How Do You Know If a Patient's Pain Is Real Or If They Are Drug Seeking?

When a patient comes into the office and says, "Doctor I have a lot of back pain and the only thing that works is Oxycontin, I've tried everything else," how does the doctor know if the patient is legitimate or not?

Unfortunately there are few tools to objectively measure a patient's pain to know whether it is legitimate or if the patient is faking. Usually, patients are asked to give a pain score on the Visual Analog Scale which is pain on a scale of 0 to 10. There is also a scale which uses facial expressions for pain severity, which is great for children.

A widely held estimate is that 15 to 20% of patients are malingering (faking) their symptoms in order to obtain drugs illegitimately. They are either abusing them or selling them (or both), and faking an illness is the most effective way of obtaining their inventory. Another reason for faking is to obtain disability, which provides for a nice paycheck to patients while everyone else in society pays for it.

Opioids are now the second leading cause of accidental death in the US, only behind car crashes. While the Institute of medicine is reporting that pain is often undertreated, the Office of National Drug Control Policy reported that narcotic prescriptions are up 48% since 1999.

There are some well known red flags to patients who are "drug seekers". Patients who call in saying they are from out of town and cannot obtain their medical records from their previous pain doctor are suspicious. Also, if a patient states they do not have insurance and want to pay cash for their treatment may be utilizing their insurance at another pain doctor and trying to hide that by skipping their insurance plan payments.

Over 35 states have instituted statewide prescription registries, where doctors can see if patients are receiving narcotics from other doctors. There are a few problems with the system, including the delay in prescriptions registering, incomplete participation, and the fact the systems cover only that individual state. A nationwide system, signed into effect by President Bush in 2005, has not been fully implemented due to lack of funding.

About 80% of pain issues are handled by primary care doctors. And it can be very tricky. Even the best of tools available to fellowship trained, board certified spine doctors show that over 50% of the time an exact diagnosis evades medical specialists. Figuring out the pain generator can be elusive, hence figuring out whether a patient is faking can be tough to discern.

It's not just inner city drug addicts who sell or abuse their prescriptions. Retired folks do it, executives do it, and even legitimate chronic pain patients take too much of their medications, effectively abusing them.

So what to do? Well, there are no go-to methods for detection that are foolproof. A few helpful tools include urine or oral drug testing (screening), pain management agreements, and as mentioned the prescription registry monitoring system. Otherwise, keep your radar up for red flags.