Learning how to distinguish legitimate pain vs. narcotic/opioid seekers

[Aunt Val]

Hi, everyone,

I'm early in my clinical year and currently doing an internal med rotation.  Today I sat down with a patient who started telling me about her very difficult life situation, her depression, and chronic pain from a past physical trauma.  Due to circumstances beyond her control, she now finds herself without medical insurance and almost out of pain medication from the pain clinic, which she can't afford to go back to.  She asked if we could prescribe her some pain meds for a short time until she could get back on her feet.  She gave lots of details, her story was consistent, and she seemed legit.  I think she was telling the truth and genuinely needed help.

Except--I found out when I briefed my preceptor about the encounter that the patient had failed to mention failed drug screens several years ago.  It was in her records.  Three strikes already.  The clinic has hard and fast rules about these things, so no pain meds.  I don't fault my preceptor for refusing--she's very compassionate and gave some other options and a referral.  But the situation got me to thinking:  What would I have done?  Is there just one right answer?  And how does one learn the clinical discernment to make good decisions in this type of situation?  I feel very naive when it comes to drug abuse.  What's the balance between being naive and becoming jaded?  Any examples of situations that have helped you learn to be discerning while still exercising compassion?

[MT2PA]

The best predictor of future behavior is past behavior, as my favorite psych preceptor liked to say.

She may have fallen on hard times.  I think the answer is that you have to do your due diligence.  If your state as a PMP (or something similar) you should check it.  See when it was last prescribed in your system.  See if she's been elsewhere recently.  Does her pain require narcotics or is non-narcotic management reasonable.

Frankly I think your preceptor did the right thing.

[thinkertdm]

 Your first clue is when they ask for opioids out of the gate.  The second is when they swear such and such “won’t” work.  Third is when they argue with you about your choice.
opioids are never an emergency; check uds, check the state pmp.  
Best answer: why won’t nsaids work?  Is it warfarin?  Work with or adjust it accordingly.  Is it an other thinner anti platelet?  Short courses still not contraindicated.  
Topical nsaid, capsaicin, lidocaine all good choices.

Dont forget nsaids increase cardiac risk; while it’s nice to prescribe the ones with funny names no one has heard of, like etodolac, nabumetone, relafen, etc, remember that sometimes they increase the risk more.

Oh, if they start up with a long elaborate story, then they are trying to confuse you.

The best treatment is tincture of time.

 

[rev ronin]

On 8/17/2019 at 2:02 AM, thinkertdm said:

Oh, if they start up with a long elaborate story, then they are trying to confuse you.

This.  Plausible sounding stories are either true, or from good liars.

So...
1) Let them talk, tell you their story "Is that all?"
2) "I'm going to go run a PMP query.  Is there anything you haven't already told me that I will find on there?"  Then run the query, if you haven't already.  If they've 'forgotten' anything more than a few Vicodin from a dentist, we're done.
3) "We're going to have you pee in a cup, for an instant-read drug screen. Is there anything that might show up in there you want to tell me about?"  Then run the drug screen, and have the send-out confirmation done for any discrepancies before any prescribing, no matter what their protestations.  If they can't pay for the drug screen, they can't get drugs from you, simple as that. If they can't pee right now, they can have as much time and water as they need until the clinic closes, but they must give a sample before leaving the premises, or again, we're done.

TL;DR: trust everyone, but cut the cards.