Recognising and responding to drug seeking behaviour

• Specific request for an opioid or a gabapentinoid
• Request for a prescription for a drug of dependency or prone to problematic use (gabapentinoids, benzodiazepines, z-drugs and combinations thereof)
• Previous episodes of drug seeking documented in patient notes, special notes or system warnings
• Unwillingness to try simple analgesia
• Unexpectedly high doses of analgesia required (primarily opioid but may include gabapentinoids)
• Vague intolerances of alternative or simpler analgesia
• Demanding or aggressive behaviour
• Drug seeking suspected by a colleague
• Inconsistent history and examination findings
• Multiple presentations with the same complaint at primary or acute sites or services including Out of Hours
• Differing history given to different staff members or services (account given to NHS24 may differ to that of the triaging clinician, which may then also be different from the account given if seen face to face)

The MDDUS (Medical and Dental Defence Union Scotland) have provided helpful advice on prescribing controlled drugs.

There should be respectful, non-stigmatising approaches to assessment which takes into account the person’s circumstances including:²⁶

• Physical and mental health
• Personal, social, educational or employment circumstances
• Any drug use
• Safety of person being assessed

Offer clear information on DFMs and their effects, including risks and benefits. Provide information and signposting to support individuals to make a shared decision. Useful prescriber tools and information include:

• Opioid side effect lottery
• Opioids aware
• Opioid thermometer tool
• Dealing with drug seeking behaviour webinar

Set ground rules around prescribing DFMs and schedule regular reviews. Watch out for polypharmacy and co-morbidities. Support individuals to reduce or stop if the medicines are not wanted, needed or working. Tapering DFMs requires careful planning and collaboration and should not be done abruptly. Tapering of opioids is explored in Opioid management general principles and detailed in 'Practical steps to reduce high dose opioids'.

Be alert to signs of drug seeking behaviour and emerging dependence or addiction. Consider professional responsibilities for any prescribing, so that any prescription is safe and appropriate for that individual. Operate within guidance on prescribing, including private prescribing, and refer to local formularies and guidance. Consider a practice-wide system and process for DFMs and apply this consistently. There is an example of a practice protocol in 'Example GP practice policy for opioid deprescribing in chronic pain', which can be adapted for local practice, cluster or board use. Some practices use a ‘patient contract’ which sets out expected behaviours and agreements for both parties when starting to prescribe a DFM.

‘Thanks for being honest about what you want. I will be honest too. These medications are not recommended for long term pain management. They are often harmful for people, and we are responsible for safe prescribing. If you want a second opinion you can speak to another clinician in the practice. I'm happy to work with you on managing this better but need to be honest.’

If the individual persists with their request, and ends up in a circular conversation, a useful approach is to say, ‘we've discussed this already, is there anything else you want to talk about’. If they persist, then say ‘the answer is no.’

An alternative approach may be to say, ‘I'm not able to prescribe that but if you want, I can discuss with one of the senior staff and then phone you back.’  This helps to defuse a potentially heated situation and let the individual phone back later which can be safer in a conflict situation.

• ‘Medicines are not working’ – review and stop them, as with other medication
• Underlying condition resolved, but individual still taking medication
• High doses (e.g. over 90g morphine equivalent dose), especially when co-prescribed with other DFMs (gabapentin, pregabalin, benzodiazepines, z-drugs)
• Has the individual’s condition changed? For example, intercurrent illness, getting older, renal or hepatic function compromised – a dose reduction will be needed to avoid toxicity

Be aware of information on local substance use services and where to find local advice and support for dependence on prescribed medicines.

DIRE score for opioid treatment predicts compliance with opioid treatment for non-cancer pain. DIRE score of 7 – 13 indicates that the individual is not a suitable candidate for long term opioid analgesia, 14 – 21 indicates a good candidate.

Opioid Risk Tool (ORT) may help identify those at high risk of problematic substance use and who might benefit from other modalities of pain control besides opioids. Questions assume some knowledge of medical history.