A Patient with Legal Drug Addiction in Primary Care
Essentials
Addiction is a different phenomenon than physical drug dependence, where withdrawal symptoms prevent the discontinuation of medication that maybe is no longer needed. Addiction typically leads to harmful behaviour, such as attempting to obtain prescriptions for escalating doses without caring about the consequences.
A certain degree of suspicion is required of a physician so that he/she does not inadvertently support the patient's addiction. The most important goal is to identify those with legal drug addiction and steer them to treatment. When a physician identifies a patient with legal drug addiction, he/she should be able to show empathy, be direct and have a sincere wish to understand and help the patient.
When selecting the line of therapy, a physician should consider whether he/she is able to treat the patient by him/herself or whether the patient should be referred to a unit specializing in the treatment of alcohol and drug abusers.
The chosen line(s) of therapy and pharmacotherapy should be recorded with appropriate accuracy along with their justification.
Drugs used on the street
Benzodiazepines (especially those with a rapid onset of action, such as alprazolam, midazolam, temazepam and also diazepam)
Buprenorphine
Oxycodone
Methadone
Ethylmorphine
Pregabalin and, increasingly, gabapentin
Codeine
Tramadol
Methylphenidate
Dextromethamphetamine
Cough preparations containing opioids
Drugs that have an intoxicating effect when used in combination with alcohol
Atropine-containing antidiarrhoeal drugs
Biperiden
Strategies employed by drug-seeking patients
Target
Young physicians
Physicians who, due to personal problems or malpractice, are willing to write prescriptions in exchange for financial gain
Naive, empathetic physicians
Additionally, being in a hurry, having too much work and lack of professional support predispose to situations where drugs may be prescribed with poor justification.
A drug-seeking patient
knows the normal indications of controlled drugs and gives a medical history with text book symptoms
may admit to be a drug misuser wishing to stop using drugs and needing them only temporarily to see him over the worst period
may try to elicit sympathy with emotional stories
often feigns physical problems, such as neck pain, migraine or urinary tract stones; prescribing narcotic or strong pain killers for an unknown patient is hardly ever justified, at least at the first appointment
often presents documentary evidence concerning his illness, for example medical reports, doctors' certificates or prescriptions from well-known physicians; some of the patients do actually have a genuine history of the illness they claim to have
may show scars as evidence of injuries or may appeal by telling pitiable stories
may only visit seldom, but regularly, and may visit several physicians (”doctor shopping”) leaving each one with an impression of a patient who uses drugs only as prescribed
may threaten the physician directly with violence or suicide or with blackmail, for example by writing to a newspaper.
A drug seeker may be a well turned out young man or an attractive young woman.
If misuse is suspected
Even though withdrawal symptoms may be troublesome they rarely are life threatening, although the seizure risk associated with benzodiazepines must be borne in mind. Broaching this directly with the patient often helps to put the physician in charge of the situation.
Remaining calm conveys the impression of a confident physician who will not be easily fooled.
A high risk of dying from overdose intoxication is present in uncontrollable misuse. Amnesia caused by high drug doses as well as self-destructive, demanding and threatening behaviour are typical symptoms in drug addicts. A patient in this condition should be carefully examined and, despite all the difficulties, efforts should be made to keep him/her within reach of care.
The physician may offer an appointment at a drug withdrawal centre and help the patient during his rehabilitation.
Naproxen combined with quetiapine (25-50 mg) or levomepromazine (25-50 mg) may be used as a first aid medication for pain; this will also help the patient sleep. Hydroxyzine 50-100 mg, mirtazapine (15-30 mg) or doxepin 10-50 mg are suitable alternatives in sleep disturbances.
Opioids or psychostimulants should never be prescribed to patients whose behaviour clearly indicates that they are seeking these drugs.
If it is necessary to prescribe benzodiazepines in order to relieve immediately threatening withdrawal symptoms
a prescription should not be issued at the first visit but
the patient should be given a suitable dose of the medicine on the premises and
an appointment should be made for the next visit or the patient is directed immediately to a detoxification centre.
Benzodiazepines should not be prescribed to unknown patients, or to those inclined to addictive behaviour. Neither should large doses, high strength tablets or large amounts be prescribed.
Even if you would be in a hurry, check really what other drugs affecting the central nervous system the patient has.
Appropriate investigations (a thorough physical examination of a patient with pain) or consultations will give the physician more time and will allow him/her to turn away drug seekers in a non-confrontational and professional way.
A physician must not succumb and write a prescription if threatened by a patient with substance abuse problems. The patient should be told that a security guard or the police will be summoned or that the blackmailing will be reported to the authorities. Violent patient: see Encountering a Violent or Threatening Patient.
A positive first step towards a working doctor-patient relationship may be a physician's acknowledgement of the patient's possible physical, psychological or social problems, and his/her willingness to offer any available assistance.
It is important to bear in mind that some of the patients who use benzodiazepines regularly actually need the drug in order to treat chronic and severe anxiety states. Potential signs of misuse should be monitored regularly and interfered immediately while at the same time supporting the patient.
When prescribing benzodiazepines, check local official guidance.
Examination of a drug misuser and assessment of treatment needs
A drug misuser who is in a chaotic state of mind may require institutional or even hospital treatment.
In a hospital setting, the examination may either be carried out with the consent of the patient or, if prerequisites are met, he may be compulsorily sectioned under appropriate legislation.
The assessment of treatment needs may be initiated in primary care if the patient is able and willing to co-operate by supplying the relevant information about his chaotic misuse of drugs.
The following facts should be established with the patient:
when were the drugs first prescribed and for what indication
when did the misuse start
when did it get out of control
what proportion of a daily drug dose consists of drugs prescribed by a physician and how much is purchased illegally
Decide whether the patient can safely be treated as an outpatient or whether outpatient phase should be preceded by a withdrawal period within an insititution.
Usually high drug doses or polysubstance use speak for institutional drug withdrawal.
Agree with the patient a clear goal for the treatment and its timeline.
The goal may be reduction of dose or withdrawal.
Be flexible with timelines, but not with goals, unless there are cogent reasons.
As the therapy progresses and the patient's situation alleviates, the interval of dispensing the medication may be increased.
When treating patients who have problems with pain, aim at cooperating with the pain management unit of your area. Abuse does not mean that there is no need for appropriate pain management.
Medication to control the withdrawal phenomenon and associated symptoms are delivered either under supervision at a health care facility or by pharmacy staff under special agreement. The progress of the patient is monitored at sufficiently frequent intervals.
If the medication is given at a health care facility, the patient should have preferably daily meetings with his nurse. During the first 2-4 weeks, the treating physician will comment on the progress 2-3 times a week (based either on a consultation between the physician and the nurse or on a meeting with the patient). After the situation has been brought under control, the intervention of the physician is only needed every 1-4 weeks.
The initial aim is to stabilise the patient's drug habit in order to break the vicious circle between the increasing need for drugs and subsequent overdoses as well as to prevent the emergence of withdrawal symptoms, such as convulsions or delirious states. The stabilising dose does not usually need to be higher than the maximum recommended dose, even in patients who give a history of drug use with, occasionally, very large doses. A need for higher doses is an indication of a referral to a suitable drug rehabilitation centre.
The diagnosis and/or other indications of drug use and the degree of dependence are established during 2-8 weeks of treatment. The speed of dose reduction is planned individually Long-Term Benzodiazepine Use and Withdrawal.
The treatment of addiction to opioid analgesics principally follows the same guidelines as the treatment of benzodiazepine addiction.
The dose of tramadol, codeine or other prescribed opioid analgesic should be gradually decreased under close supervision.
If the opioid withdrawal symptoms become too troublesome, they may be alleviated with clonidine.
If the craving for opioids seems to be reactivated after the withdrawal symptoms have been suppressed, naltrexone may be used to prevent a relapse. In this case the patient should not have any opioid residues left in the body (naltrexone may be started with small doses, for example 12.5 mg initially 7-10 days after the drug was stopped and after convincing proof has been obtained by drug screening test(s) to show that the patient does not secretly use opioid agonists).
If opioid withdrawal repeatedly fails, the condition may in some cases be interpreted as chronic opioid dependency that warrants opioid replacement therapy. National legislation and other local regulation provide more detailed guidance on this.
During benzodiazepine and pain medication withdrawal it is recommended to regularly evaluate the situation by screening tests with regard to use of pharmaceuticals or potential extra drugs (beyond the prescribed dose) and, if necessary, refer the patient to a more active treatment provided by specialized services or an institution.