Treating Pain-Killer Addiction: Stick to the Plan

By Gordon Ownby
CAP-MPT's General Counsel

Physicians treating individuals who are addicted to prescription pain medications face probably the most manipulative of all patients. The interpersonal dynamics in this kind of physician-patient relationship make it all the more important for the physician to stay in control and stay on plan.

In February, the patient admitted himself to a rehabilitation clinic for addiction to Vicodin and Valium. He had been taking 10-15 tablets of the Vicodin per day and 10-15 Valium per day for neck pain from a motor vehicle accident. The patient remained voluntarily hospitalized for a month and upon discharge received a treatment plan to participate in a “chemical dependency group” and to get outpatient therapy.

The patient first presented to Dr. P, a psychiatrist, in May. The patient presented with complaints of anxiety, depression, and pain in his neck and face. The patient told Dr. P that he was taking Valium for anxiety. On that visit, Dr. P prescribed Remeron, one per day, and 100 tablets of Valium, 10 mg. On his return two weeks later, the patient reported to Dr. P his use of Vicodin ES for orthopedic pain. On the patient’s return the next week, Dr. P prescribed 60 tablets of Vicodin.

For nearly the next two years, Dr. P had approximately 30 sessions with the patient. On these visits, Dr. P discussed with the patient a variety of stressors. These included tension and stress related to his employment, difficulty coping with his parents, a history of difficulties in marriage and other relationships, and generalized feelings of depression.

During virtually each visit, Dr. P recommended that the patient cut back on his medications. During many of these visits, however, Dr. P wrote new prescriptions for Valium and Vicodin.

Approximately three months into his therapy with Dr. P, the patient again voluntarily admitted himself for detoxification. The patient’s history at this hospital states that he was taking 10-12 Vicodin per day and 10 Valium per day. (Over three weekly visits just prior to this admission, Dr. P had prescribed 300 Vicodin ES to the patient, 200 Valium, and 100 Xanax tablets.)

The discharging physician noted that he spoke with Dr. P about supervising the patient’s continuing detoxification program. In a visit just after the hospitalization, Dr. P provided the patient with a “withdrawal schedule” for the Valium and Vicodin. More than two weeks later, however, the patient told Dr. P that the withdrawal program was not working. Dr. P prescribed 60 tablets of Valium and 60 tablets of Vicodin on that visit.

The sessions continued for another 18 months. Finally, Dr. P told the patient that he would not continue prescribing Valium and Vicodin. On that last visit, Dr. P wrote final prescriptions for Valium and Vicodin so that the patient could avoid withdrawal pending admission to another detoxification program. The patient entered another detoxification program several weeks later and filed a lawsuit against Dr. P later that year. In the suit, the patient alleged that Dr. P negligently prescribed excessive amounts of medication, leading to his addiction and accompanying pain and suffering.

Obviously, Dr. P’s attempts to gain the patient’s confidence in order to assist him in withdrawing from the addictive medications failed. The lawsuit was resolved informally prior to trial.

According to risk management literature, physicians often under-treat patients with pain out of the concern over addicting their patients to prescription drugs. These same physicians may nevertheless fall prey to manipulative, drug-seeking patients. Academics who have written on the subject say that a basic clinical survival skill when patients exert undue pressure to obtain a prescription drug is to just say “no” and stick to it.

Comments on Case of the Month may be directed to Gordon Ownby, CAP-MPT’s general counsel, at gownby@cap-mpt.com