There are no fixed characteristics of drug-seeking patients. In an unpublished study of general practitioners, we found that they tended to identify 4 groups that comprise the vast majority of their drug-seeking patients. These were:
1. patients known to the practice who were dependent on benzodiazepines and wanted to maintain a continuous supply
2. patients known to the practice seeking an opioid (dependence may have arisen following treatment for chronic pain, but later, dependence rather than pain relief had become the major reason for using opioids)
3. patients unknown to the practice seeking a benzodiazepine (these patients are typically younger than those in groups 1 and 2 and many are not drug dependent)
4. patients unknown to the practice seeking an opioid (these patients also tend to be younger than those in the first two groups and most will be dependent on opioids)
Patients in the first two groups may be readily identified given their familiarity to the practice. More problematic is how to identify those seeking drugs who are not known to the practice. A number of indicators may be useful. These include patients:
– presenting near closing time without an appointment
– requesting a specific drug and refusing all other suggestions (may display considerable knowledge of drugs)
– presenting with inconsistent symptoms being reported (e.g. does not appear to suffer significant pain)
– reporting a recent move into the area from somewhere beyond the vicinity of the practice, making direct validation of prescribed drug supply with the previous practitioner difficult.
Table 1
Five questions to determine whether drug use is appropriate or constitutes abuse*
Intent: Is the drug used for a legitimate medical purpose?
Effect: Does the drug improve the quality of the patient's life?
Control: Is the physician helping the patient maintain control over use of the drug?
Legality: Is use of the drug legal and uncomplicated by illegal drug use? Pattern: Is the pattern of use one of appropriate medicinal doses or is it one of intoxicating doses?* Affirmative responses to all 5 questions usually indicate appropriate medical use. 1-5 negative responses usually indicate inappropriate or non-medical use. All responses should be documented in the patient's chart. (Derived from DuPont and Saylor)
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Those patients reporting a recent move may have a supporting letter apparently from their local practitioner. This should be checked if at all possible - it may have been used numerous times and may have been written on stolen letterhead.
Careful observation of patients may be useful in identifying them as drug users. Look for signs of drug use, intoxication and withdrawal. Benzodiazepine intoxication is characterised by sedation, poor co-ordination and balance, impaired memory and general impairment of cognitive function. In contrast, benzodiazepine withdrawal is characterised by anxiety, irritability, palpitations and tremor. Opioid-intoxicated patients may present with pupillary constriction, itching nose and skin, difficulty concentrating and dry mouth. Injection site marks may be evident. Patients experiencing opioid withdrawal may present with dilated pupils, increased heart rate and blood pressure, diarrhoea, muscle cramps, aches and pains, frequent yawning, rhinorrhoea and lacrimation. It is important to note that opioid-dependent patients may seek benzodiazepines, particularly if they are experiencing withdrawal and want these drugs to alleviate some of the symptoms.