One Of The Day’s Toughest Visits, The Drug Seeking Patient
I recall a good colleague of mine who hated dealing with such patients. She would always trade patients with me because I didn’t find these interactions all that terrible. I am going to share with you some of my tricks to have less confrontational visits with such patients without giving into their requests.
I use “drug seeking” which all clinicians are very familiar with (well except the pathologists…and radiologists). I obviously am not referring to someone who has an acute pain that needs to be addressed. It’s more a phrase that refers to a patient who makes an appointment for the strict purpose of getting a controlled medication refilled that they aren’t using for actual pain or are abusing.
If you dislike such patients, if you judge them or if you hate them then you already have a much bigger barrier to overcome. Instead understand that every person can have a weakness, an addiction, a character flaw… it’s just that in this case their issues/problems are spilling onto your world and you find yourself having to deal with it. Argh!
Accept that this person probably had very different circumstances in life and for whatever reason either got hooked on these meds or is benefiting in another way from obtaining them. So think of it like this, you are dealing with 2 very separate issues in one visit:
- the underlying reason for wanting the drug
- the actual prescribing of the medication
Your Standards of Practice
Some docs have this and many don’t… your practice methodology, your boundaries, your unique style. If you don’t have one I recommend developing one. Sit down with a pen and paper and chart it out. If you don’t have set, verbalized, stated boundaries you’ll never realize when they are crossed and so you will find yourself at the whim of the situation. I have developed my own for various issues/conditions, here are some examples:
- I follow a strict SOAP method of going through the exam. Let the patient speak their mind, go to the exam, order tests, summarize and form assessment/plan.
- I don’t let a patient be rude/threatening/abusive towards me and I respect them in return.
- If I’m having a hard time making sense of the H&P then I step out of the exam area and tell the patient “I need to look some things up”.
- I don’t treat pain as an emergency.
Understanding The Drug Seeker’s Mindset
I had a ‘reformed’ 30 yo guy who used to make his rounds 1 weekend a month at various urgent cares and dental offices and would collect 2,000 or so pain pills. He would sell them over the weekend and make a very sizable profit. He told me his methods and the basics were:
- at first he would appear helpless and he would practice his pains by looking it up online
- then he would act frustrated and try to rush the doctor
- then would get angry and continue to make eye contact until the doctor would break it
- he would always ask for a paper script if available
- he would just insist, repeatedly asking, begging, pleading
He said the final method usually wore down the clinician. He would get names of the ‘easy’ clinicians from random online forums or word of mouth. He would change the number of pills dispensed on paper scripts, he would have friends call in meds for him pretending to be the doctor’s office. Wonderful.
Try These Steps For the Next Drug Seeking Patient
- Walk in firmly, with plenty of energy, assertive, make eye contact and don’t overdo the smile.
- Maintain direct eye contact, follow their motions keenly with your head and eyes, appear objectively interested in their very lengthy HPI without coming across as incompetent or fearful.
- During the HPI do not answer any questions about any particular meds they may want, ask them if you can do an exam, proceed with the exam.
- Ask them what it is they are here for and exactly what medication they want and what they have taken in the past.
- Make sure they are done talking, command their full attention with direct eye contact and let them know that based on your exam and history you don’t think any opioids or benzos are necessary and you are willing to either try a TCA or gabapentin etc.
- If they interrupt you, calmly but firmly say “Excuse me, allow me to finish talking”. Finish whatever you have to say and give the patient 2 options (only 2) – for example a steroid/toradol injection/referral or a TCA/gabapentin.
- Resist arguing. Have the patient pick between the 2 options you provided and let them know that you almost never give benzos or opioids in the urgent care.
How To Answer Those Pesky Questions
So, if you completed step 7 the patient may be flustered and definitely caught off guard. If done effectively most of these patients will give up. But some will remain persistent and attempt to irritate you. My recommendation here is to simply repeat yourself (only once) and say: “I’m sorry but the two options I can offer you at this time based on my clinical judgement is [whatever 2 options you gave them].”
Below I have some sample fun conversations that have taken place in my urgent care and my responses. I have had good success with these responses, I hope they work for you as well.
Them: Well those don’t work for me so I’m not gonna take something that doesn’t work for me, I’ve already tried them!
You: I’m sorry then, it appears that I won’t be able to help you out with your pain at this time.
Them: So what you’re saying is that you don’t care about my pain and you’re just gonna let me suffer??
You: I hear that you think I’m brushing you off. Again, if either of those 2 options would work for you I would be happy to make them happen in order to help you with your pain.
Them: Well, then get me someone who CAN help me! Get me your supervisor or something.
You: I am the final person that makes the medical/clinical decisions here. There is nobody above me that you can speak with.
Them: Well, I’m not leaving until I get something for my $%&@ pain.
You: You are clinically stable and cleared so you may hang out in the room for a little while longer, after that we need you to leave the room/premises or security will escort you out.
Them: Give me your medical reasoning why you don’t think I should have xxx that I’ve had for xxx years.
You: I’m sorry that’s my final decision. Your attitude also is quite abrasive at this time. I won’t explain to you why I reached my medical decision.
Them: You say you don’t give narcotics for chronic headaches so why does my doctor do it? Are you saying they are wrong and you’re right?
You: You are welcome to see your regular doctor. I am the doctor you are seeing tonight and I make my own clinical decisions and can’t answer for another provider.
Them: Okay, tell me again why you won’t give me the medication that I came here to get. The medication that I NEED for my pain.
You: I’m sorry, I won’t repeat what I just told you.
Them: I’m gonna go into withdrawals you know, what happens then? It’s on your head if something bad happens to me.
You: If you get withdrawals from your benzo’s I recommend going to the ER. Withdrawal from opioids are uncomfortable but not life threatening.
Them: You’re a %$%@ and you should go &*%$ yourself because you are a huge waste of my *&%^@ time!
You: (walk out, contact security)
When you read some of these replies they may sound antagonizing; instead they are supposed to come across as firm and convincing. If you start out firm and don’t contradict yourself the visit will go by smoother than you think. From personal experience I can tell you that when you are kind but firm and fair these kinds of patients will be understanding. Don’t explain yourself, otherwise you will get sucked into a very dark hole that you can’t get out of. Frankly, many of these patients have mastered the art of manipulating people… they are probably much better and sometimes much smarter than us docs.
The only power they have is arguing and being forceful/tearful/insistent. Make your clinical decision, make good eye contact, be respectful but firm and repeat yourself only 1x. Use a lot of affirmation: “I hear you are frustrated and angry that you can’t have the medicine you are requesting…”, “So you are saying that the otc meds you are taking aren’t helping the pain”. Affirmations alone are sufficient to acknowledge the patient. You don’t have to have a solution for them. You should stand behind your clinical judgement.
- Be respectful but firm.
- Follow your methods for every single visit, don’t stray.
- Hear the patient out, do your exam, give them your non-opioid/benzo options and end the visit.
- Do not repeat yourself but once.
- Do not argue with the patient, use affirmations to acknowledge what they said 1-2x and then end the visit.
- There is nothing wrong with you ending the visit by walking out.
- You do not owe the patient a medical explanation when you know that it will only create a way for the patient to further argue with you.
What methods do you use in your practice?
What is the most challenging part of such visits for you?