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Detecting Drug AbuseCAPA

Halifax N.S. 25 October 2014

Presented byMary McGrath, MSc, CGC, CIM, ICCAC

Registered Psychologist

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Common Drugs of Abuse

• Cannabis • Cocaine/crack cocaine• Opioids• Benzodiazepines• MDMA (Ecstasy, Molly)• Methamphetamine• Gamma hydroxybutyrate (GHB), Rohypnol,

Ketamine, Spice, Salvia, Bath salts• Psilocybin • Mescaline

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Unexplained Problems Due To CocaineMedical & Behavioural

• Burns on mouth/hands• Cardiac arrhythmias • Chest pains• Pneumonitis• Bronchitis• Chronic rhinitis Excessive use of nasal

spray decongestants • Nasal septum perforation• Nosebleeds• Dizziness/fainting spells• Hypertension• Stroke• Insomnia• Sweating• Weight loss • Berry aneurysm• Sexual dysfunction

Psychiatric

• Anxiety• Agitation, irritability• Depression • Disordered thoughts• Mood swings• Panic attacks• Psychosis & paranoia• Delusions • Hallucinations • Skin picking/scratching• High levels of energy and

activity for days w/o sleep

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Unexplained Problems Due To Cannabis

• Stomach pain/nausea• Night sweats• Cardiac arrhythmias• Postural hypotension• Severe anxiety/panic attacks, paranoia• Decreased fertility (sperm )/Menstrual abnormalities• Respiratory problems including daily cough and phlegm

Giveaway signs:• Bloodshot eyes• Visine®• Heavy cologne • Dry mouth

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Unexplained Problems Due To Opioids

• Constipation• Bronchospasm • Flu like symptoms: muscle aches, nausea or

vomiting, abdominal cramps and diarrhea, hot/cold flashes, watery eyes runny nose tachycardia, fever

• High BP, increased heart rate• Decreased appetite• Difficulty sleeping• ED

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Drug Seeking

• Drug seekers often do not fit a specific profile. They include patients of every socioeconomic status, age and gender

• Though drug seekers come from all walks of life, they tend to share certain traits and use similar tactics.

• Drug seekers are not necessarily drug abusers. Many drug-seekers sell or barter most or all of the prescription medications they obtain.

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Waiting Room/Triage Characteristics

Unusual waiting room behavior: Presents in “excruciating” pain with facial contortions. While waiting to be seen, patient sits quietly reading or watching television, not showing distress, but expression of agony returns as soon as their name is called. Hostility & Intimidation: Threaten litigation or suicide if not accommodated or demands immediate actionExcessive politeness: Overly polite & sudden change if not satisfiedGives evasive medical history: Unable to give specifics regarding onset of pain & gives vague medical historyAppears intoxicated or sedated

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Drug Seeking: What does it look like?

• Repeated ER visits with pain complaints• Using multiple prescribers• Request extra because they’re going on vacation • Reporting pain when it should be gone• Reporting pain from an accident that did not

happen• Dropped meds in the sink/toilet/lost prescription

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Drug Seeking: What does it look like?

• Asking for drug with a rapid onset of action• Asking for high potency drugs• Asking for drug that is water-soluble or has

high volatility• Claims to have a high tolerance to drugs• Offers bribes or sex, or may make outright

threats of harm to person or property• Threatens to file a complaint

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Drug Seeking: What does it look like?

• Dental pain• Requesting a medication by brand name or have

very specific preferences• Reporting medications as lost or stolen• *Requesting medication parenterally • *Headache• *Back pain• *Reporting > 10/10 pain

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Drug Seeking: What does it look like?

• Insists of being seen right away• From out of province visiting and forgot meds• Feigns physical problems (abdominal/back pain,

kidney stone, migraine)• Feigns psychological problems, such as

depression, anxiety, panic attack• Says non-narcotic analgesics don’t work• Pressures the practitioner by eliciting sympathy

or guilt

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Drug Seeking: What does it look like?

• Makes appointments for late afternoon• Calls physician at home• Medications consistently run out prematurely• Refuses diagnostic work-up • Unwilling to try nonpharmacological

alternatives e.g., physiotherapy, nonopioid analgesics

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Drug Seeking: What does it look like?

• Unusual knowledge of controlled substances • Gives textbook symptoms, using specific

“medicalese” • Refuses to provide urine for drug screen• + drug test for illicit drugs/- for prescribed meds• Cutaneous signs of drug abuse - skin tracks and

related scars on the neck, axilla, forearm, wrist, foot and ankle. Shows signs of "pop" scars from subcutaneous injections

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Skin Popping & Track Marks

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Drug Seeking: What does it sound like?

• "I have this toothache & can’t get in to see my dentist." • "I have shrapnel still embedded in my bones." • "I’m new to the area and haven’t found a doctor." • “My doctor is out of town.“• "I have an appointment with my doctor next week but

need something to get me through the weekend."• "I was beaten up and they stole my Percocet Rx I just got

yesterday."• "My back is killing me and I'm allergic to Advil.“• Appeals to the ego “I heard you were good.” “You’re the

best doctor I’ve ever had.”

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Drug Seeking Stories

• “I sat on my prescription bottle”• “Someone broke in and stole them.” • “Nothing else works”• “I’m allergic to everything except …”• “I’ll hurt myself if you if you don’t’ give me ….”

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Drug Seeking Stories

A patient’s urine tested positive for hydromorphone. When confronted by physician, he claimed that he laid out his father's hydromorphone tablets every morning and the medication had been absorbed through his skin.

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Drug Seeking Stories

A man deliberately let himself be hit by a car in a crosswalk so he could “legitimately” get narcotics for alleged pain.

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Drug Seeking Stories

“My parrot ate my pain pills”

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Questions To Ask(American College of Physicians-American Society of Internal Medicine 2002)

• How often does this patient present?• Does the patient refuse to allow you to talk to previous doctor?• Have you had trouble contacting the patient between visits?• Are prescription pads disappearing?• Does the patient say that only a particular drug will work, or that no

other drug has ever worked?• Does the patient refuse to go to one primary care physician?• Does the patient frequently report losing medications?• Does the patient demand drugs with high street value?• Does the patient have prescriptions from multiple doctors or have

prescriptions filled at multiple pharmacies?• Is the patient cooperating with the full treatment plan—physical

therapy, alternative medicines, etc.?

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Thank you.Questions?