Recognizing Prescription Opioid Abusers - from MD's reference book.

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Stella Marie
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Date Joined May 2005
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   Posted 9/4/2009 2:43 AM (GMT -6)   
At my last appointment with my PCP we were talking about medical terminology and the difference between dependence and abuse. We have a great relationship and he just got a new copy of one of his pocket manuals on managing chronic pain and so he gave he his older copy.  It had some interesting checklists.  I am attaching one about abuse. because it comes up often in our postings.  I though some people might find it interesting......

Recognizing Prescription Opioid Abusers

Medication Related Indicators:

·        Purposeful over sedation

·        Uses pain medication in response to stress

·        Uses more than prescribed

·        Requests frequent early renewals

·        Runs out of medication early

·        Reports lost or stolen prescriptions

·        Attempts to obtain prescriptions from other doctors

·        Hoards or stockpiles medications

·        Buys medication on the street

·        Insists on certain medications by name

·        Expresses a strong preference for certain medications or routes of delivery

·        Expresses concern over future availability of controlled substances

·        Misrepresents analgesic prescription or use

·        Indicated that he/she must have analgesic

·        Predominant issue of office visit is discussion of analgesic medication

·        Reports minimal/infrequent relief from opioid analgesic

·        Difficulty agreeing to medication agreement


·        Some of these behaviors can be normal.

·        None are diagnostic.

·        Take a therapeutic approach with your patient.

·        Set limits.

From “Managing “Chronic Pain with Opioids in Primary Care”  by M. Karz. MD, et al

Because we frequently talk about this, I thought this was interesting because the source is  from and actual MD's check list.   Just an FYI

Stella Marie

Co-Forum Moderator for Chronic Pain

Rare neurodegenerative /movement disorder called “Multiple System Atrophy”.  Mobility issues,, neuropathic pain,  spasticity, central apnea, collagenous colitis, joint and body pain, swallowing and respitory  involvement,  Implants: intrathecal pump  & neurostimulator.  Extra features: O2 & wheelchair

 Not all of us can be Cinderella, but some of us can be Fairy Godmothers.......


Post Edited (Stella Marie) : 9/4/2009 1:52:23 AM (GMT-6)

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Total Posts : 314
   Posted 9/4/2009 10:10 AM (GMT -6)   
Expresses concern over future availability of controlled substances

Now that one I have can say I would think a lot of us do still if not one point.

I know before I really got established with a pain dr and was one a routine regular appts and scripts on specific days. I always dreaded/was scared or terrified of running out of medication without being able to have more, or need them b4 next script.

I just feel that a lot of people with Chronic pain they dont want to feel that intense pain so I would htink of course it would make you express concern over future medication. thats sorta funny you've posted this because Id assume my pain mangement dr has this book also and/or has seen this 'checklist' and I happen to be talking about the sitution of getting like anxiety about running out, and he said he found that normal in most people usually so. I mean depression/anxiety runs with chronic illness right? so wouldnt you think that thinking about running out of medication would be icing on that cake? Just my opnion I know you had said at the end... Stella that some of the behaviors can be normal, sorry the book said this, but stella quoted but I really feel strongly about that. I mean I know an addict would definatly be worried about future access but I would think a chronic pain patient would have these fears or worries at some point in their illness lifetime. And I really feel there is not a single thing or issue involved that is wrong about that. Why would we not mind not having anything in the future and having basically for some of us our life taken from us for atleast the 2nd time, the first people before you found pain medication .

Mrs. Dani
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Date Joined Jun 2009
Total Posts : 2787
   Posted 9/4/2009 11:08 AM (GMT -6)   


   Dear Stella,

     Good morning *huggs* How are you? I hope you are doing okay. I am hoping to try to accomplish some rather large tasks today, and here I sit.. Procrastinating!! hehe

      I really liked this post.  Alot of food for thought.   shakehead  I am glad you posted this. This subject does seem to come up very frequently, esp with new members worried about addiction vs. dependence.

  ...Sometimes I think it is a blessing to be allergic to most Narcs.  :-)  On the other hand, it sure does make it hard for my doctors to treat my "chronic pain".    rolleyes   (inflammation / bone loss)

*warm huggs*


TWO roads diverged in a yellow wood,  
And sorry I could not travel both  
And be one traveler, long I stood

Stella Marie
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Date Joined May 2005
Total Posts : 601
   Posted 9/4/2009 12:59 PM (GMT -6)   

Boy to I agree with you. I think most if not all pain patients worry about adequate treatment. For me, i personally lost a PM doctor to retirement and his replacement was the drug ****. He assumed the all of the former doctor's patients were over medicated and he made it a personal goal to reduce each and every patient. So within one month - my adequate pain control went from great to horrible. It was a nightmare and because I have a pump changing PM's is not that easy. I had the worst 3 months of my life. I learned you can't take everything for granted. God forbid, if your doctor should drop dead tomorrow or not be able to practice, who would replace him or her. This was my worst nightmare. I had to desperately find a new PM without appearing like a drug seeker. I could not leave the replacement doctor's practice fast enough - but finding a new doctor is not that easy. For this reason alone, I will always worry about my next Rx. I think all chronic pain patients do - just look at how we are treated at Emergency Rooms.

Stella Marie

Co-Forum Moderator for Chronic Pain

Rare neurodegenerative /movement disorder called “Multiple System Atrophy”.  Mobility issues,, neuropathic pain,  spasticity, central apnea, collagenous colitis, joint and body pain, swallowing and respitory  involvement,  Implants: intrathecal pump  & neurostimulator.  Extra features: O2 & wheelchair

 Not all of us can be Cinderella, but some of us can be Fairy Godmothers.......


Regular Member

Date Joined Aug 2008
Total Posts : 326
   Posted 9/4/2009 1:57 PM (GMT -6)   
Ditto. I'm facing some of that exact anxiety right now. I'm getting ready for a cross country move and having to find a new doctor etc. I'm sure that I'm going to "Expresses concern over future availability of controlled substances" when I see my doc here next Thurs. I don't want to be on the other side of the country and not have any resources. I know what I went through getting to where I'm at now, I don't want to backslide. I want to keep moving around and not feel like I'm trapped in a bed all day.

Sorry...let me end this anxiety rant. lol
Curious people are interesting people...I wonder why that is.
~Bill Maher

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Date Joined Jul 2008
Total Posts : 2317
   Posted 9/4/2009 3:04 PM (GMT -6)   
Thanks so much for posting this.

I still think that a well-trained PM is going to know enough to understand how to appropriately apply these standards. Personally, it always became quite clear who were the addicts when they would get kicked from the clinic I went to. The normal people would be concerned about their pain. If the PM offered them anything that would help the slightest bit with their pain -- prescription-strength advil, a script for massage, old-school a/d's (amitriptylene, nortriptylene, etc. -- forgive my spelling) -- they would jump at it. They weren't happy about it, but were glad to get even the slightest bit of relief. Plus, for withdrawals, they were generally pretty willing to take non-narcotic treatments like anti-nausea, clonidine, etc.

The middle group was people with addictive tendencies who worked very hard to manage their medications & to eliminate/reduce as much risk as possible by selecting tamper-proof patches, pain pumps, a person to administer daily meds, etc. They were closer to the addicts while on the meds (though were careful not to be breaking laws or violating ethics), but resembled non-addicts when they would be kicked from the clinic [which was rare].

On the other hand, the addicts just went completely off the deep end. They would scream that they were going to die if they didn't have a 3-month supply of narcs. They weren't willing to take any help at all if it wasn't a strong narcotic. "NOTHING" else ever worked even just the very slightest bit to help their pain. The difference wasn't that massage helped reduce their pain by 1 point whereas narcs helped reduce it by 4. For the addicts, the difference was nothing helped reduce their pain by even a single (or half) a point except narcotics which made them "pain free" most of the time. Since the goal of pain medicine is never, ever to make the patient pain free, that was a huge red flag for my PM. But he was really careful & considerate so he wasn't just jumping to conclusions. He always offered patients he kicked from the clinic withdrawal meds, but usually the addicts would just flat out refuse hoping to strong arm the doctor into giving them the narcs. It was just insane, really. Regardless of what they thought, they weren't hiding their problem from anyone. The whole waiting room could tell when someone had a serious addiction problem.

I know a lot of CPers get all worried that they will be labeled by their PM's as addicts. Though that label is used a LOT in hospitals, by PCP's, by family/strangers/co-workers, etc., there is a lot of new research & information out there at this point for PM docs. Licensing boards put a lot out there. Professional associations put a lot out there. There have been numerous articles in professional journals that go in to much more detail than the information Stella just posted. I really don't think that PM's have much of an excuse to not be able to tell the difference and from what I've seen and heard, it is not too common that PM's make the mistake of mislabeling people as addicts. Just another argument for trying as much as possible to find a specialist. Some PCP's are well-trained in pain medicine, but it seems much more common that PCP's haven't read up on how to properly dose CPer's, how to correctly identify addicts & other key topics required to properly treat/manage CP patients imho.

But I think patients need to take some responsibility too. When I used to teach elementary school, I used to tell my students that they not only had to actually listen when someone was giving a presentation or lecture, but that they also had to appear to be listening -- i.e., turn their face towards the speaker, face their body as much towards the speaker as possible, make eye contact from time to time if it is a small group, nod their heads when they understand & take notes if that is helpful & appropriate. I think a similar notion holds true for CPer's. We need to not only actually be not-addicted, but we also need to appear to not have the traits of addicts, as much as possible. That's where I think Stella's post can come in handy. Sharing medications (esp. controlled substances), stockpiling medications without our doctor's knowledge, going to multiple pharmacies without informing our doctors, getting prescriptions from other doctors without 1) telling the new doctor who we are seeing & what we are taking and 2) as soon as possible calling/emailing our PM to inform them of what new meds we were prescribed while their office was closed, refusing to try alternative treatments like massage, PT, behavioral changes, acupuncture and so on, deciding on our own to take meds more frequently prescribed without checking with our PM's FIRST to see if that's okay, taking meds for something other than the reason they were prescribed (like taking meds prescribed for back pain for a headache, or taking pain meds to help us relax), etc. can end up making us LOOK like addicts even though we're not.

Now, I am not suggesting hiding things from our PM. Anyone who knows me knows I am 1000% against that. All I'm saying is maybe (& I include myself in this) we need to dial it down a bit when we're with our PM's. They're not counselors. They don't need to hear about all our fears. They are our caregivers, though, and they do need to right away know if there need to be changes to our treatment. I think sometimes we get so anxious about out PM's mislabeling us "addicts" that we make med changes on our own. That ends up making people look way more like an addict than if they had just called their PM's office & explained that the pain was out of control.

But that said, you are right on, ChP, about concerns re: pain med access being something a number of patients think about. Anxiety/Depression many times do co-exist with chronic pain/chronic illnesses (I don't know the current numbers -- at one time I read it was 60% co-morbidity rate of CP & Depression). However, there are lots of wonderful treatments out there to manage the anxiety/depression. CPer's don't HAVE to suffer with anxiety/depression. They can get treated & substantially improve those symptoms. While adequately managing pain can have a positive effect on mental illness, likewise adequately managing mental illnesses can have a positive effect on pain. Treating the depressive disorder & the occasional very anxious thoughts/feelings, had definitely helped me both feel better & to get the pain a bit more under control.

By treating my depression & managing anxiety with things like visualization, forcing myself to think positive thoughts, etc., I worry less about having meds available & what would happen if I ran out (pain would get worse, lose job, lose home, be homeless -- arrrgghh!). Instead, I focus on the fact that with only a couple of exceptions, I've never run into any problems at all getting my prescribed medications on schedule. And even when I have had a couple glitches (DEA shut down a pharmacy I used & once my PM was out for 2 months & his back-up would only offer to prescribe me certain meds, all of which I was allergic to), I found a way through the problems. Yes, it was unpleasant for a couple weeks, but I didn't die & I didn't become homeless & I didn't even lose my job. I was in a lot of pain, but I took it as a time to try out alternate treatments. When I start to feel stressed, I try to focus on how well things eventually worked out those times. Like I said, it wasn't very pleasant so I don't mean to make running out of pain meds less than it is, but I try not to make it more than it is either. Not accusing you of doing that, just sharing my experience. Hopefully that will help others, but if not it is always a good reminder to me -- especially now that I have only a week's worth of meds left until I run out. :O My PM was not being honest with me about why he switched me to a new medication, so I lost my trust in him & need to find a new PM.

Anyways, I know this was a really long post, but I do want to encourage everyone to try to think about how Stella's post might be helpful to you. If we each are able to somehow change our actions/words just a little on even one of those items (if any apply), I think it would help. For me, I'm picking the one about talking about pain meds for much of the office visit. When all of us band together & commit to showing clearly that we really are above reproach, then all that's left is to get doctors better educated. One thing at a time, I guess. :)

Moderator -- Depression Forum

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Date Joined Aug 2008
Total Posts : 326
   Posted 9/4/2009 5:09 PM (GMT -6)   

As always you are one of the people that I appreciate hearing from the most. You have the same tendency as most people that are important to me in my life. You tend to cut to the heart of the issue.

Curious people are interesting people...I wonder why that is.
~Bill Maher

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Date Joined Sep 2009
Total Posts : 8
   Posted 9/4/2009 11:53 PM (GMT -6)   
Interesting post. I am suffering with thoratic back pain. From my research, it should only take a few weeks to feel better. I ended up going to my PM and PT because advil just didn't do the trick. I took the max. amount of advil and still had pain. I tried to call my doctor, but they closed at 1 p.m. I gave in earlier today and took a muscle relaxer left from a muscle strain last year. I slept for several hours and felt better. However, I have a 3 day weekend and I have a lot of work to do, especially with children. I don't want another muscle relaxer and the OTCs don't work. I want something to get through the weekend, but I'm worried that the walk in clinic may think I'm seeking out drugs. I keep going back and forth with this.

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Date Joined Jul 2008
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   Posted 9/5/2009 8:59 AM (GMT -6)   
Great post Stella, gives me food for thought. But I have give you a flip side to this. I've been treated for CP for the last 9 years and have always done what my doctors wished, never took my meds over what was precribed, made it early to my appts and never gotten mad at my PCP docs or any other person I have dealt with as far as health care personal.

Now each of you know that dealing with CP is very hard, but it makes it even harder when you have three psychologists saying that "I'm hiding my pain from my doctors." Now I don't understand this...because of all the above. If because I care about my appearance or that I try hard to keep my thoughts from running into the Dreary Woods that I am not telling my pain right then I think the whole psych field is NUTS@!!!!

I was taught from when I was a small child you don't show reveals weakness. I have been told I laugh at inappropriate times (excuse me for being nervous!) and that I hide my real pain that I am feeling because I don't walk or look like I'm in pain. Okay.....someone please explain this too me???


What doesn't kill us only makes us fight back harder! :P

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Date Joined Jul 2008
Total Posts : 243
   Posted 9/5/2009 12:02 PM (GMT -6)   
I agree that a good PM will be able to use that list appropriately, but this is the one that's stuck in my mind -

Predominant issue of office visit is discussion of analgesic medication

In this day and age of the 7-minute doctor's appointment, we almost have to make the predominant issue of our appointments analgesic medication.. it takes 5-7 minutes just to side effects smhair

Regular Member

Date Joined Aug 2008
Total Posts : 326
   Posted 9/5/2009 1:37 PM (GMT -6)   
Too true. Thankfully my PM is okay with just sticking with the things that are tried and true with me. So we don't have to talk a lot about meds. We mostly talk about other things such as PT and injections. But, I know that I am lucky in that respect.
Curious people are interesting people...I wonder why that is.
~Bill Maher

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Date Joined Nov 2007
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   Posted 9/5/2009 2:00 PM (GMT -6)   
I don't think most doctors would see that one in isolation as a problem. But if you put it together with one or two others, then the red flags start going up. Or if someone is resistant to trying any other form of pain relief - like, for example, has never tried PT and is unwilling even though it might help. I do agree with you, though, that doctors hate it when we're all over the place and they're trying to keep to their schedule. So if meds are they issue - as they well may be for us CPP's - then we have no choice but to raise that.

Scarred - I do think that the belief that showing your pain is "weakness" is probably what your psychologist is referring to. Maybe even saying that to your doctor will help him understand why you may not show your pain easily, but still, you need to try your best to challenge that belief. That's the only way your doctors can know how much pain you're really in. For you, maybe writing down your symtoms and going in with a list may help.

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