It’s 3 AM, Sunday, when the triage bell sounds. It’s Linda, a 37-year-old patient, well-known to emergency department (ED) staff, complaining about her “usual” migraine. Of course, she has a “bad one that Imitrex won’t touch.” And the latest neurologist she saw “just doesn’t understand my condition and won’t give me medication that works.” All he suggested were nonsteroidal antiinflammatory drugs, to which she insists she’s allergic, despite no previous documentation of any reaction in her extensive charts. Grimacing and photophobic, Linda appears upset and nervous in triage. Oddly though, minutes later when you call her back into the treatment area, she’s watching TV, smoking, and laughing. But when you call her name, she displays an expression of sheer agony, shielding her eyes from the light.

James calls the office at 4:30 Friday afternoon. He has had back pain all week and wants to have his wife pick up prescriptions for Vicodin and Soma. He understands the office is busy; an appointment now would be impossible. James says he doesn’t need to be seen, because it’s his “usual” pain, and he’s had medications prescribed by phone previously.

Timothy is at his primary care clinic two times a month with painful herpetic lesions around his urinary meatus. Each time, he receives a requested prescription for 30 Percocet tablets to “get him through.” You’re moonlighting in an ED one weekend when Timothy arrives. Staff nurses tell you he’s a “regular,” and “the physicians usually give him what he wants to get rid of him.”

What could these three patients have in common? They may be drug seekers, patients engaged in behaviors, verbal requests, or mannerisms aimed at obtaining addictive substances for nontherapeutic individual use and/or for resale. For example, Linda and James may need to obtain medications to satisfy an addiction or pseudoaddiction, while Timothy may want to stock up on prescription drugs to illegally sell them on the street.

Drug seekers, who vary in age, gender, and socioeconomic status, may be hard to recognize. They may be unaware of their behavior or, conversely, deliberately deceiving health care workers. Their behavior can frustrate nurses, evoking ineffective interventions or provoking outright hostility. Drug seekers can be difficult patients; they require careful observation, interventions, and documentation to remedy their true problems. Would you be able to recognize and differentiate them from other patients?

Is drug seeking a problem?

Modern U.S. drug laws evolved from initial laws and treaties contained in the Harrison Narcotics Act of 1914,¹ although the significance of narcotic abuse as a medical concern was documented much earlier in the 1877 writings of Levinstein, a German physician.² Currently, the Controlled Substances Act of 1971 mandates the strict regulation of controlled substances. The act delineates five specific categories or schedules based upon actual or relative abuse potential, related potential for individual or public harm, current knowledge of pharmacologic properties, and the scope and pattern of abuse of the substance or similar substances.³

Misuse of prescription drugs that are regulated by this act surpasses all illegal drug usage combined. For example, the National Institute on Drug Abuse (NIDA) reported that in 2003, an estimated 6.3 million people — nearly 2.7% of the population age 12 or older, had used prescription drugs nonmedically in the previous month.⁴ Data from 2003 revealed that nonmedical use of legally manufactured, controlled substances accounted for 17% of drug-related ED admissions.⁵ Numerous studies relate substance abuse, which often involves legal prescriptions, to an increased incidence of major social problems, including AIDS/HIV, homelessness, and crime.^4,5

Health care professionals themselves contribute to the problem. For example, the abuse of prescriptive authority has drawn widespread attention, most recently from the U.S. House of Representatives subcommittee investigating Medicaid fraud. An alarming 20% of every Medicaid dollar is spent for substance abuse-related care. The committee concluded that some physicians weren’t performing adequate patient evaluations or prescribing responsibly, merely acting as “drug dealers armed with prescription pads.”⁶

NIDA notes that more than half of primary care physicians report difficulty discussing misused prescription drugs and substance abuse, yet less than one-fourth had difficulty discussing depression.⁴ Although many drug seekers acquire drugs by merely manipulating health care professionals, the activities of providers themselves, sometimes financed by fraudulent health care claims, fuel the problem. For instance, providers might prescribe drugs for phoned-in complaints and bill insurance companies for a visit without really seeing the patient.² This is especially common with benzodiazepines prescribed for anxiety, and pain relief medications. An apathetic “why bother” attitude interferes with the confrontation of drug seeking and abuse.

Who are the real victims?

Drug seeking victimizes the seekers, other patients, and health care professionals. Drug seekers become victims of their own diseases, poor pain management, addiction, and criminal behavior. At the same time, they exploit the health care system, divert resources and time from other patients, erode public confidence in the professionals they scam, contribute to family discord, and become potential safety threats to themselves and society.^7,8 Health care professionals who appear to abet illegal drug-seeking behaviors risk the loss of their licenses or the revocation of their controlled substance dispensing number issued by the Drug Enforcement Agency.^1,3

Drug seekers have good reasons to pass over traditional “street drugs” to search out health care professionals for prescribed medications. For instance, these drugs have better potency, consistency, purity, availability, and resale value; and there is less risk of HIV associated with professionally delivered injections. Enhanced access to care from laws that mandate care regardless of ability to pay and social programs that provide prescription drugs at low to no cost also contribute to their appeal.^1,8 Even the emphasis on efficiency of health care delivery systems promoted by managed care boosts their availability. For example, it’s easy to reduce the lengths of ED visits and time spent listening to patients by simply writing prescriptions and dispensing.⁷

A dark side obscures a full understanding of drug seeking. It’s difficult to study what is unlawful.⁹ Legally obtained prescription medications are often sold to purchase illegal drugs or finance prostitution.¹⁰ Street markup is considerable and the use of these drugs is diverse. Some potent sedatives, hypnotics, and opioids are crushed, diluted, and injected, while antihypertensive medications, such as clonidine (Catapres), are taken by mouth to manage withdrawal symptoms of cocaine or heroin.¹¹

Understanding drug seeking

One force that drives patients to seek out prescriptive medications is the complex, subjective phenomenon of pain. Many health care professionals have difficulty evaluating it. The extent of pain can be masked by stoic behavior, exaggerated by hysterics, or disguised by coexistent psychological problems. It’s also hard to differentiate the behaviors of patients driven by pain from those with other motives.⁷ Most patients who complain of pain don’t seek a euphoric state, but relief from disabling or unbearable discomfort. But among them are patients who seek drugs to cope with addictions or provide them with illicit incomes. It takes experience gained through exposure and a keen eye to differentiate among them.

Other forces behind drug seeking and abuse — addiction, pseudoaddiction, tolerance, and physical dependency — are often misunderstood. For example, addiction has been wrongly equated with physical dependency and tolerance. And pseudoaddiction is a complicated phenomenon that often goes unnoticed.

Addiction is a psychological dependence or craving for drugs. Addiction is a chronic, relapsing, yet treatable disease.¹² It is characterized by both denial and compulsivity in a constant search for the psychological effects of mood-altering substances. Addicts who are not in treatment or recovery no longer have control over their drug use, despite its harmful, negative effects.^9,12

One of the surest signs of addiction is lack of improvement or worsening in psychological well-being and social or vocational function, despite the best pain control attempts.^9,12 Addicts sometimes use medications prescribed to them in ways to intensify their effects, such as taking them on an empty stomach, with alcohol or other drugs, or at dosages or frequencies exceeding what was prescribed. Consequently, addicts often run out of medication before expected.⁹

Pseudoaddiction is a behavioral manifestation of inadequate pain control. Unrelieved pain can cause so much anxiety and distress that some patients develop the mindset of an addict. They try to procure more medications as a result of unrelieved pain or in anticipation or fear of running out of analgesics. The resulting drug-seeking behavior may lead health care personnel to inappropriately identify these patients as addicts.¹⁴ It’s important to remember that pain management is the most common force driving patients to seek prescription medications.¹³

Tolerance is the need for an increased drug dosage to produce the same effect or level of previously experienced analgesia.¹⁴ This physiologically learned cellular response may be acute or chronic, depending upon pharmacokinetic properties and individual metabolic factors, such as the ability of the liver or kidneys to excrete the drug. Recent research indicates that opioid tolerance may induce abnormal pain sensitivity and can actually render the medications less effective or even enhance the sensation of pain.¹⁵ Tolerance, a neurobiological response common in pain management, isn’t always obvious and doesn’t necessarily signal addiction.¹⁶

Physical drug dependency is the neurobiologic basis for drug craving,¹⁴ when brain pathways related to brain glucose metabolism and mechanisms within the dopaminergic and limbic systems act to positively reinforce and reward drug use. Environmental “cues,” such as increased social acceptance by peers, also provide reinforcement to induce drug craving and drug-seeking behaviors. Physical drug dependency is manifested by withdrawal symptoms after abrupt discontinuation of the drug or if an antagonist is administered.¹⁴ Although this dependency isn’t the same as the psychological problem of addiction,¹⁴ it may occur together with either addiction or pseudoaddiction.

A taxonomy of drug seekers

Drug seekers are informed people. They know preferred medications by name, strength, color, price, and manufacturer, often better than prescribing practitioners. The most sought-after substances include narcotic pain medications, benzodiazepines, stimulants, hypnotics, and barbiturates.^5,7 Diverse motivations ranging from personal drug use for medical or psychological reasons to seeking drugs in the absence of illness purely to support criminal activity preclude a single profile for drug-seeking individuals. However, drug seekers can be loosely grouped for easier recognition.

• User-abusers seek drugs because of addiction, pseudoaddiction, or physical drug dependency.¹⁷ They may have initially used prescribed medications for valid medical conditions, but now use them for other reasons, despite negative consequences.

Some are professional patients, who exploit chronic medical conditions or feign illness to secure drugs. They know the medical aspects of their disease; use resource materials, such as the Physicians’ Desk Reference or textbooks not generally accessed by other lay public; and exploit medical jargon or “buzzwords” that are familiar to clinicians. For example, the patient may complain of a migraine that is “intense, but has my usual pattern,” meaning that treatment requires only medication and not diagnostic tests.^9,17

Professional patients try to persuade providers to diagnose by history, and when tests are performed, they may try to make the results fit their alleged disease, such as tainting urine specimens with blood to emulate renal pathology or arriving with their own diagnostic reports from prior “workups.” Usual complaints include dental abscesses or toothaches, back pain, colitis, orthopedic problems, metastatic cancer, narcolepsy, headaches, tic douloureux, carpal tunnel syndrome, sciatica, diabetic neuropathies, painful herpes simplex lesions, shingles, depression or anxiety, insomnia, and sickle cell disease.¹⁷

Professional patients attempt to control the interview and apply psychological pressure to health care providers. They often refuse workups or leave before treatment is completed, if they perceive their drugs of choice will not be given. On the other hand, they can be overly talkative, polite, and friendly with staff, trying to evoke sympathy and manipulating them to dispense the right drugs.

• Pseudoaddicted patients are those who have been legitimately prescribed medications for pain management. As a result of inadequate pain control or in anticipatory fear of running out of medications, pseudoaddicted people engage in drug-seeking behaviors to procure an adequate supply of pain medications. The cure for pseudoaddiction is comprehensive and frequent assessment of pain and adequate management.
• Psychologically disturbed patients obtain prescriptions in association with mental illness, such as dual diagnosis, schizophrenia, Munchausen syndrome or Munchausen syndrome by proxy, or a tendency toward suicide or self-injury. They may inflict external trauma upon themselves or violate their own body cavities to create a valid reason for requiring medications; they may present with problems such as ruptured tympanic membranes, nasal mucous membrane or oral trauma, corneal abrasions, soft tissue injuries, bruising, fractures, or vaginal bleeding inconsistent with menstrual flow.¹⁷ Substance abuse among this group, particularly with amphetamines, sedatives, and hallucinogenic drugs, is much higher than the general population.¹⁴
• Entrepreneurs are “street pharmacists” who obtain prescriptions for medications that can be resold for profit.¹⁷ Their tactics include stealing prescription pads; forging prescriptions; or calling in prescriptions by phone, while posing as a prescribing physician.^7,17 They are engaged in a covert business activity that entails few risks and great rewards for minimal effort. They may also rummage treatment areas for drug paraphernalia having potential street value, such as needles, syringes, or partially filled or prefilled syringes.

Entrepreneurs often refuse diagnostic testing, intramuscular injections, or medications for immediate consumption. They encourage providers to prescribe a maximum amount of pills or ask for a number that is easily converted to a greater one (for example, 10 can become 40 or 100 with a stroke of a pen).¹⁷ They will also request that prescriptions be written separately (so they can selectively fill them) and discarding the ones for medications without street resale value. Potent extended-release medications, such as oxycodone (Oxycontin), that can be crushed and used for immediate effects, are especially sought after.⁸ Often they express a preference for brand name drugs over generics because of street recognition as “the real thing.”⁷ They may even express a preference among drugs in the same class based upon resale value — for example preferring a high-dose hydrocodone/acetaminophen (Vicodin) — with a street value of $15 per pill to oxycodone/acetaminophen (Percocet) at $10 street value per pill.⁹ Entrepreneurs are often hurried, because they may intend on visiting several facilities or offices. They know exactly what they want, adamantly refusing alternatives.

What to do

Confronting a drug seeker can be therapeutic at best, dangerous at worst, and almost always difficult. Although only nurses with advanced practice status have the authority to prescribe, all nurses are involved in the assessment, medication, and direct care of drug seekers.

Problems are apt to arise when these patients realize that their search for drugs might not be successful. Some may simply leave when they figure out they won’t get what they came for. Others may become hostile or intimidating, threatening suicide or litigation. Avoid confronting drug seekers alone and maintain your professional boundaries, carefully assessing and intervening appropriately for the safety of the patient, yourself, and other staff. Don’t hesitate to involve social services, psychiatric support, security, or even the police in extreme circumstances.^8,17

Be cautious not to violate patients’ right to privacy — unless they have given consent for you to share information with other local emergency departments, that late night call to warn other nurses of a potential seeker “on the hunt” may get you into trouble. Electronic surveillance systems and pharmacy tracking programs have assisted in uncovering and documenting many drug seekers’ behaviors. Speaking with a pharmacist regarding a prescription suspected of being tampered with is, however, within the expected need to share information to provide adequate and consistent health care. Many insurance companies also monitor the use of prescription medications closely, which help to identify the pseudoaddicted and user-abusers, but of little assistance in identifying entrepreneurial seekers.¹⁸

Nurses have an obligation to do no harm, and to knowingly support addictive or illegal behaviors is unethical and can even be illegal. Nurses should not remain silent objectors when called upon to medicate patients they believe are drug seekers; they need to appropriately voice their suspicions to prescribing providers, especially when this information may assist in the identification, diagnosis, and treatment of problems of abuse or criminal behavior. Clearly and objectively document your concerns and observations (such as inconsistencies in behaviors from the waiting room to the treatment area) on the medical record, using direct patient quotes whenever possible. Providers should be encouraged to review the entire medical record, not just the complaint data for that specific visit, before controlled substances are provided.

Nurses need to move beyond the narrow role of controlling disease and injury and examine the psychodynamics behind their patients’ problems. Assessing and identifying substance abuse isn’t only the domain of psychologists and therapists, but the responsibility of every health care provider. Treatment, however, should be reserved for specialists. Nurses can focus on assessment and clear documentation to aid future referral. Meanwhile, be sure to secure prescription pads, sharps containers, and drug paraphernalia from possible theft.

Veteran drug seekers are eventually found out. Some enter treatment programs, others go to jail, and a few die as a result of addictive or criminal behaviors. Most simply wear out their welcome at your facility or office and move on. When dealing with suspected drug seekers, strive for cautious balance. The desire to reduce drug diversion or abuse shouldn’t be at the expense of patients who need treatment for addictions or an adjustment to their pain management program.^7,13 Be careful not to label patients too quickly but to identify and document behaviors that support your suspicion of drug seeking. Tips and cues presented here can sharpen your skills when evaluating suspected drug seekers.