Presentation: Often provide well-developed clinical histories that may sound very ‘real’.
Behavior: Aim to exploit doctors’ desires to minimize patients’ distress, typically being very pleasant rather than aggressive.
Legitimate Complaints: Some patients may have legitimate medical issues but have developed dependency or tolerance over time, requiring larger doses to function daily.
Spectrum of Drug Misuse Behaviours
Range: Drug misuse behaviors can vary widely and may not be obvious during the consultation.
Examples of Behaviors:
Doctor Shopping: Visiting multiple doctors to obtain prescriptions.
Forging Prescriptions: Altering or forging prescriptions to obtain drugs.
Claiming Lost Medication: Frequently reporting lost or stolen medication.
Early Refill Requests: Consistently requesting early refills.
Non-Compliance: Failing to follow prescribed treatment plans while requesting more medication.
Managing Drug Misuse
One-Doctor Policy:
The RACGP advises a one-doctor policy within the practice for prescribing any drugs of dependence.
Special arrangements should be made to cover leave to maintain this policy.
Aim: Minimize drug-seeking behavior and its resulting harms and costs to the healthcare system.
Risk Assessment:
Assess the risk of opioid misuse using the patient’s drug and alcohol history or tools like the Opioid Risk Tool.
Prescribing Boundaries for “At Risk” Patients:
Adjust boundaries to include once or twice weekly pickup from a local pharmacy.
If instability persists, consider referral to Drug and Alcohol services.
Behavior Standards:
Set clear behavior standards for patients on opioid therapy, including:
Obtaining scripts from one doctor and one pharmacy.
Receiving staged supply through the pharmacy.
Regularly attending appointments and engaging with other supports.
Agreement on the cessation of a therapeutic trial if needed.
Addressing consequences of inappropriate behavior.
Managing Manipulative Behaviors
Caveat:
While most patient involvement is clinically driven, some requests may involve manipulation.
Right to Healthcare: Patients have a right to good healthcare but not to access drugs of dependence.
Clinical Boundaries: Maintain clinical boundaries and refuse therapy if it is detrimental to the patient’s health.
Responding to Manipulation: Educate on appropriate responses to manipulative behaviors. Use scripted replies for difficult situations.
Strategies for Clinicians
Consistent Monitoring: Regularly monitor and review patient prescriptions and usage.
Communication: Maintain clear and open communication with patients about the risks and management of drug dependence.
Education: Educate patients on the risks of drug misuse and dependence.
Support Systems: Implement support systems within the practice to identify and manage drug-seeking behavior effectively.
Referral: Refer patients to addiction specialists or support services when necessary.
Summary
Awareness: Clinicians should be aware of the wide spectrum of drug misuse behaviors and adopt strategies to manage them effectively.
Policy Implementation: Implementing a one-doctor policy can help minimize drug-seeking behavior.
Patient Care: Balancing the need to manage legitimate pain with the risks of drug misuse is crucial in providing effective patient care.
