How to manage drug-seeking behavior in patients with suspected substance abuse or dependency?

Managing Drug-Seeking Behavior in Suspected Substance Abuse

Recognize that apparent "drug-seeking" behavior often represents legitimate medical needs—including pseudoaddiction from undertreated pain, therapeutic dependence, or anxiety about symptom recurrence—rather than true addiction, and conduct a careful clinical assessment for objective evidence of pain before labeling patients as manipulative. 1, 2

Initial Assessment Framework

Distinguish Between Types of Drug-Seeking Behavior

The critical first step is understanding that drug-seeking behaviors have multiple etiologies, not all representing addiction 1:

• Pseudoaddiction: Behavioral changes mimicking addiction but actually secondary to inadequate pain control; patients seek alternate sources or increased doses because prescribed analgesia provides insufficient relief 1
• Therapeutic dependence: Patients with adequate pain relief demonstrate drug-seeking behaviors because they fear reemergence of pain or withdrawal symptoms, representing efforts to maintain comfort rather than addictive disease 1
• Pseudo-opioid resistance: Patients with adequate pain control report persistent severe pain to prevent reduction in current effective opioid doses 1
• True addiction: Chronic neurobiological disorder with loss of control over use, craving, preoccupation with nontherapeutic use, and continued use despite harm 1

Perform Objective Clinical Assessment

Conduct a careful clinical assessment for objective evidence of pain, which decreases the chance of being manipulated while supporting appropriate opioid use when legitimately needed 1, 2:

• Reports of acute pain with objective findings (vital sign changes, guarding, limited range of motion, visible injury) are less likely to be manipulative than chronic pain with vague presentations 1
• Look for consistency between reported pain severity and observable signs 1
• Document specific physical examination findings that corroborate the pain complaint 1

Stratify Patients by Severity

After positive screening, stratify into three categories 1:

• Hazardous use: Benefits from brief physician counseling 1
• Substance abuse: Requires brief counseling plus intensive ongoing follow-up and reevaluation 1
• Substance dependence: Needs combination of counseling, specialty treatment referral, and pharmacotherapy (drug tapering, naltrexone, buprenorphine, methadone) 1

Management Approach

For Patients on Opioid Agonist Therapy (OAT) with Acute Pain

Continue the usual dose of OAT and provide aggressive pain management with additional opioid analgesics as needed—never discontinue maintenance therapy during acute pain episodes 1, 2:

• Verify maintenance doses with the patient's methadone clinic or prescribing physician 1, 2
• Reassure patients that their addiction history will not prevent adequate pain management 1, 2
• Discuss the pain management plan in a nonjudgmental manner to decrease anxiety 1
• Recognize that patients on OAT typically receive treatment doses that block most euphoric effects of additional opioids, theoretically decreasing abuse likelihood 1, 2

Use higher doses of short-acting opioid analgesics at shorter intervals due to cross-tolerance and opioid-induced hyperalgesia 1:

• Write continuous scheduled dosing orders rather than as-needed orders 1
• Implement multimodal analgesia (NSAIDs, acetaminophen) and adjuvant analgesics (tricyclic antidepressants) to decrease total opioid requirements 1
• Avoid mixed agonist-antagonist opioids (pentazocine, butorphanol, nalbuphine) as they may precipitate acute withdrawal 1, 2

For Patients with Suspected Opioid Use Disorder

Offer or arrange evidence-based treatment, preferably medication-assisted treatment with buprenorphine or methadone maintenance therapy combined with behavioral therapies 2:

• Use DSM-5 criteria to assess for opioid use disorder or arrange evaluation by a substance use disorder specialist 2
• Identify treatment resources in your community and work to ensure sufficient treatment capacity 2
• Recognize that substance use disorder is a chronic medical condition requiring the same longitudinal management approach as other chronic diseases 1

Communication Strategy

Use a motivational rather than confrontational communication style during all interactions 1:

• Understand that patients dependent on opioids are often perceived as demanding due to distrust of the medical community, concern about stigmatization, and well-founded fears of undertreatment or OAT discontinuation 1, 2
• Patient anxiety related to these concerns can be profound and complicates adequate pain relief 1
• Address stigma directly, as it leads to social alienation and prevents patients from seeking care 1

Critical Pitfalls to Avoid

Never allow concerns about being manipulated to cloud clinical judgment about legitimate pain medication needs 1, 2:

• Physicians' concerns about manipulation are substantial, difficult to quantify, and emotion-laden, representing a powerful motive underlying reservations about prescribing opioids 1
• Undertreating acute pain leads to decreased responsiveness to opioid analgesics, making subsequent pain control more difficult 1, 2
• Pain is always subjective, making assessment challenging, but this does not justify withholding appropriate treatment 1

Never discontinue OAT during acute pain episodes 1, 2:

• Discontinuing maintenance therapy worsens pain due to increased pain sensitivity associated with opioid withdrawal 1
• Daily opioid treatment requirements must be met before attempting to achieve analgesia 1
• Notify the addiction treatment program regarding hospital admission/discharge and confirm timing and amount of last maintenance dose 1

Special Considerations

Screen for Comorbidities

• Comorbid mental illness and intimate partner violence are common in patients with substance use disorders and require concurrent management 1
• Assess for infectious disease risks (HIV, hepatitis, STDs, tuberculosis) in persons who use drugs illicitly 1

Documentation and Monitoring

• Careful record-keeping of prescribing information (quantity, frequency, renewal requests) is strongly advised as required by law 3
• Proper assessment, periodic reevaluation of therapy, and proper dispensing help limit abuse 3
• Be aware that "doctor shopping" and emergency visits near end of office hours are common behaviors, but preoccupation with adequate pain relief can also be appropriate in patients with inadequate pain control 3