If you're a doctor or physician, you should know that a professional drug seeker's primary objective is to dupe you into participation in the illicit prescription drug trade. However, don't be fooled; while the average bungling drug seeker doesn't care if you lose your license or go to jail, the professional does. This is because their success as a criminal is tied to a good relationship with you, the dentist, the ED and the psychiatrist. But don't get cocky and think that no-one flies under your radar; the professional drug seeker does things you've probably never considered before. How would I know? I was once an extremely persuasive drug addict.
Today I'm a CAS, Board Certified Interventionist and founder of a prominent drug rehab center. I learned from my mistakes years ago, but because my life is dedicated to working with addicts, I've been privy to some shocking stories of clever drug-seeking behavior that targets you and your practice. I'm not talking about the dope fiend whose drug seeking attempts are obvious to any physician with a pulse. I'm talking about the professional drug seeker, and I can tell you that many of them take their job as seriously as you take yours.
What you've been taught to look for might help identify the desperate and relatively inept addict: reporting lost or stolen medication, asking for a drug by name, frequent ED visits with difficult-to-prove pains, etc. However, a 2012 study of drug seeking behavior – considered the most comprehensive such study to date – indicates that the “typical” signs of drug seeking might not have that much relevance after all, (1) and they definitely don't apply to the professional drug seeker.
The following are 8 things that professional drug seekers do to manipulate you into writing a prescription:
1.) They won't ask for the Drug by Name
These are not stupid people. They know that asking for a drug by name is going to get them red-flagged immediately. Instead, they'll employ one of several strategies:
*Pretend to mispronounce the drug. For instance, they might state that during a previous injury or illness a certain drug worked well for them. Veecodine? Vickodin? Of course, you correct them with “Vicodin,” and now it was you who mentioned the drug; not the patient. Psychological tricks like this comprise a large segment of the pro drug seeker's arsenal.
*Bring a friend. By bringing along a “credible” third party – such as a wife, mother, father, grandparent or some other person, the third party can make suggestions for drugs without casting suspicion on the patient: “No doctor, the Ibuprofen just made him itchy; it was Oxycontin that helped his pain and let him sleep.”
This tactic may also be employed outside of your office, once the patient has been discharged with a prescription they did not find suitable or no prescription at all. This may be quickly followed by an irate phone call from someone purporting to be the patient's family member. This person may assert that the treatment as offered was not sufficient and make demands for a potent prescription drug, or indicate that the pain has significantly increased since leaving your office and request that something “be called in.”
*Careful pain descriptors. Because they can't come right out and ask for a specific drug, the professional drug seeker will use carefully crafted pain descriptions instead. They know not to rate their pain as a 10, to lower their pain rating after taking a monitored dose, and if they carry on with a painful ruse they are likely to be consistent and convincing; not dramatic and impatient like their amateur counterparts. These individuals know that the best tactic is to describe how the pain or symptoms have impacted their ability to eat, sleep, work, perform family duties and go about the tasks of daily life.
2.) Well-Presented, Intelligent & Capable Speakers
The professional drug seeker is no schlep. They generally present quite well, are articulate, use eye contact and are able to engage on a wide number of subjects. One of their first tasks is to uncover something personal about their doctor or nurse and find a way to work this information into a natural conversation – especially by claiming to have similar interests or experiences. Compliments for your offices, staff and so on will probably be reserved but well-timed. A good professional drug seeker always gets his doctor to talk about him or herself as much as possible, whereas the junkie will primarily talk about themselves. The end result is that by focusing attention on them, the junkies are often caught, while focusing the attention on the doctor allows the professional to act, distract and charm their way to a prescription.
The professional drug seeker also goes to great lengths to maintain a good image. I know of several former opiate addicts who always went to the doctor or pain clinic with a fresh haircut, clean-shaven and in a sharp suit. Then with their tie partly undone and looking good but somewhat tired – depending on their supposed condition – they seemed like anything but a street-level drug-seeking junkie.
Of course, it's important to note that not every pill huckster is using their own product, so just because you're targeted by a professional doesn't mean you're dealing with an addict.
Finally, the professional drug seeker tends to be an excellent speaker. They could make – and might actually be, as in the case of Rush Limbaugh – an excellent politician (2), or an attorney, an actor, a journalist or some other type that is gifted with words, gestures and story-telling ability. They're also superior listeners; they listen to every word you say and look for their way in.
Consequently, they may come off to an observant physician as insincere.
3.) Use of Medical Terminology
Professional drug seekers feel that they need to be elevated to your level, so in order to acquire this illusion they'll often study a significant amount of medical terminology. These individuals are also naturally inclined to research the drugs they swindle you for and learn about their methods of manufacture and distribution, medical uses, related conditions and so on.
While this limited education might assuage the doubts of an overly busy doctor, one who takes the time to understand their patient will begin to question why the individual has such command of a specific branch of medicine or pharmaceuticals without any academic, professional or even direct personal experience in the matter. For instance; consider the restaurant worker who asks you about reuptake of serotonin, or a hairstylist inquiring about the specific chemical composition of each substance within a pill. If it doesn't make sense, it's cause for concern.
4.) Medically Altering the Body
Professional drug seekers know that the tired old shtick of phantom, unsubstantiated pain in the back, neck and head won't wash for long. As a result some will medically alter their bodies in order to fake a condition or elicit pain meds for a real but deliberate injury:
*Patient may present with very precise injuries: incisions, carefully and/or strangely shaped avulsions, broken toes, punctures, etc.
*Patient may present with controlled burns or scalds, without characteristic “splattering” indications.
*Patient may take drugs that cause symptoms of real conditions. For instance, I once knew a prolific drug seeker who would take a few hits of meth before faking an anxiety attack; he claimed this increased his heart rate enough that he'd be given tranquilizers and sedatives during his ED or office visit and of course he'd get some to take home as well. I've also heard accounts of drug seekers using blood thinners, diabetes and cancer medications in order to skew test results and present with “false” symptoms.
*Patient may taint urine or stool with blood or other substances.
*Patient may dilate pupils in order to fake neurological conditions – this trick is also echoed in the Code Babe RN Blog, where a drug seeking patient reportedly dilated her left eye in order to feign a brain tumor. (3) (The ruse worked and the patient got a dose of Dilaudid in this case.)
5.) Faking Medical Evidence
Professional drug seekers develop tools and resources to aid them in their trade. This includes faking medical evidence. In some cases x-rays, MRIs and other tests are stolen, altered and presented as evidence to an unsuspecting doctor. Some individuals work with accomplices who pretend to represent another healthcare provider and send fake records to the target physician's office. Other faked medical records include adulterated blood workups and ED reports.
6.) Convincing & Immediate Medication Mishaps
The average drug seeker may claim that their medication has been lost or stolen in order to obtain a refill. Professional drug seekers are not above this behavior, but generally call their doctor immediately after a prescription is filled to make this claim. A favorite story is that the medication fell into the toilet – making it irrecoverable and impossible to verify. By calling to report the missing medication straight away, the professional does not fall into the regular pattern of drug seekers who wait until they've taken most of the medication before attempting to scam for more.
7.) False Identification
With more and more states requiring prescription drug monitoring programs, the professional drug seeker must adapt in order to avoid detection. One of the most effective ways to do this is to obtain false identification in order to get prescriptions using multiple aliases. In fact, in some large hospitals former addicts reported being able to visit the same ED and gain multiple prescriptions in the course of a week using different aliases. This was accomplished in part by observing ED staff shift change procedures.
8.) Working in Teams
To maximize yield and profit, professional drug seekers often work in teams; generally of two but sometimes more people. The second person can be used to distract medical staff or advocate on behalf of the patient as indicated previously, or they can scout the hospital or practice for other opportunities to acquire drugs.
However, teams may be discovered because they will often present with similar “unexplainable” symptoms but at different times. Meaning, today team member #1 is seen in the ED for back pain, and tomorrow team member #2 is seen for debilitating migraines that “have been keeping her up for 5 nights in a row.” However, the doctor who saw team member #1 two days ago noticed that team member #2 was in the room at the time and complained of no such consistent migraine symptoms and in fact seemed vibrant and well-rested.
You may also notice a clear role reversal in team members – one member provides support and distraction during an ED or office visit while the other plays the role of patient, then the next visit the roles are reversed. The fact of the matter is that professional drugs seekers may have difficulty keeping all of their stories together, and this becomes even more difficult when more than one person is involved in the scheme.
The problem with the professional drug seeker is that they are responsible for a much higher rate of prescription drug diversion than the average drug seeker. They're not just in it for personal use in most cases – they're in it for profit and business in this regard is good.
So when it comes to your staff, your license and your practice, the best defense is to know your patients as well as possible. Read their charts. Ask them questions that aren't directly related to their alleged condition and listen to their answers. Use your state's prescription monitoring database if one is available. If a patient says something that doesn't make sense, don't just let it pass and allow them time to regroup and change their story – question it right away and clearly document your concerns.
Ultimately, you might be able to identify the average drug seeker within the first few minutes of an office visit, but if you've not been careful, a professional drug seeker may be someone you've been providing prescriptions to for years. So while it's important that a ratty old book should not be judged by its cover, neither should one that appears legitimate and well-polished, as often these are the ones with the darkest stories to tell.
(1) Casey A. Grover, MD, Reb J. H. Close, MD, Erik D. Wiele, BA, Kathy Villarreal, RN, Lee M. Goldman, MD Quantifying Drug-seeking Behavior J Emerg Med. 2012;42(1):15-21. Accessed 01/26/2013
(2) Rush Limbaugh Arrested on Drug Charges CBS News/Associated Press 03/05/2009 Accessed 01/18/2013 http://www.cbsnews.com/2100-201_162-1561324.html
(3) You Ain't Foolin' Anyone, K.D. Lang Code Babe: The RN Blog 11/22/2011 Accessed 01/25/2013