believe there is a legitimate pain issue, then I’ll evaluate if that patient might be a good candidate for nonsteroidal anti-inflammatory drugs. I’ll think about whether they’re a good candidate for other medications like gabapentin, pregabalin, duloxetine, or tricyclic antidepressants. These alternatives can be used to help with pain as well as facilitate reducing the narcotics. Finally, and this is extremely important, I’ll talk to patients about things they can do that don’t involve drugs, like physical therapy, meditation, and acupuncture, that have a role in treating chronic pain.
CATR: There is a new black box warning for combining benzodiazepines and opioids. Could that provide a new tool for doctors to negotiate with medication-seeking patients?
Dr. Raskin: Absolutely. It’s nice to be able to say, “You know what? This is contraindicated, and there have been some good studies to say that this is a dangerous combination, so let’s see what we can do to not have you be on this combination.” So, again, it’s a good tool to use when you’re talking to your patients.
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.
~ Damon Raskin, MD
CATR: Patients occasionally threaten doctors with legal action if they don’t get what they want. Do you have any advice for handling that situation?
Dr. Raskin: I think the best way to protect yourself as physicians is to document the conversation, including your concerns and why you are not prescribing the requested medication. That should be enough protection. After all, there is nothing that says doctors have to prescribe controlled substances just because a patient wants them.
CATR: Do you have any advice for doctors who feel beholden to patient satisfaction scores and are afraid they’ll lose revenue if they say “no” to drug-seeking patients?
Dr. Raskin: I think of the Hippocratic Oath that we take when we become doctors. It’s about patients’ best interests, not satisfaction surveys. If we continue to give patients something we feel is not in their best interests just to make them happy, then that’s not fulfilling our oath. It’s an ethical issue and a moral one. We go into medicine to help people, not to harm them. And remember, saying “no” to a drug-seeking patient doesn’t mean you’re abandoning the patient. You can still offer addiction treatment or referral to an addiction specialist.
CATR: Thanks very much for your time, Dr. Raskin.