When internist Juliet Mavromatis answered a phone call from a nearby pharmacy a few years ago, she was greeted with some unexpected news. One of her patients was attempting to fill a prescription, and the pharmacist had some concerns.
"She had been my patient for probably two or three years, and she and I had a good relationship," says Mavromatis, who was at the time practicing at The Emory Clinic in Atlanta. "I didn't think she was doing anything illegal — certainly not forging prescriptions."
Mavromatis had been prescribing the woman narcotics for chronic pain, and as she and the pharmacist compared notes, to her dismay she realized the woman had been copying her prescriptions and attempting to fill them more often than directed.
Still, when the pharmacist asked Mavromatis if she wanted to press charges, she refused. "This is a woman who became addicted to drugs and who had an illness and wasn't going out on the street and selling drugs," she says. "She didn't intentionally create her addiction. She became addicted and then was acting like an addict and broke the law."
Later that day, Mavromatis received her second unexpected phone call. This time, the woman was on the other end of the line, asking to come into the office for a visit. "She came in and was tearful and apologetic," says Mavromatis, who is now a solo physician in Atlanta. After speaking with the woman, Mavromatis decided to continue treating her, with the caveat that she would no longer prescribe the woman pain medication. "Saying 'I'm not going to see you anymore' is just basically sending her to the next doctor, and it's not really a solution for her," says Mavromatis, noting that the woman successfully came off the medication on her own. "The most compassionate solution is to work with patients, help them recognize when they have a problem, and then help them use medications appropriately or get off the medication."
All too common
For most of you, this scenario is a familiar one, though it plays out in different ways. Patients become addicted to prescriptions and start abusing them, and then their behavior changes in ways you would never expect. Worse, prescription abuse sometimes leads to tragedy. About eight years ago, Mavromatis lost a patient — a young mother of five — to an accidental overdose. Unbeknownst to Mavromatis, the woman had visited another clinic and obtained a prescription for a longer-acting narcotic, which she was taking in addition to the medications Mavromatis was prescribing her.
Part of the challenge in dealing with prescription-abusing patients is identifying when a patient is experiencing a problem and/or when a problem is escalating. Anyone can become vulnerable to abusing prescriptions because anyone can become addicted, and when patients become addicted, many are adept at hiding it, says Barbara Sullivan, associate director of the Utah Addiction Center at the University of Utah in Salt Lake City.
That's why it's essential to have open, honest relationships with the patients to whom you prescribe controlled substances, she says. You should discuss the addictive qualities of medications with patients; inform them that you will be carefully monitoring them when they are taking the medications; express concern if problems crop up; and discuss alternative approaches to treatment. Focus on creating a dialogue with the patient, she says, rather than simply doing all the talking. "In a lot of ways, it's like being a parent. The better you know your child, then the better you can tell when something is different or something is up."
A strong physician-patient relationship also increases the likelihood that a patient who is addicted, or feels that he is becoming addicted, will share this with you. In fact, Mavromatis credits the strong relationship she had with the female patient who copied her prescriptions as a key reason why the woman contacted her after the pharmacy scare. "She didn't feel like she had to run away from me," says Mavromatis. "She felt like she could come in and be truthful with me and we could salvage the relationship."
Alarm bells
When treating a patient with controlled prescriptions, the earlier you can identify a problem the better. Always keep an eye and ear out for changes in behavior, failure to maintain eye contact, slurred speech, ready excuses for inappropriate or problem behaviors, and/or a nervous or jittery manner, says Sullivan.
Also, learn to identify medication-seeking behavior. Patients who compulsively use medication, continue to use medication despite harm, complain they need more medication, horde medication, or request specific medications should raise your concern, says psychiatrist and attorney H. Westley Clark, who serves as director of the Center for Substance Abuse Treatment under the Substance Abuse and Mental Health Services Administration in Rockville, Md.
Also, learn to differentiate between "yellow flag" and "red flag" behavior, says Cleveland-based internal and addiction-medicine physician Theodore Parran. Yellow flag behavior indicates a patient may be abusing prescriptions and you should proceed with caution when treating him. Red flag behavior indicates a patient's health or safety is threatened, and you should immediately stop prescribing the medication, says Parran, who is also a professor at Case Western University School of Medicine in Cleveland.
Examples of yellow flags
• A patient asks for one or two early prescription refills.
• A patient takes all of his prescriptions but marijuana shows up in his toxicology screening.
• A patient reports that her spouse had a migraine so she gave him a bit of her own medication.
Examples of red flags
• You receive information from others that a patient is diverting or selling his medication.
• A patient alters, forges, or rewrites prescriptions.
• A patient suffers an accidental overdose.
• A patient threatens you or your staff.
• A patient continually raises yellow flags despite your warnings and attempts to reorient her.
A good prescription drug monitoring program makes it easier to identify when yellow and red flags are raised, says Parran.
Also, Parran says, require all of your patients to whom you prescribe controlled substances to sign informed consent forms.
*For five essential elements to include in your prescription drug monitoring program, visit: http://bit.ly/monitoring-program.
*For four commonly overlooked items these forms should include, visit:
http://bit.ly/informed-consent.
Careful approach
As soon as you begin to suspect a patient may be abusing prescriptions, express your concerns to him, says Sullivan. Do not, however, accuse him of abuse or approach him in a judgmental manner, says Clark. "Make sure that we don't take our suspicions and make them facts without exploring what's going on with the patient," he says. Instead, explain your concerns, describe why it may be risky for him to continue taking the medication as he is taking it, and reinforce your commitment to work with him.
If the patient recognizes the problem: Speak to him about a treatment plan. This plan will vary, of course, depending on the type and extent of the problem. For instance, in a non-emergency situation (perhaps a few yellow flags have been raised) consider a slow taper off the medication, says Parran.
If you believe it is necessary to stop prescribing immediately (perhaps a red flag has been raised) educate him about withdrawal symptoms, and attempt to refer him to a formal addiction-treatment provider, says Parran. If he refuses, do your best to help him manage the withdrawal and continue to try to talk him into a referral.
If the patient is in denial or refuses to recognize the problem: Try to get the patient to acknowledge the issue by discussing how his behavior has changed due to his medication consumption, says Clark.
If the patient continues to deny a problem, document your attempts to treat him, and document his reactions and resistance. Then, recommend evaluation by someone more skilled in addressing addiction issues, says Clark. If the patient refuses, tell him you cannot continue to write pain medications for him.
At this point, many prescription abusers will "fire" you, says Parran. If your patient does not, however, that does not necessarily mean you must discharge him. Consider continuing to treat him without prescribing him controlled substances.
Sticky situations
When a prescription abuser has committed a felony to gain prescriptions, not only will you need to determine if you will continue treating him, you also need to determine if you want to press charges.
For Parran, reporting the crime comes down to how you define your role as a physician. "My only advice to physicians is to be very clear in their own minds what their job is," he says. "Is it to stick with purely being a physician to this patient, in which case taking the patient off the controlled substances and dealing with the withdrawal is really as far as their job goes? Or, does the physician consider part of their job to be the so-called civic professionalism aspect of trying to notify the public health or the criminal justice authorities about somebody who is committing felonies?"
Be careful, however, when facing such a difficult dilemma. In some jurisdictions, you may be legally obligated to report such an incident if certain conditions are met, says Clark. Your state medical board may also issue a reprimand for failing to report an incident.
Aubrey Westgate is an associate editor of Physicians Practice. She can be reached at aubrey.westgate@ubm.com.
This article originally appeared in the June 2012 issue of Physicians Practice.
