Aberrant Drug Behaviors and Responsibilities of Primary Care

Primary care has a great opportunity to assess patients’ drug taking behaviors when they enter the healthcare system. It’s very rare that a patient would start their care with a specialist, and primary care is where most people would go outside of some sort of acute care setting. So, their ability to discuss risks with the patient as well as the risk of the treatments that they may be exposed to can really set patients up for success. Aberrant behaviors can often make clinicians reluctant to work with patients in pain, because they don’t know why some of these behaviors are occurring. A drug test may come back that’s inconsistent with what they expected to see and they may decide to just stop treatment. But all drug testing is not equal, and labs make errors. Sometimes we get results that don’t make sense. It’s important to listen to your patients and fundamentally that is what we should all be doing when approaching any health condition or aberrant behavior. Listen to them, conduct our exam, get the supporting data, and put all of that together to make a differential diagnosis. How do you broach the topic of aberrant drug taking? Patients need to understand what we have observed, and what the risks are. I often use the analogy that if somebody has a high cholesterol level we know they’re at risk for having a heart attack. Now will they have a heart attack? That we don’t know, but they are at risk. So, if the patient has a strong family history of drug and alcohol abuse, or they themselves have a history of drug and alcohol abuse, or they have psychiatric comorbidities, they need to know that taking an opioid is putting them at much greater risk of developing an aberrant behavior than somebody that doesn’t have those things. They need to be very cautious taking an opioid and we need to make sure that we do our job in overseeing their care so that they don’t suffer some sort of treatment-related harm. Risk is something we need to talk openly with patients about, and not tiptoe around. My job, my opportunity is to look at the toolkit that I have and think, “Is there anything there that can help this patient have less pain and a better life and be more functional, and also minimize risk from the treatments that I might provide?”