How doctors can spot addiction in their patients

Addiction is a worsening public health crisis in America, and the statistics are daunting.

• Nearly 20 million Americans ages 12 and older have struggled with a substance use disorder in recent years, according to the American Addiction Centers (AAC).

• There were more than 93,000 drug overdose deaths in the United States in 2020—marking a nearly 30% increase over the previous year, according to the CDC.

• The wider costs of this health crisis are massive: $740 billion is lost each year in workplace productivity, healthcare costs, and crime-related costs because of drug misuse and addiction, per the AAC.  

• The COVID-19 pandemic and measures put in place to curb it have exacerbated the addiction crisis, notes the American Psychological Association (APA). People who suffer from substance use disorders are at greater risk of developing COVID-19, and they experience worse symptoms when they contract the virus. According to the CDC, 13% of Americans started using substances or increased their substance use to cope with pandemic-related stress or emotions. 

On top of that, a recent surge in counterfeit prescription pills capitalizes on and contributes to the worsening addiction crisis in America. Issued in late September, the DEA’s first Public Safety Alert in 6 years warns of a flood of fake prescription pills entering the illicit drug trade. These counterfeit pills often contain highly addictive and dangerous drugs like fentanyl and methamphetamine, and are killing Americans.

So what can doctors do about it? Let’s take a look at some ways to detect addiction and substance use issues in patients.

Talking with patients about substance use problems

Doctors have an important role to play in identifying patients with substance use disorders and addiction and helping them find treatment. 

In the case of opioids, identifying a problem early improves the patient’s chances of recovery. However, patients often hide substance use problems, so doctors need to provide specific and safe opportunities to discuss them, refraining from causing their patients to feel cornered.

In its opioids resources guide, the APA recommends a two-screening approach to give all psychological patients an opportunity to discuss substance use—questions that can serve as a guide for physicians. An initial screening question like “How many times in the past year have you used a prescription medication or illegal drug for nonmedical reasons?” can identify patients who should undergo further screening and assessment.

Three responses to this question indicate a cause for concern: Patients who say they use medication for the express purpose of getting high or changing their mood; patients who use more medication than they were prescribed, or for a longer time; and patients who purchase medication illegally or via “doctor shopping.”

If the first screening question raises warning flags for the clinician, the APA advises moving on to a more rigorous screening process to identify substance use disorders. The National Institute on Drug Abuse Modified ASSIST Screening Tool is free, does not take too much time to complete, and provides relevant, useful information for patients and physicians. 

In line with the APA recommendations, physicians may use a universal screening question to learn about patients’ alcohol, tobacco, prescription drugs (for nonmedical reasons), and illegal drug use in the past year. The NIH also recommends using the National Institute on Drug Abuse (NIDA) Modified ASSIST Screening Tool with any patients who disclose risky substance behaviors. 

Identifying drug-seeking behavior

Doctors must remain vigilant against drug-seeking behavior. Almost a third of all prescription drugs in America are used illegally without a prescription after falling into the hands of family and friends of patients or criminal networks who sell them. Doctors are an important line of defense against this dangerous activity, and they can employ various strategies to prevent them from occurring.

The American Academy of Family Physicians (AAFP) has published a multi-step approach that all doctors can take to ensure the drugs they prescribe are used only for their intended medical purposes. 

First, doctors should involve the entire care team in screening for warning signs. Inconsistencies in patients’ signs and symptoms can provide early clues that indicate drug-seeking behavior. If the whole team is on the lookout, drug-seeking behavior may be easier to spot. A phone call to a previous physician or pharmacist can also help doctors to build a clearer picture of a patient’s symptoms and whether they match a patient’s descriptions.

Doctors need to be mindful of suspicious behavior from patients as well, as this is often a good indicator of their substance use habits. Drug-seeking patients tend to lack patience and become obsessive, often calling physicians out of office hours.

Doctors treating an injury should obtain a thorough history of the injury from their patient, including details on the type and amount of force applied to the body when the injury occurred. When the patient describes their pain, it should follow the natural history of the injury. Patients claiming to have constant pain long after an injury has healed may be embellishing important details.

A physical exam and appropriate tests can also help doctors differentiate legitimate pain that requires treatment from addictive behaviors. Inconsistent responses to a physical exam are a telltale sign, because it’s difficult for patients to consistently fake an injury while physicians examine their posture, point tenderness, percussion tenderness, range of motion, and active resistance. Urine toxicology testing can also provide the doctor with useful information when assessing potentially drug-seeking patients.

Finally, prescribing non-pharmacological treatments such as physical therapy or home exercises can help to distinguish patients with genuine pain from drug-seeking patients. A patient who is not willing to try therapies like these may not be genuinely looking for improved function. The AAFP recommends verifying that patients will keep trying at least five non-pharmacological solutions before prescribing opioid medications.

For more information about safe prescribing practices, check out 4 controversial meds to be prescribed with caution on MDLinx.