A talk with addiction specialist Dr. Casey Grover about behavioral indicators of so-called “drug-seeking behavior,” which is when people try to deceptively convince doctors to prescribe them drugs. Grover hosts the podcast Addiction in Emergency Medicine and Acute Care. We talk about: why Casey thinks “drug-seeking” is a bad, unhelpful term; what behavioral clues doctors use to determine if someone might be “drug-seeking”; why most behaviors aren’t that reliable; America’s drug problems (opioids, fentanyl, methamphetamines).
A transcript is below.
Episode links:
- Apple podcasts (embedded below)
- Spotify
- YouTube
Resources discussed in this episode or related:
- Research paper How Frequently are “Classic” Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department? by Casey Grover et al
- Opioid risk tool discussed by Grover
- Paper by Jenny James: Dealing with drug-seeking behavior
TRANSCRIPT
[Note: transcripts will contain errors.]
Zach: Welcome to the People Who Read People podcast, with me, Zach Elwood. This is a podcast about understanding other people and understanding ourselves. You can learn more about it at behavior-podcast.com.
If you’ve enjoyed this podcast, would you be willing to give it a review? If you’re willing to do that, please leave it a review on Apple Podcasts; if you don’t know how to find that, there’s a link to Apple Podcasts on my site at behavior-podcast.com.
In this episode, I talk to Dr. Casey Grover about so-called drug-seeking behavior, which is the term used for when people who have drug addictions, for example, to opioids, attempt to deceive doctors in order to get a prescription.
I learned about Dr. Grover when I read a research paper from 2012 that he was a part of; the paper was called How Frequently are “Classic” Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department?. That study looked at a population of patients who were flagged as being likely to have so-called drug-seeking behaviors, and found that the behaviors that were often most associated with drug-seeking were pretty uncommon in these people’s emergency department visits. To quote from that study: “The most prevalent classic drug-seeking behavior was complaint of 10/10 pain, followed by complaint of headache, and then complaint of back pain. The least prevalent behavior was complaint of lost medication.” end quote. That paper also pointed out that such behaviors were pretty common genuine complaints of people in emergency departments, which pointed to the general unreliability of using such behaviors for the basis of making decisions.
Dr. Grover is also the host of a podcast about addiction, which is called Addiction in Emergency medicine and acute care. To quote from the podcast description: “A practical and evidence-based podcast on how to think about, diagnose, and treat substance use disorders in the Emergency Department and Acute Care.” end quote
In this episode, we talk about the reasons why most of the well known drug-seeking behaviors aren’t strong evidence of addiction; we talk about some behaviors that can be meaningful; we talk about the pressures doctors face to both give patients the care they need while at the same also trying to avoid giving drugs to people with drug abuse problems; we talk about America’s drug problems, including our problems with opioids, meth, and fentanyl. One of Casey’s recent podcast episodes included his thoughts on why the phrase ‘drug-seeking behavior’ is not a helpful one and should be retired, and we talk about that, too.
A little more about Dr. Grover: he’s the Chair of the Division of Emergency Medicine at Community Hospital of the Monterey Peninsula. He graduated from medical school at University of California, Los Angeles as one of the top three students in his class. He completed his residency at Stanford in Emergency Medicine, and was chief resident. He’s also currently in the process of becoming board certified in addiction medicine in addition to being board certified in emergency medicine.
Okay, here’s the talk with Dr. Casey Grover.
Zach: Hey Casey, thanks for coming on.
Casey: Thank you so much for having me. I’m very pleased to be here.
Zach: So maybe we can first talk about, maybe you can explain a little bit about what the term drug seeking behavior means, and maybe also why you are not a fan of that term.
Casey: I. That is a fantastic question to get us started. And I think the definition and understanding of what the term means has changed over time, kind of in my understanding and also in the understanding of the general medical community. Um, so I graduated medical school in 2010 and at that time, drug seeking really, we associated with people trying to seek prescription opioids.
And at the [00:04:00] time, really kind of what we all did was. When we identify this behavior is we as doctors said, you patient have a problem. I’m not gonna prescribe you anything you need to be discharged. And that really was in part, um, what drove the movement from the first part of the opiate epidemic of prescription opioids to the illicit.
Opioid market, which was the second wave or the second part. So I personally, by telling someone who is asking for a refill of their, you know, oxycodone, you’re drug seeking, you need to be discharged. I pushed people personally from prescription opioids to heroin. I. And at the time it, it was kind of just what we thought made sense.
This was a new phenomenon of overprescribing opioids. This was a new phenomenon of seeing young people coming to the emergency department or their primary care setting, asking for opioids. And over time I now realize that we really missed the mark. [00:05:00] Drug seeking is a symptom. Just like nausea, it’s not a diagnosis and that’s really where the problem is and why I initially researched drug seeking behavior ’cause I wanted to learn more about it.
And over the last 10 to 12 years, I’ve really began to understand it better and the nuances that drug seeking behavior is a symptom that must be further investigated by us as doctors and healthcare professionals.
Zach: So if you think someone is addicted and you don’t wanna push them away, obviously for the reasons you mentioned, what is the, the proper path?
Is it to ask more questions and, and maybe try to get them into a program, something like that?
Casey: A absolutely. So, you know, kind of if you break it down. Drug seeking behavior may be one of several things. Number one, it is what is called a use disorder. I think people are used to the term addiction, but I now think of the term as a doctor opioid use disorder.
They are functionally addicted to [00:06:00] opioids. For those people, I’ll often actually offer them medications to help treat their opioid addiction. People may recognize either Suboxone or methadone. Um. But it may be more complicated. They could be in withdrawal, meaning they’ve taken opioids regularly and when they stop, they get withdrawal symptoms.
They might be afraid of withdrawal. They’re on their last dose of oxycodone, they’re about to run out and go into withdrawal. Or this person might have addiction and real pain, or they might just be having pain. It becomes so nuanced. But to come back to your question, specifically for so-called opioid addiction or opioid use disorder, I now offer my patients in the emergency department medications.
Counseling and I often recommend them to follow up with a drug treatment program, whether that’s residential or sometimes just following up with a mutual support group like Narcotics Anonymous. Um, but my goal is treatment. When I [00:07:00] identify this behavior in somebody who has opiate addiction, I.
Zach: I imagine that must be a, a kind of touchy, awkward subject, especially if they’ve been, you know, trying to be deceptive about, uh, why they want the, the drugs.
Is, is that a difficult conversation to, you know, to segue into?
Casey: Yeah, I mean, unfortunately, um. You know, we’ve seen such devastating effects of the opiate epidemic that things have really changed. So in 2010, I often felt like I had to play detective at work. Um, you know, somebody would come in with back pain.
And I was trying to guess, is this real? Is it not? Now, um, generally the medical community has really tightened down on the number of opioids that we prescribe. Mm-hmm. And with the arrival of ultra cheap fentanyl. If patients have an addiction, they’re usually buying it on the street. So for me, I tend to not have to have those difficult conversations as much as I did say 10 years ago.
Which is tragic because you and I both know how much fentanyl is killing America and the rest of the [00:08:00] world. And you know, I. A couple of times we’ve kind of joked in a kind of a dark humor way of, gosh, I miss when people were coming to the ER for pills. ’cause at least they were safe. Mm. You know, if it was five milligrams of oxycodone that they got, it was actually five milligrams of oxycodone.
Now if you buy five milligrams of oxycodone on the street, it’s probably fentanyl, or who knows what else? So, you know, I think the, the, the most difficult conversation I have is when someone doesn’t recognize that they’ve got a problem. That they’re developing addiction or developing an opioid use disorder, and I have to sit down and be non-judgmental and really engage them to say that there’s more here than I think you realize and I’m worried about you.
Mm-hmm. Um, but yes, over the years I’ve had plenty of very difficult, confrontational conversations when patients want an opioid and I don’t feel comfortable as the treating doctor.
Zach: This topic usually seems to be around opioids and and painkillers, but is there some percentage of [00:09:00] so-called drug seeking behavior that is about uppers, like Adderall or Ritalin or other classes of drugs?
Casey: Well, I, I’m gonna try to make a joke here, and I wrote about this. I have asthma. When I ask my doctor for an albuterol refill, I have albuterol seeking behavior.
Zach: Hmm.
Casey: So in some ways, drug seeking behavior is what it is. A person’s trying to obtain a, a medication or, or therapeutic drug,
Zach: bad term. To
Casey: your point, I think the.
The kind of the connotation of drug seeking is usually of addiction or the so-called use disorder. And for that, people can be addicted to many different substances. Opioids, sedatives like benzodiazepines. People really like Xanax. Unfortunately, that’s a very highly addictive drug. Sometimes it’s muscle relaxants, sometimes it’s stimulants.
We even sometimes see people, uh, who have addictions to other medications that are not as common, such as, um, [00:10:00] Gabapentin, which is a nerve pain agent, or even sometimes medications for severe mental health. So, to answer your question, people can so-called druge for many different therapeutic classes. Um, I think we are most aware of it simply because of what we’ve all seen with opioids in America.
Um, but it, it’s many different drug classes.
Zach: So I was reading some in preparation for this. I was reading some papers and articles and listening to your podcast too, and looking at the research paper you did on these topics. And the thing that really stood out is just how difficult it is to determine if someone is seeking drugs for addiction related reasons versus other reasons.
And it totally makes sense because detecting deception is just so hard in general. And then if we’re talking about opiates, OPI, opioids, you know, pain is so. Subjective. And so it makes sense that it would be pretty easy for people who have a use disorder to emulate that behavior and for no one to know.
So all that’s just to say it [00:11:00] makes sense that it would be a pretty hard task to, uh, differentiate someone who. Has a use disorder from someone who doesn’t? And am I getting all that correct? That summary?
Casey: You said it beautifully. It is exceptionally challenging and when I did research in the early 2010s on this topic, that was what I was trying to answer.
But again, at that time it was predominantly patients getting prescription opioids and often addicted to those opioids. Or fearful of withdrawal or in withdrawal. And I, I didn’t really understand the topic well enough, nor did really anyone at the time, um, kind of like with COVID, how we had to kinda learn on the fly with America’s opiate epidemic.
It was very similar. No one had ever really seen kind of what would happen if you distributed a potentially addictive medication widespread across, across the country. So. My preliminary research, I wanted to try to figure out are there certain things that we can pick up on as doctors [00:12:00] that suggests this person might be having a problem with their opioids.
And I don’t know how much, um, you spent reading the papers, but my statistics really weren’t that strong. But it’s really some of the only research that’s ever been done on the topic to try to quantify it. And to your point, it’s. Just so hard to confirm that a person has an opioid use disorder unless they admit it.
And if they’re trying to be deceptive because of all the shame and stigma that comes with addiction, you know, you might not get that answer, so. Mm-hmm. It’s really hard. Um, and for me as a doctor now, and I’m. Soon to be board certified in addiction medicine. Um, it’s really time with the patient being non-judgmental and really being willing to listen and ask some difficult non-judgmental questions and make a therapeutic alliance to say, you know, sir, even if you have a problem, I’m still gonna take care of you.
But yes, you said it beautifully that it’s, it’s a very nuanced and challenged diagnosis to make, if you will. And I just wanna [00:13:00] clarify again. Drug seeking isn’t a diagnosis more of a symptom, but to really make that final diagnosis of the person who came in saying they have back pain only to realize that they have a, uh, an opioid use disorder and they’re trying to obtain prescription opioids.
Zach: And I’d, I’d imagine it’s can be a blurred line too. Uh, right, because some people. WI, I would presume, wouldn’t technically be aware that they were addicted and they may actually view it in terms of having bad pain. Am I, am I correct in that?
Casey: Absolutely. It is exceptionally nuanced. Um, and sometimes you can have kind of all four of the behaviors.
You can have drug dependence, drug withdrawal, addiction, and pain. And what’s hard is, and you sent me an example of somebody who was very frustrated about how. Patients with real pain have been often turned away when they need, uh, legitimate pain relief. It’s been just really hard to parcel out is this pain?
Is it uncontrolled pain? Are we developing an addiction? There are some [00:14:00] obvious red flags, you know, if somebody’s, I. Melting their pills and injecting them, or smoking their pills or snorting their pills. Those are obviously extremely major red flags that somebody is developing an opioid addiction. Again, also known as an opioid use disorder.
But if somebody just comes in and they’re like, doc, my pain is worse. You gotta go up on the dose. That can be really challenging. Mm-hmm. Um, I tend to look for a few kind of, uh, risk factors for addiction. So has this person been addicted to something else? Um, now with a lot, a lot of electronic medical records, when I open the person’s chart, I see their history automatically.
And if somebody has had, for example, an addiction to alcohol, alcohol and opioids can often be similar. And the. Predisposition for addiction to opioids is much higher because of the previous addiction to alcohol. So I usually ask my patients if I’m worried, you know, is there a family history of addiction?
Do you currently have a different addiction? Have you had a previous addiction in the past? And those are all things that I might think of [00:15:00] that are gonna increase my concern that what might seem just like pain could have a more complicated facet of addiction going on as well.
Zach: That’s really what struck me about this.
You know, I’ve, I’ve heard, and I, I’ve even thought this myself, that, you know how much doctors have theoretically contributed to this. You sometimes see doctors as a whole get grief or criticism about the opioid epidemic, but you know, like you’re saying, it’s, it’s a really tough spot to be in as a doctor because, I mean, the last thing you want to do.
Deny someone who, who is suffering, uh, some, some help. So, and, and if it’s basically hard to determine if someone is being deceptive about their pain, it, it’s understandable that most doctors would err on the side of providing the help. And it’s similar, you can see it as similar to the legal system, you know, where you’d rather see a hundred guilty men go free, then punish an innocent person.
It seems like there can be a, a similar dynamic at work that helps us or makes us err on the side of. Providing that those drugs. And does that all sound? [00:16:00] Am I getting some of that right?
Casey: Yeah, there. There’s only one other kind of point that I would like to add, which is that there’s so much more to pain management than just opioids.
Mm. And I’ve been the chair of my hospital’s pain management committee for about six years now, and myself and one of my colleagues where I work. We were kind of the canaries in the coal mine in our community as early as like 2013 to say something’s not right with opioids. And we would tell our colleagues, please don’t prescribe opioids.
And they said, well, okay, but then what can I use? Hmm. And we have sense. About the mid 2010s as physicians really focused on what are called alternatives to opioids or A LTO Alto, and as an example, when somebody had a pinched nerve in their back when I was in residency, I was really taught to give them opioids and that’s it.
Hmm. Now I use what’s called a multimodal approach. I will use an [00:17:00] anti-inflammatory. I will use a steroid. I will use acetaminophen. I will use a nerve pain agent. Sometimes I’ll even add in an IV lidocaine drip or even an antidepressant. And those six drugs combine in an additive fashion that can often be much stronger than a single dose of an opioid.
So I think it’s. Even gotten better from a pain standpoint that we have such better approaches to pain management than we did when this started. As an example, I just gave a lecture on managing kidney stones without opioids, and most people are aware that kidney stones are one of the most painful conditions that we treat.
And so it’s really been great as a physician that as we as doctors have cut down on our opioids, we’ve opened the door to so many other great non-opioid options, and I’m very grateful that. You know, my hospital has been really tip of the spear on writing new protocols and using drugs in new ways that are not addictive and are very effective for pain management.
So it’s a little bit of a different [00:18:00] scenario, you know, as compared to 2010 versus 2022. We just have more options for pain relief. In addition.
Zach: It’s probably an impossible question to answer because it’s so broad and probably varies across the country. But do you think, do you have an opinion on whether.
The problem these days with opioids is that people are prescribing them too much or, or too little. Has it swung the other way?
Casey: Yeah, that is a fantastic question. You are a hundred percent correct. It has definite regional variations. Um, I think that the pendulum in 2010 was to over-prescribing and the pendulum in 2022 may be towards the side of under prescribing opioids.
And you know, I have a number of. Uh, patients that come through the emergency department that, you know, say something to the effect of, you know, I was told the only place I could get an opioid was the ER ’cause it was too dangerous. And there are plenty of patients who can be managed on long-term opioids [00:19:00] by their primary care physician and they do really well.
Not every person who takes chronic opioids gets addicted. Now I have to say, with a caveat, I prefer to avoid. A new start of an opioid in my practice. So I’ll give you an example. If you come in with a fracture, I’m gonna try to do everything I can to keep you as comfortable and treat your pain and avoid starting an opioid.
But if they’re needed, I use them in my practice regularly. I think, and again, you sent me, um, a, I believe it’s a, a Twitter post from somebody who talked about patients being denied opioids. That absolutely does happen. And you know, the circumstance that I find frustrating is you have somebody who’s, you know, 85 years old, they’ve never had an addiction, they’re on a blood thinner and they have a lot of medications, so they can’t take kind of that multimodal approach I talked about.
They take, you know, two to. Two opioids a day so they can walk their dog. They’re not crushing their pills, they’re not snorting their pills. They’re doing fine, and their doctor [00:20:00] says, we need to taper you right now. I think this sounds so silly to say, but really doctors should just use their best clinical judgment if opioids are helping someone who doesn’t have another option.
Then it’s totally appropriate. Obviously that patient would need to be monitored to make sure that they don’t develop any signs of an opioid use disorder. If it’s a 17-year-old that can be managed without opioids, then do that. Um, but I think overall, unfortunately, the pendulum has swung away from opioids.
Whether that’s the right thing from a population standpoint is an interesting question because when they look in the studies, when people get started on an opioid, there’s a certain percentage that end up on the long term. A new start of an opioid is not a benign or kind of innocuous event. So I think if you look at across America.
If we had been more judicious with opioids 20 years ago, we’d see a very different landscape. But on the individual patient level, you know, [00:21:00] again, a person with legitimate pain that’s never misused, their medications may be suffering because their doctor’s not willing to prescribe opiates for them.
Zach: So let’s talk about, uh, some behavioral indicators of people who may be seeking drugs for use, disorder related reasons, and with the caveat, of course, as we’ve said that.
Many of these behaviors, or, or, or all of them probably are, uh, aren’t that reliable and are very, you know, very subjective and can actually be done by people who legitimately have pain and such. Uh, but maybe you could talk a little bit about, of the, of the various behavior indicators, behavior behaviors that tend to.
People tend to point to. Are there some that stand out for you as, as being the most reliable?
Casey: Yeah, absolutely. Um, so the, the research I did, uh, back in the early 2010s, I. I just kind of asked around my colleagues what tips you off that a person is trying to obtain opioids, and we all kind of had a list in our mind and it [00:22:00] was non-specific complaints like back pain, dental pain, or headache that are pretty common and usually don’t involve a lot of testing.
Things like asking for a medication by name, asking for an IV dose rather than an oral dose, saying that your pain is more than a 10 out of 10. Um, asking for a refill. There were a lot of things we looked at and it’s a little hard to understand kind of if that study is still relevant today because again, the landscape has changed so much.
Interestingly. Back pain in my career has really changed when I was in residency in the early 2010s, most patients with back pain were on chronic opioid therapy and were either out and needed a refill or were on that dangerous line of is this addiction or is this pain? I. My back pain patients now are pretty legitimate.
You know, many of them have a pinched nerve. Some of them need an epidural injection, so I think that kind of non-specific pain complaint no longer applies. And people when they come in for these complaints, tend to be very [00:23:00] open to whatever I want to prescribe. And oftentimes patients will actually tell me, doc, I heard about those opioids.
I don’t want those. The one that I do think still carries some weight is asking for a medication by name, particularly when it’s a medication that’s known to be. Somewhat euphoric. And if people will ask me, doc, what are you gonna give me? And I’ll say, you know, I’m gonna give you a dose of an IV anti-inflammatory.
We’re gonna give you a little bit of an opioid, some acetaminophen and a nerve pain agent. And they say, okay, I don’t have any red flags. But if they say, I have to have this medication at this dose. What I now call that is they’re opiate sophisticated. Mm-hmm. They may be a chronic pain patient who is really knowledgeable about how their body responds to opioids.
They may also have opioid addiction, and that’s just a flag to me that I need to dig into their chart more. Mm-hmm. And spend more time talking with them, you know? Do I see in the chart that they had an opioid overdose in the past? Do I see that they were on methadone in the past? It’s just, it’s more work on my [00:24:00] part, which is appropriate for me to do.
Mm-hmm. Um, the other one that’s still interesting is when people say that their pain is greater than 10 out of 10, that to me means the patient wants to get my attention. And that doesn’t necessarily mean it’s addiction, but they, they want to make a statement to me. Doctor, this is serious. Sometime it is because they are addicted and they really wanna push me to give them a shot of morphine or something.
Sometimes it’s, they’re just miserable and they want me to do something and you know, I think other than that, you know, most now, most often now, when people are requesting refills, it’s pretty legitimate and. Since 2010, we now have what are called prescription drug monitoring programs where you as a doctor can log in, um, and look to see what medications someone’s been on.
And I’ll give you an example. I had a patient show up from out of town. Which made me a little bit nervous. And he said he was on Fentanyl patches, which are really, really [00:25:00] potent. And I was nervous. I was like, is this guy trying to obtain opioids because of an addiction? And I logged in and I was able to see that he’s been getting his fentanyl patches every month regularly from the same doctor.
It exactly matched with his story. And I said, sir, I am so happy to help you. And I think, again, kind of like with. Pain going from just opioids to this multimodal approach. There’s more tools available to us as doctors to be able to dig in a little deeper to the history. So I think the one that really kind of makes me the most nervous as a doctor, if somebody has a specific request about name of medication and then also the route and the dose, and again, that just means they’re sophisticated.
I do have to do more work to really dig in.
Zach: Yeah, that kinda reminds me of police interrogation there. There’s nothing that. Specifically will say, this person, you know, is X. It’s more like an indicator that you should ask more questions or look into [00:26:00] it, you know? I think, I think that’s what some people get that confused about police interrogation things too, where it’s like something may be a little suspicious and it doesn’t mean that the cops should think that they’re guilty.
It just means, oh, maybe I’ll follow up on that question a little bit more. That kind of thing. And, and I think that some people can have a, a, a sense or belief that. You know, people are, are just being like, oh, this means that, you know, where it’s, it’s a lot, as you’ve said, it’s a lot more subtle than that and just is there, there’s nothing that will a hundred percent mean anything.
Casey: Yeah. And, and I’m, I, I may be a little bit of an outlier on this. You know, I, I wrote a piece why I believe that the term drug seeking needs to be retired. ’cause I still do occasionally see physicians who identify drug seeking behavior and tell the patient I. That’s it. We’re done. You’re discharged. Mm. I’m not gonna continue this for you.
It still happens. Um, I, I believe that I’m doing those patients harm because, you know, if they have prescription opioids and I cut them off, [00:27:00] they may go to the street market and I don’t want them on fentanyl. If they’re addicted, they’re risk at risk of overdose. I need to treat them. And if they’re just in really bad pain, well I can help with that too.
So I think, you know. I would like to believe that physicians are doing a better job of identifying, Hmm, something’s, something’s making me nervous here. I’m gonna dig deeper. But I think there’s still, unfortunately maybe some reflex to say, something makes me nervous. I’m gonna cut this person off, and I’m gonna tell them that I, I can’t do anything else for them.
Which to me is, is why I wrote the article. It’s a tragedy to your point, you know, patients need the appropriate treatment, particularly for pain, and I wanna do my best to advocate for my patients.
Zach: Yeah, to make an analogy, it’s, it’s probably like any profession where, you know, and the analogy in the, in the police world would be a, a detective who’s interrogating somebody and, and they’re acting strangely, and the detective just immediately a hundred percent thinks they’re guilty without good evidence.
You know, there’s probably, uh, in any [00:28:00] profession, there’s, there’s people overreacting or, or taking a little bit of evidence as, as definitive evidence or something.
Casey: Absolutely.
Zach: Would you say it’s also the case that I assume that, uh, you know, when, when it comes to practice in the field, that, that doctors are kind of subjectively because these things are so subjective and unreliable.
I’d imagine a lot of it just comes down to doctors getting a, a general feeling of how suspicious or trustworthy someone is. And that might depend on, you know, very subtle things, things we haven’t mentioned, you know, just like. Very subtle things, like a story not coming together very logically or someone seeming a little strange, uh, their eyes being a little shifty or something, or someone rambling too much about their reasons.
Basically the same kind of subjective things that can make police, interrogators, interrogators suspicious of someone they’re interrogating. And this isn’t to defend those, uh, more subjective things. It’s just to say that probably it makes [00:29:00] sense because we are dealing with such a. Subjective, uh, area in such a, a, a vague and gray area that it, it probably makes sense that doctors do have to rely on these more subjective reads and their feelings and such.
And do, I’m wondering if you have anything to say about that.
Casey: Yeah, I mean, I think there’s a couple of, couple of answers here. So the first is, is there has been some research on this, and I just pulled this up on my phone while we’re talking. There’s actually a scoring tool called the Opioid Risk Tool for Narcotic Abuse, and I don’t really like that title ’cause number one, narcotic.
Would suggest that it’s illegal and these could be prescription opioids and then abuse is a stigmatizing term. Um, it probably would be best, you know, to be said as the opioid risk tool to assess for opioid use disorder. But I’ll get off my soapbox there about stigmatizing language. But it’s essentially a tool that you can plug in the patient’s variables and it’ll give you some predictions on whether or not the patient’s at high risk for [00:30:00] misusing their, their opioids.
And it’s important to understand exactly when that tool can be applied. And that was really, as I understand it, for the chronic pain clinic where somebody’s on opioids long term and the doctor wants to see are they going down that slippery slope from just pain. To pain and an opioid use disorder. Um, so there are a couple of different, uh, scores.
If I remember correctly, there’s probably about five or six. None of them really caught on in the emergency department just because it was so hard to study and it was more geared again, towards the chronic pain clinic, chronic opioid management world. Um. To your point, sometimes it really is subjective.
Uh, I was thinking about a case where somebody came in and I just got a really weird vibe. Um, it was a young female patient, we’d never seen her at my hospital before, and she kept repeating the same phrase over and over again, trying to describe her pain. [00:31:00] And it almost seemed rehearsed. And I asked her point blank, have you ever been on an opioid before?
She let me. She was very compliant. She let me give her whatever meds I wanted, you know, alternatives to opioids to try to treat her pain. And she said, doctor, I’m doing better, but I think I’m gonna need something stronger. And I just got this weird little kind of vibe of, gosh, something seems weird here.
What I did in her case is I logged into California’s prescription drug monitoring program and I found that she’d had something like 30 or 40 opioid prescriptions of all, almost all from different doctors to suggest that she was basically going clinic to clinic, emergency department to emergency department, trying to obtain opioids.
And that gave me that confirmation. And if, if I hadn’t found that, I may have just given her the benefit of the doubt and said, this is a legitimate pain patient. And in her case, what was really challenging, I. And this was probably about five or six years ago, is I tried to offer her treatment for opioid use disorder and she said, doctor, I don’t have a [00:32:00] problem.
And then asked to be discharged. So, um, it, it’s just a, it’s, it’s, it’s almost like parenting. You know, you kind of know when your kid’s up to something. Medicine is about pattern recognition just as much as you know your child. That’s the look when my child’s hungry. That’s the look of my child’s tired.
It’s almost just looking for this patient is behaving differently than the majority of my patients. Something doesn’t add up. And you’re right, it’s, it’s subjective and I think that’s again why it’s incumbent upon us as doctors to. Take more time with the patient to really try to parcel out what’s driving this behavior.
And again, if it’s prescription opioids, you gotta check that prescription drug monitoring program to really get that objective data. ’cause that, for me, sealed it that this is somebody who’s not using opioids appropriately. So, yes, very subjective. And, um, I think some people feel like they have good radar, you know, and I, I don’t know if they ever get accurate feedback if they cut someone off who was a legitimate pain [00:33:00] patient because it’s, again, so subjective.
You know, as an example, if I miss a case of appendicitis. Usually my colleague will follow up with me or in my uh, department. We have like a monthly educational lecture where we review cases where we can learn from them. There really isn’t that in this space, so if somebody kind of self proclaims or self identifies as somebody who’s really good at picking up drug seekers, they could be really wrong and they don’t get really good feedback to, to learn from it just because oftentimes those patients just won’t come back to our department.
Zach: Do you have any other, uh, interesting anecdotes that, that come to mind for, uh. These kinds of things.
Casey: Well, I mean, you know, sometimes, you know, it can really spiral when people who have a opioid use disorder don’t get their meds. Um, I can think of a case when I was a medical student about a patient who lied about having cancer to get really high dose prescription opioids.
And I was able to, as a medical student, review his [00:34:00] medical record. Um, and without getting too into the weeds, I was able to basically prove that he was lying about his, his cancer and that he had never had it. And this was all to obtain opioids. I. And, uh, when we confronted him of, you know, sir, you’ve not been honest with us, he just erupted.
He yelled at staff, he threatened to commit suicide. He ended up going on an involuntary hold and being admitted to psychiatry. And I don’t know if he was able to, you know, even see an addiction medicine specialist when he was admitted. Um. You know, not as much anymore. Patients would sometimes verbally be abusive with doctors and nurses when they wouldn’t get what they want.
Um, I actually had a patient as recently as about a year ago, who just absolutely screamed at my staff that he wasn’t getting opioids. And you know, that’s, it’s, I. You know, healthcare is really hard right now. I mean, morale and healthcare is low, and I really try to defend my staff. Um, so you, you know, it just, it, addiction is just so disruptive to the [00:35:00] brain as far as the ability to weigh out what is a good decision and a bad decision, and it can really cause people to escalate when they don’t get what they want.
Zach: Do any anecdotes, uh, spring to mind of the opposite situation where you were pretty sure someone had an a use disorder, but. Ended up not having one, anything like that?
Casey: Absolutely. I mean, that goes back to my point about the Prescription drug monitoring program. Uh, as I mentioned earlier, you know, I had a gentleman who showed up to my emergency department, never been to my hospital before from out of town requesting really high dose opioids.
And I was just already kind of skeptical and I did my homework. I actually called his old doctor. Um, he was from OUTTA state. His doctor confirmed, no, this is legitimate. I manage him. She actually faxed me records to confirm, and I was actually grateful that I was his doctor that day because I. I, in my work that I do wanted to do what’s right, I wanted to take him seriously.
I wanted to make sure that if [00:36:00] he needed these meds, I could get them for him. Or if it was a use disorder, I wanted to be able to offer him treatment for addiction. So, in that case, I mean, I, you know, I know I, I, I, I hope. This is not true, but I worry that a couple of my colleagues, you know, in my region of California might have looked at ’em and said, you’re looking for that, and you’re from outta state.
You’ve never been here before. Yep. I’m not buying it. Mm-hmm. Um, but you know, you, you kind of dig deeper. You do your homework as a doctor and you can prove that people are legitimate patients and then they’re so grateful that you took them seriously. It, it ended up being a, a really great interaction between me and him.
He was, um, you know, very grateful that, you know, he was out visiting. You know, my part of California for personal reasons for family, and he didn’t have to fly back home, uh, and disrupt his, his family obligations to be able to go get his meds that he had accidentally forgotten. So, absolutely, I can think of many more similar cases.
Zach: So I guess, uh, I’m, I’m gathering that you would probably agree that training for doctors in this area is, uh, should, should [00:37:00] be better. It’s not as good as it could be.
Casey: I got one lecture, uh, on addiction in medical school, and ironically it was only on gambling addiction. Um, and my training in medical school from 2006 to 2010 was that pain is always to be treated with opioids.
Once acetaminophen and ibuprofen don’t work and you always escalate the doses of opioids. Um, as the patient needs. Um, I believe now there is a lot more work going into education for medical students. I’ve actually personally been asked to speak to medical students, um, about the work that my colleagues and I do, you know, at my hospital.
In this sphere to be able to treat patients appropriately and really kind of dig into what’s really driving the behaviors. Um, and definitely across the nation we are seeing that residency trainings are starting to incorporate addiction. We do have one residency in my county in California, and they do a wonderful job of [00:38:00] giving their residents exposure to addiction.
Many of them come work personally with me and my colleagues, kind of in my, uh, kind of in my sphere of addiction, pain, and emergency medicine. Um, and then really being so aggressive about alternatives to opioids for severe pain. Um, it’s really incredible how much pain relief you can give people without opioids.
So I. Truly, we are seeing more and more over time as America is getting deeper and deeper into what is now the fentanyl crisis. And we just see how bad things are. Uh, I’m actually pretty hopeful. Uh, we just hired three new physicians at my hospital and they are all, uh, very savvy with kind of this sort of con conversation that you and I are having to really kind of dig in and understand those nuances.
Zach: So we’ve talked, we focused on, uh. Opioids and painkillers. But is there anything that comes to mind in terms of differences in behavior for. People that might have a use disorder with, uh, amphetamines or, or other uppers. [00:39:00]
Casey: Yeah. It’s unfortunately the same story as with prescription opioids turning into street fentanyl.
Methamphetamine is, uh, it is so cheap. It is so prevalent. In about kind of the mid 2010s, the formulation of how methamphetamine was made, changed from a plant-based process with Ephedra, um, to a lab-based process. And it just allowed the production of methamphetamine to skyrocket. And in California, the price of methamphetamine dropped by 90% you about the last seven years.
So if again, it’s the same answer, if people really want potent drugs, it’s so much easier to get them on the street than to go to a doctor and get them. That being said, 10 years ago, um, you know, absolutely patients were coming to the emergency department requesting stimulants like Adderall or Ritalin or, um, you know, those A DHD stimulant meds.
Um, and it’s just, again, it’s, it’s as the, as the landscape has changed, [00:40:00] we don’t see that very much anymore. Um, now people do occasionally come in saying, I’m outta my A DHD meds, can I have a refill? And if it’s a Friday, I’ll give them, you know, three doses until Monday if I can confirm that it’s legitimate.
Um, sometimes I’ll, if I can’t confirm it, I’ll say, you know, you’re not really gonna have withdrawal. It’s the weekend. Let’s get you followed up with your doctor on Monday. Um, but yeah, it’s, it’s, it’s much less common than it wa than it was before. And I think just in general, across all the, the different classes of drugs, the street market has just gone crazy with how available and cheap these drugs are.
And if people really are looking for something, it’s just so much easier, unfortunately for them to get it off the street.
Zach: And I’ve, I’ve heard those stories, you know, from, from people personally about saying they, they have a DHD and, you know, need help studying for a test or whatever. They can’t focus and, uh, using that deceptively to, to get, um, Adderall, Ritalin and such.
Do you think there all will ever be like a pushback against that in the same way? I guess it could [00:41:00] be viewed as. Those are theoretically paths to, you know, stronger, um, amphetamine use and and such. But I haven’t really read anything about that. I’m curious if that’s, if that’s a concern of anyone’s.
Casey: Yeah, I mean, I think anecdotally, um, I am seeing much less primary care management of A DHD with stimulants and people are really in the medical community saying.
If you need a stimulant, you should actually see a psychiatrist. Hmm. Um, and I think that’s been, you know, what’s also happened with opioids is if I, if me as your primary care doctor, if I can’t manage your pain and you need to be on long-term opioids, I need you to see a specialist. And I think that’s been kind of what has.
Happened a lot in a good and bad way. Sometimes primary care physicians that could manage opioids just don’t wanna get involved at all. Sometimes it’s absolutely the right move to send someone to a pain specialist because there are more options, uh, than just opioids. But really in my community, and I think in kind of in my region, kind of gen, the general consensus is if you have [00:42:00] a DHD.
You need to see a psychiatrist. If they determine that you need stimulants, they will manage it and we will defer that to them because we wanna make sure it’s really the right thing for you. And, you know, absolutely A DHD can be very debilitating. Um, I’m very lucky where I work, we have a lot of great psychiatrists and, you know, I trust them if they’ve got someone on stimulants, I, I know that they’ve really done their homework and trying to make sure that the diagnosis is right and that they’re choosing the right.
Therapeutics for the patient.
Zach: Mm-hmm. Does seem like people are taking it much more seriously due to the Yeah. The recent, uh, yeah, last few years, absolutely. Of opioid crisis. Yeah. Do you have any, uh, anything else that we haven’t talked about that you’d like to mention?
Casey: Yeah, I mean, I think the only thing that has, you know.
Really me losing sleep at night, you know, in this topic that we haven’t yet covered is just the street market and our youth. And what’s so interesting is when I was in high school, really the only drug out there was alcohol. [00:43:00] And alcohol is very well labeled. It’s regulated, it’s sold in a store, you know exactly how much you’re getting and if you drink too much, it usually is.
You know, bad decisions, slurred, speech, vomiting, alcohol’s actually relatively hard to overdose on in my college years. In the early two thousands, a couple of my friends were starting to dabble in prescription pills, and at the time it was almost all from physicians. And so if you bought five milligrams of oxycodone, it was actually five milligrams of oxycodone.
And so, as you know, kind of the youth have this inherent desire to experiment. It really wasn’t that dangerous for experimenters. Most of our opioid overdoses at that time weren’t people who were chronically on opioids or misusing their opioids or even using illicit opioids. But now what we’re seeing is high schoolers going and buying pills on the street.
And they’re having fatal or near fatal overdoses the first [00:44:00] time they try because of what’s in the street pills, which is fentanyl and these ultra potent fentanyl analogs. And what’s so hard is these kids are being sold Ritalin. They’re being sold. Adderall, they’re being sold Xanax, they’re being sold, you know, Percocet, and it doesn’t contain any of that.
It’s almost all fentanyl. And these Fentanyl derivatives and just the stakes are so much higher for our youth right now. And that’s just so scary that I. You know, it’s, it’s if somebody, you know, just wants to have fun on a Saturday night and 10 years ago when they bought a pill on the street, it was no big deal.
Those stakes are so high now, and so we’ve seen an increasing number of overdoses, including fatal overdoses in our youth, and that’s just so devastating to a community, a school, a family, a friend group. Um. And then of course the tragedy of that young loss of life. So I think that’s one thing that, you know, I, I didn’t necessarily think of as we were just starting to see fentanyl [00:45:00] arrive in my community and the illicit market was just at what great risk it put our youth because of what they were used to in the past.
What the wide availability of legitimate prescription drugs on the street.
Zach: It seems a lot more dangerous out there for sure. Some of the news stories I’ve seen with Fentanyl being in a wide range of drugs and deceptively given to people. Absolutely. Uh, there’s a, I was gonna mention this in the intro, but might as well mention it here too.
There’s a great book. I actually haven’t read it, but I’ve read part of it, the least of us, and I can, oh yeah, I just, I just finished it. Yeah. And it’s the, by the author of Dream Brand, I think, which was also about es He’s wonderful. Yeah. Es yeah. Um, and yeah, that’s, that’s, I read an excerpt from it, but yeah, he talked, he talked about some of the things you talked about where, you know, for example, the, the meth problem is related to the opioid problem too, because some of the people that were addicted to opioids, uh, transition to meth when opioids weren’t available, and the new meth, uh, formulation that you mentioned is so much more mentally destabilizing.
Absolutely. And ends up absolutely. Ends up with people in the, uh, you [00:46:00] know, in taking up mental health, uh, facilities because of the, the meth in a, in a pretty quick order. It’s, it’s, it’s much more aggressive than the, the old plant-based, uh, ephedra variety. But yeah, so all these things are, I. Kind of related and, uh, pretty, pretty scary stuff these days with the drugs and, and also, you know, seeing that related to, uh, someone related to the, the homeless crisis we’re facing.
You know, uh, that, that’s part of that too.
Casey: Totally agree. And, and if anyone hasn’t read them, dreamland was Sam Quinones first book, um, about waves one and two of the opiate epidemic, and then the least of us was his follow-up. Looking at waves three and four. And just to clarify those waves, wave one was doctors over-prescribing opioids.
Wave two was people transitioning to illicit opioids, usually heroin. And the arrival of increasing amounts of heroin into the US wave three is fentanyl. And then as you stated, wave four is meth. And it’s so interesting that just cheap and easy to get meth has [00:47:00] taken people that traditionally use opioids and don’t like stimulants, and we’re seeing them use.
Methamphetamine because it’s so cheap and easy to get. Um, it’s just, it’s so sad. You know, you drive up and down California’s highways and you see tents, uh, and many of those, pat, many of those people unfortunately, have methamphetamine use disorder. Um, and you’re right, the, the newer formulation of methamphetamine causes a lot more psychotic symptoms.
Um, my most recent episode of my podcast was on methamphetamine psychosis, and oh my gosh, that is just so debilitating.
Zach: Hmm. And your podcast is called,
Casey: uh, mine is called Addiction in Emergency Medicine and Acute Care. Um, I put it together about 18 months ago. Um, it’s a podcast written for a medical audience, but I try to keep it pretty simple.
Um, I do have some non-medical people that listen to it. I kind of, the way I think of it is when I go to work and I’m gonna work tonight in the emergency department, oftentimes I’m. Kind of confronted by a clinical question like, is drug A or is drug B better? [00:48:00] Or what’s the best way to diagnose this condition?
And I usually kind of dive into the medical literature, um, to answer the question and then in my own mind, try to come up with what I think is the best practice or the best approach or the best diagnostic algorithm. Just because unfortunately a lot of this stuff outside of having formal addiction medicine training is, is kind of hard to get.
Um, so I’m also sitting for my addiction medicine boards and this was a way for me to learn. And yeah, shameless, shameless plug addiction and emergency medicine and acute care. I’ve had a lot of fun making it.
Zach: Alright, thanks Casey. This has been great. Anything else you wanna mention before we, uh, we end it?
Casey: Just wanna say thank you for having me and thanks for talking about this very important topic and, uh, thanks for, for putting this out on the air.
Zach: Thanks for your work.
That was Dr. Casey Grover, addiction specialist and host of the podcast Addiction in Emergency medicine and acute care.
This has been the People Who Read People podcast with me, Zach Elwood. You can learn more about it at behavior-podcast.com. If you’ve enjoyed it, please consider leaving me a rating on Apple Podcasts; you can find a link for that on my site at behavior-podcast.com.
You can learn more about [00:49:00] [email protected]. If you’ve enjoyed it, please consider leaving me a rating on Apple Podcasts. You can find a link for that on my [email protected]. Thanks for listening. Music by small skies.