The Drug-Seeker: an Urban Legend?

I doubt there are many people involved in the wonderful world of chronic pain on either the treatment side or the lack of treatment side who haven't heard of that malicious and devious creature known as the drug-seeker. Depending on one's point of view, he is either a Svengali-like manipulator able to hypnotize even the most jaded doctors into forking over Vicodin by the jugful or a pathetic, toothless rube claiming to be allergic to every drug known to man except that one beginning with a "d" (Dilaudid, or Demerol). To hear some doctors talk about it, it seems that everyone with pain is either a drug seeker or a wuss who couldn't handle a paper cut without an IV morphine drip. But it seems the drug-seeker is universally blamed by both doctors and patients alike for the hostile and negative attitudes people with chronic pain routinely encounter from the medical profession.

One of the interesting things about the drug-seeker phenomenon as it is often described on many medical blogs is that you often read accounts of drug seekers that are remarkably consistent from one blog to the next, as if everyone has encountered the exact same guy using the same pathetic story to scam for drugs. Usually, it will be an ER nurse or ER doctor talking about a guy who claims to be allergic to "Tylenol, ibuprofen, and every other NSAID, and Toradol doesn't do it for me; but I can take Vicodin and that other drug that begins with a "d"...uh, I had it the last time I was here...what's that thing called...oh, that's right! Dilaudid! (or Demerol, both powerful narcotics). If you read medical blogs a lot, and I do, you will likely encounter some version of this story with only minor variations.

In fact, this story is so common that someone has even begun marketing an assortment of magnets and buttons on cafepress.com with a guy in a hospital gown voicing this very story!

The caption reads:
"YEAH RIGHT!

Well, I hurt my back about three months ago and heat and ice just aren't cutting it. I'm allergic to Tylenol, Ibuprofen and Naproxen and Toradol just doesn't work for me. I had really good luck with that one medicine I got the last time I was here. What was it called? It started with a "D". I think.. Does Demerol sound right?

It starts with a "D" all right!
DRUG SEEKER!"

The thing about this story is that it's obvious that anyone actually using this line is going to earn himself a one-way ticket onto the blacklist and can forget about ever getting drugs in that hospital again. No doctor would be likely to give meds to a guy like this particularly as they all claim to have heard this story a million times, so you would think that by a simple process of evolution the drug scammers would either put their heads together and come up with a better spiel than this, or would be forced to give up on trying to score drugs at the ER.

Yet according to the DEA, drug scammers are so sophisticated that there is allegedly an "epidemic" of prescription drug abuse and diversion going on, and drug seekers must therefore be quite skilled at obtaining drugs (of course, the DEA is full of crap, too, but I digress). This is particularly true as most people with real chronic pain problems report incredible difficulty getting doctors to take their pain seriously and prescribe any painkillers at all, let alone an adequate dose, and frequently report being accused of drug-seeking or of being whimps who can't take pain. If soaking your spear with the blood of your first "drug-seeker" is a rite of passage for many docs, being falsely accused of being one is a rite of passage for people with chronic pain.

In truth I can see how a sophisticated drug addict who knows how to play the game would have a far better chance of getting pain meds than some poor girl who has never had severe pain in her life, but one day injures her back and limps into the ER complaining of severe pain. She naively says she's allergic to NSAIDs, but her friend gave her an OxyContin that worked great for the pain, and "can I have one of those?", not realizing that she just signed her own arrest warrant and won her doctor $50 bucks from the "first drug seeker of the night" pool.

So I would imagine anyone actually dumb enough to use a story like our poster boy above would more likely be a legitimate chronic pain patient who doesn't know any better than a scammer, and that this archetypal drug seeker you encounter on so many many med blogs is in reality just an urban legend, stitched together like Frankenstein from bits and pieces torn from real people with real pain who were too naive to know they were walking into a minefield when they stepped into their doctor's office and used the "P" word for the first time. It is highly improbable that so many different doctors, in so many different places, would have had so many encounters with this many individual patients who all presented with almost identical stories.

Snopes.com, the noted debunker of urban legends, defines urban legends as:

...narratives which put our fears and concerns into the form of stories or are tales which we use to confirm the rightness of our world view. As cautionary tales they warn us against engaging in risky behaviors by pointing out what has supposedly happened to others who did what we might be tempted to try. Other legends confirm our belief that it's a big, bad world out there, one awash with crazed killers, lurking terrorists, unscrupulous companies out to make a buck at any cost, and a government that doesn't give a damn.

Folks commonly equate 'urban legend' with 'false' (i.e., "Oh, that's an urban legend!"). Though the vast majority of such tales are pure invention, a handful do turn out to be based on real incidents, and whether or not something actually happened has no bearing on its status as an urban legend. What lifts true tales of this type out of the world of news and into the genre of contemporary lore is the blurring of details and multiplicity of claims that the events happened locally, alterations which take place as the stories are passed through countless hands. Though there might indeed have been an original actual event, it clearly did not happen to as many people or in as many places as the various recountings of it would have us believe.

It definitely seems as if our archetypal drug seeker story meets the definition of an urban legend, both in the sheer improbability of its being true in so many different areas, as well as the fact that it serves to "confirm the rightness" of the medical profession's "world view," which is to err on the side of undertreating pain in patients with legitimate pain problems. If you can convince yourself that everyone with adverse reactions to drugs or who requests a drug by name is an addict, you don't have to go home and hate the person you see staring back at you in the mirror each morning.

Perhaps you should.

How common is "drug seeking" really? No one has ever done a formal study of actual drug-seeking behavior that I'm aware of, but there have been numerous studies on the incidence of actual opiate addiction in chronic pain patients and in the general population as a whole, and every study I am familiar with show very low rates in both groups, the highest estimate being less than 3 percent for cp'ers using a rather bizarre definition of "opioid use disorder," whatever the hell that is, and 1 percent for the general population. So it is really hard to see where this legion of Toradol-shunning Dilaudid zombies is coming from, given the naked facts.

But facts are things that are readily discarded whenever they prove inconvenient in the world of medicine, just as they are in the rest of our world. Far better to cling to convenient half-truths and urban legends if they make you doctors feel better about yourselves, because after all, it's all about you. Most likely, there is at most a small minority of pain patients who fall into the category of drug-seeker and a very large majority of people with legitimate pain problems being falsely accused of drug-seeking out of ignorance and bigotry. Many of those people are forced into the role of drug-seeker by the very fact that doctors are reluctant and unwilling to treat pain aggressively, thus it becomes a self-fulfilling prophesy. If a guy shows up in your ER with excruciating pain and you give him 10 Vicodin, why are you shocked that he would add a "zero" to the "10?" What choice did you give him? Maybe if you had treated his pain appropriately with an adequate amount of medication for the $1,600 he brought into your hospital he wouldn't have had to do that.

But that fact is just too inconvenient for you to hear, isn't it?

Anything but Opiates!

Master Juba, from DEAsucks.com, sent us this article which he originally wrote for his site:

Anything but Opiates!

The DEA's intimidation tactics against doctors who prescribe opiates has another unintended effect; Doctors who treat narcotics like they were poison, but are quick to use a drug like Neurontin for a purpose it was not designed for, and not approved for, all on the word of a sales representative from a drug company. At least when the Perdue reps were pushing OxyContin on doctors, it was a pain medicine to be used for pain and no one billed it as a cure for high blood pressure or cholesterol. The pushing of Neurontin by pharmaceutical reps visiting doctors has been an issue for years. Even after the hubbub about the aggressive way Perdue pushed OxyContin, the folks selling and pushing Neurontin made the OC campaign look like a joke. Sales reps were interviewed on national news programs like "60 Minutes" and "20/20" saying that their management really put the screws to them to ("lie") tell doctors that Neurontin was not only the greatest drug coming down the pike for seizures, but to push the point hard to doctors that it was great for all kind of off-label uses, including chronic pain.

Congressmen and the FDA were appalled and up in arms about the whole thing... for about 3 weeks. Then it just kind of faded away, never to be heard from again. Doctors began serving it up for chronic pain in doses so high it was absurd, not to mention dangerous. And the whistle-blowing drug company reps who testified they were told to lie were fired with extreme prejudice, so no matter how loud they hollered about Neurontin poisoning, it looked like sour grapes.

Some people were actually getting some relief from Neurontin. Of course they aren't keeping track of how many folks had problems like developing seizures from taking it in high doses (and seizures wouldn't seem like an unusual thing to happen to someone on Neurontin) and there's no way to tell how many of those helped by the drug would have been helped even more by a real pain medication like a narcotic.

But society can't have narcotics handed out like candy to everyone with pain. That would never do. We can hand out seizure meds like candy though, and that's OK. If we do hand out a narcotic, we have to make sure we put a poisonous substance like acetaminophen in it, so we can show the systemic damage caused by narcotics, if the patient takes enough to try to break even with the pain.

It's a scary world where doctors would rather see someone on a medicine that's not approved for the condition, that could cause other systemic damage, that they have no real research on what it does for pain or how it works or what high doses do over the long haul, rather than to put a patient on a medication actually designed to fight pain. A medication that has been in use for the last 5,000 years, since the first poppy was picked, and has been proven effective and safe, if used properly. Neurontin was approved by the FDA in 1993 as an anti-seizure medication for epileptics. In addition, it is approved as a treatment for a condition related to shingles. Neurontin is believed to be linked to suicidal behavior, including suicide ideation and attempts.

Neurontin is manufactured by Parke-Davis, a subsidiary of Pfizer, and used to regulate the nerve activity in epileptics. To date, there are about 2 million people in the US with epilepsy. However Neurontin was prescribed for additional uses, for which it did not have FDA approval. Parke-Davis settled a criminal lawsuit related to such unapproved prescriptions. Yet, it is believed that approximately 80% of all Neurontin prescriptions were filled for unapproved medical conditions, which makes Neurontin side effects much harder to measure.

The eleven illegally promoted, unapproved uses for Neurontin include: bipolar disorder, peripheral and diabetic neuropathy, monotherapy for epileptics, reflex sympathetic dystrophy (RSD), periodic limb movement, attention deficit disorder (ADD), restless leg syndrome (RLS), trigeminal neuralgia, post-hepatic neuralgia, migraine, and drug and alcohol withdrawal symptoms.

When a patient takes a prescription for an unapproved use, the person runs the risk of having serious side effects because the medication was not tested in clinical trials for that use. The side effects could be minor to severe, but for certain, without a trial to test for interactions or preexisting conditions, the potential danger is huge.

Neurontin is believed to be linked to suicidal behavior and suicidal ideation. Evidence of suicides supplied to the FDA by the manufacturer are less than the number the FDA itself has gathered. Although the connection has not been proven decisively, no full clinical trials have been conducted for Neurontin on the unapproved uses for which it has been prescribed.

Using Neurontin for pain rather than narcotics is very dangerous. If you have been helped by Neurontin, that's great, but I wonder how much better you would feel on a real pain medication. Your doctor will never let you find out.

By Master Juba
Original article on DEAsucks.com: