Utah Addiction Center

Family and Preventative Medicine


The patient whose drugs are being diverted

Betty, a 67 year old widowed woman with chronic arthritis, has been maintained on a regimen of Lortab for the past decade. Recently her adult grandson has come to live with her, and she complains that she needs an increase dose because of the added physical and mental stress of having additional people in her home. You are concerned that she has already run through the 90 day prescription you gave her six weeks ago, and is requesting a new prescription.

  • How would you approach the patient (either cooperative or resistant)?

    (The goal is to develop a positive, non-judgemental rapport with the patient?)

    • Use your rapport. Wait to address her Lortab refill request until after you've discussed less threatening issues.
    • Don't be afraid to explore the issue.
    • Display compassion and concern
    • Ensure confidentiality
    • Use a neutral, matter of fact, tone of voice
    • Acknowledge it may be difficult for the patient to share this information.
    • Be nonjudgmental. Remember this is a disease. The more nonjudgmental you are the more likely the patient is to reveal information.
    • Allow any resistance, pre-contemplation, and minimization to be okay. Remember to be nonjudgmental and avoid any power struggles. At this time it is unnecessary for the patient to admit that he has a problem.
    • If patient is resistant, acknowledge that it is difficult and uncomfortable and explain that you believe this is a health issue and is part of your over all approach to patients. Continue to gently ask questions.
    • Be redundant. If your questions are not being completely answered ask again.
    • Phrase the question appropriately. For example, ask, "Tell me why you think you need more Lortab?"
  • What data do you need to collect or what initial screening should be done? (The goal is to gather relevant history and barrier information.)
    • The patient has run out of her prescription 6 weeks early. She had previously been compliant with this regimen with no requests to renew medications early. Although this may indicate abuse of a medication, her previous compliance in addition to her grandson recently moving into her home may indicate that her grandson could be abusing her medication.
    • The potential overuse of Lortab in this patient should raise concern of liver toxicity and drug tolerance.
    • Her explanation of why she has suddenly run out of her prescription 6 weeks early will help you determine the underlying cause of her request.
    • First explore whether it is possible that her grandson is taking her medication.
    • Be sure to rule out the possibility of memory impairment.
    • If you feel satisfied that that is not the case ask the following questions to explore addiction. According to the Diagnostic and Statistical Manual of Mental Disorders, an addiction is defined by the biopsychosocial consequences of use, not just frequency and amount.
      • Tell me how you are taking the Lortab.
      • When did you run out?
      • Why has this occurred now when it has not occurred in the past?
      • What type of symptoms did you experience when you ran out?
      • Have you been prescribed pain medication in the past? (Get history of pain medication use, for what purpose, for how long it was used.)
      • Have you ever lost prescriptions in the past or run out of your refills early?
      • What kind of pain are you still experiencing?
      • How do you feel after you've taken the Lortab?
      • Has anybody expressed concern regarding your Lortab use?
      • Have you ever been in treatment for alcohol or drug abuse?
      • Have you ever had any alcohol or drug-related arrests?
      • Have you been missing work, school, or family responsibilities?
      • Do you feel that you are under additional stress?
      • Do you typically drive after taking Lortab?
      • Do you have arguments with people in your life regarding your behavior when you are taking Lortab?
      • Would you consider taking another medication to manage your pain?

    If the person becomes resistant or uncooperative try to reassure the patient that you are gathering this information to provide the best care for his health. If the patient remains resistant then ask them what they would like to do, ask them if you could ask about this issue again next time, and schedule a follow-up appointment. It is likely that fear and stigma is contributing to the patient being in the pre-contemplation stage of change.

  • What other medications/drugs is the patient using?
    • Review the patient's medication use to look for interactions or contraindications in a patient who is using Lortab.
    • Review medications from any other prescriber. If you suspect the patient is minimizing or omitting other sources of medication, do a search on the Utah State Controlled Substance Database.
    • Ask specifically about "pills." Such as "Do you ever take any other kind of pills?" and "Do you ever take anyone else's pills?" (Note: It is important to ask specifically about pills, as many people do not consider pills to be drugs of abuse.)
    • Review history of alcohol and illegal drug use. If currently using alcohol or illegal drugs, ask questions as noted in section B. (Reminder: Do not use the term "illegal drug". Instead ask "tell me about your drug use." Or ask specifically about certain drugs such as "tell me about your marijuana use.")
  • What is the pattern of patient's medication/drug use?

    • (The goal is to determine when, how often, and under what kind of stress/pain conditions is the patient using/abusing the prescribed medications or other drugs.)
    N/A

  • What internal/external obstacles and biases might the patient face?

    (The goal is to determine how receptive/resistant the client will be to a discussion regarding his/her drug use. The physician needs to be aware of the internal/external stigma and biases that the patient faces. The physician will need this information to determine how best to approach the patient.)
    If it is believed that she has an addiction:

    • Fear her pain won't be treated. (Remember that individuals with addiction can also have real pain that needs to be addressed.)
    • Fear of change, facing the knowledge that they have a serious problem, reprisals, treatment, being branded as an addict
    • Embarrassment and shame
    • Fear of rejection by friends or culture
    • The patient's belief that her prescription drug use is not problematic
    • Lack of insurance for treatment
    • Residing with somebody who has an addiction
    • Transportation
    • Fear of loss of employment
    • Fear of legal ramifications if they feel they are divulging sensitive information
    • Society's stigma and blame

    • If it is believed that her grandson is taking her medication:
    • Fear that she is either betraying her grandson or fear that her grandson will retaliate somehow should she tell her physician that he has been taking her medication.
    • Fear her pain won't be treated.
    • Fear of what will happen to her grandson
    • Embarrassment and shame
    • Fear of rejection by friends or culture
    • Lack of insurance for treatment
    • Lack of resources to help support any action that she wants to take.
    • Fear of grandson
    • Residing with somebody who has an addiction
    • Transportation
    • Fear of loss of employment
    • Fear of legal ramifications
    • Society's stigma and blame
    • Because the grandson is an adult, the inability to force him to address these issues.
  • What internal/external obstacles and biases might the physician face?
    • Belief that addiction is a moral issue and not a medical issue.
    • Belief that people with addictions don't deserve to be treated for their pain.
    • Belief that treating pain among people with addictions will exacerbate their addiction.
    • Belief that treating pain with opioids will cause an addiction
    • It is easier and quicker to just fill the prescription rather than assess for pain and addiction.
    • Lack of treatment availability (affordability, waiting-lists, services not available in community)
    • Inability to directly intervene with grandson
    • Physician's discomfort with addressing substance abuse issues and family issues
    • Time constraints
    • Physician's family history causes countertransference (misperceptions based on personal experiences).
  • What do you do now?

    (This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)

    • Discuss evidence for concern (previous addiction and any biopsychosocial concerns identified in part B)
    • Display compassion (Remember that addiction is a life threatening disease thus show the same sensitivity as you would for identifying any other life-threatening illness, such as cancer.)
    • Provide reassurance that it is treatable
    • Ask the patient how she feels about your concerns
    • Address the stigma associated with having an addiction by reassuring the patient that this is a medical illness and not a question of moral character
    If the grandson is taking her medication:
    • Discuss evidence for concern
    • Display compassion
    • Discuss her fears
    • Assess risk for physical or emotional abuse
    • Provide reassurance that there is help
    • Ask the patient how she feels about your concerns
    • Address the stigma associated with having a grandson who is taking her medications and may have an addiction by reassuring the patient that this is a medical illness and not a question of moral character
    • Explore ways to keep medication in a place that is available only to her.
  • How does the physician make a referral?

    • If it is clear that there is significant clinical impairment in the patient's biopsychosocial functioning as a result of her Lortab use. The patient should be referred to a substance abuse treatment provider for further evaluation and treatment.

    If the patient has an addiction:
    If the patient is receptive:

    • If the patient does not have insurance that covers substance abuse treatment, or does not have the ability to pay for treatment, or if the physician has no knowledge of substance abuse treatment agencies, refer to SL County Division of Substance Abuse at 468-2009 or refer directly to Interim Group Services.
    • If the patient is a veteran, eligible for VA services (this typically means having been honorably discharged) refer to VA Salt Lake City Health Care System at 582-1565.
    • Ideally physicians should begin to develop relationships with substance abuse treating agencies and can refer to medication assisted therapies. However, the physician should encourage the patient to call his insurance company to determine what services are covered.
    • Regardless of the specific referral, the physician should write down the name of the agency and the phone number and give to the patient.
    If the patient is not receptive:
    • If the patient remains resistant then consider restricting her to weekly prescriptions and request Utah State Controlled Substance Database checks regularly. Some physicians have patients sign a pain management contract.
    • The physician should write down the name of the agency and the phone number and encourage her to follow through with the referral.
    If the grandson is taking her pills:
    If the patient is receptive:
    • Refer her to an agency that can provide the appropriate resources and discussions regarding what she should do and how she should do it safely. (Examples may include Aging Services, ALANON, public mental health services, or a private therapist who has knowledge of addictions.
    • Calling the police may put her at physical risk
    • Identify an immediate way to maintain control over her prescription.
    If the patient is not receptive:
    • The physician should write down the name of the agency and the phone number and encourage her to follow through with the referral.
    • Calling the police may put her at physical risk. However, this may need to be considered if she continues to resist as the physician's knowledge of medication diversion places him or her at legal risk. Sometimes explaining this dilemma to the patient encourages less resistance.
  • When and how should the physician follow up with the patient?

    (This provides the physician with the opportunity to coordinate with other services provides to deliver comprehensive services for the patient. It also provides the physician the opportunity to take an active role in the patient's substance abuse problems. The physician can treat/oversee the substance abuse problem as any other medical condition that can have a positive outcome.)
    If there is an addiction:

    • Physician should provide referral information to the treating agency regarding concerns and respond to any requests for information from the treating agency.
    • Physician should ask the patient if they followed up with their referral and discuss resulting actions. Reinforce and encourage continued participation in treatment.
    • In case of severe addiction, physician should coordinate directly with treating agency.
    If the grandson is taking her pills:
    • Physician should ask the patient if she followed up with the referral and discuss resulting actions including any actions taken with the grandson.
    • Continue to treat arthritis as indicated.