Community Paramedics and the Drug-Seeker

Editor’s note: In 2015 EMS World offered a monthly series looking at key aspects of establishing successful community paramedic/mobile integrated healthcare programs in EMS. This series will continue in 2016, beginning here, with enhanced coverage of clinical issues and profiles of systems that have moved beyond the early stages and contended successfully with more advanced issues. Articles each month will be accompanied by regular supplemental content on www.emsworld.com. If your system is involved in CP-MIH and wrestling with underaddressed issues or doing things new and exciting, let us know at jerich@southcomm.com.

Margaret was a 74-year-old woman who lived alone in an apartment in a low-income senior high-rise. What little “help” she received was from a daughter who lived nearby but whom Margaret suspected of stealing her medications and money. As with many of our patients, Margaret had been dealing with a history of serious medical issues—high blood pressure, a dysfunctional thyroid and a heart bypass. She was simultaneously battling anxiety and depression that had been untreated for years. But it was the relentless and excruciating back pain that began after a back surgery 10 years ago that kept bringing her back to the emergency department.

The only thing that killed the pain was opioids. Most days Margaret would lie in bed all day, only getting up to take another pain pill. When the pain wasn’t being anaesthetized by the pills (or if she ran out), she would head back into the emergency department to find comfort. At first we assumed she used the medications to control her back pain. However, the longer we worked with her, the more evident it became that the pain pills were also her only way of coping with her emotional pain.

Margaret told the community paramedics that she may have gone to the hospital two, maybe three times a month to seek relief for her pain. Different sources confirmed she was actually going to various local hospitals 2–3 times a week. Some days Margaret would be discharged home from one hospital in the morning, only to end up at a different hospital later in the day. Many of those same sources told us she had been labeled as a classic “drug-seeker.”

Opioid Dependency

The Substance Abuse and Mental Health Services Administration estimates that approximately 6.9 million people in the U.S. are dependent on or abusing prescription drugs.¹ Community paramedics (CPs) working in programs designed to reduce 9-1-1 utilization or 30-day readmissions are likely to encounter this population of patients regularly, yet very little formal education is available to help CPs understand the nature of prescription drug dependency. This article will introduce the types of drug dependencies and the resources most likely to help patients suffering with addiction.

Common prescription opioids include hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), codeine and similar drugs. These drugs work in part by blocking certain pain receptors, activating the mesolimbic (reward) system of the brain and creating a sense of euphoria. Opioids not only control the physical pain associated with an injury, but also alleviate the mental stress that both acute and chronic pain can produce. Unfortunately the body soon develops a tolerance to opioids that requires the patient to take higher doses of the drug to achieve the same effect.²

Compounding the issue is the paradoxical effect opioids have on the perception of pain. Patients undergoing opioid therapy often suffer from opioid-induced hyperalgesia, which actually increases their sensitivity to pain.³ There are several theories about the molecular mechanisms involved, but the result is that the patient may require higher and more frequent doses of the opioid to achieve a pain-free state.

Escalating the dose of opioids to counter the patient’s increased tolerance or hyperalgesic state increases the risk the patient becomes physically dependent on the drugs to function. Opioid dependency occurs when the patient experiences symptoms of withdrawal when the opioid levels are reduced.⁴ However, having a high tolerance to the medication or being dependent on opioids does not necessarily mean a person is addicted to their prescriptions. According to a joint policy statement issued by the American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine:

“Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”⁴  

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) characterizes a diagnosis of substance use disorder as a patient who experiences two or more of the criteria listed in Table 1 within a 12-month period. The manual defines a continuum of substance use disorders as ranging from mild (patient demonstrates 2–3 criteria) to severe (6 or more).⁵

Compounding Margaret’s case was the potential that her chronic pain was being undertreated due to her recurrent use of the ED and lack of a primary care physician. Physicians David Weissman and David Haddox coined the term pseudoaddiction to describe cases where the patient’s chronic pain is not adequately managed, the patient’s demand for opioids increases and there is growing mistrust between the patient and her healthcare providers.⁶ In those cases the patient may display signs of addiction, but their primary objective is pain relief, not the “high” of using the opioids. Once the pain is adequately controlled, the maladaptive behaviors disappear.

Plan of Care

Margaret did not have a doctor whom she saw on a regular basis because the one who’d cared for her had died and she could not find another she liked. Furthermore, she hadn’t seen anybody for her depression or anxiety for many years and lacked any type of mental health support. The patient’s ultimate goal was to be completely pain free. Our objective was to have her utilize the healthcare system more effectively to achieve her goal. To develop our plan of care, we needed to build the medical and psychosocial support system she lacked. After conducting our initial assessment of Margaret’s situation, we developed a plan of care with input from other community paramedic team members, our medical command physician and, most important, Margaret.

The first priority was making sure she was being seen by a primary care physician and a therapist for her anxiety and depression. We began by searching for local doctors using criteria Margaret provided, then ultimately helped her choose one she was comfortable seeing. Next we worked together to find a therapist to help her manage her anxiety and depression. Ultimately she reconnected with a psychiatrist who’d treated her in the past. Fortunately the psychiatrist also specialized in geriatric mental health.

Rather than asking her therapist to address her potential substance use disorder, we worked with Margaret to enroll her in a pain clinic to better manage her pain. As is often the case, pain management at the local pain clinic was directed by a physician, but included both traditional and alternative medicine options to create an individualized treatment plan uniquely tailored for each patient. To increase the chances of success with this approach, we explained how pain clinics work, helped her enroll in a nearby clinic and provided encouragement to help Margaret adhere to the program while her therapy began.

To provide a more sustainable solution for her social support needs, we evaluated Margaret’s existing social network, which consisted of a small circle of friends who were neighbors in her apartment building. While they fulfilled some of her social needs, Margaret complained she still experienced times of loneliness. She reported that she would oftentimes sit alone in the lobby of her complex. We offered to connect her with local resources such as a nearby senior center, but she ultimately refused help accessing those programs.

Results

Lacking an alternative social support system, Margaret relied heavily on the community paramedic program for her emotional support. Telephonic and in-person follow-up conversations included conducting medication reconciliation and education, helping her complete various paperwork and applications for her care teams, and providing positive encouragement and social support.

As the patient began utilizing her new medical and mental health providers, her dependence on the ED for pain control decreased dramatically. Her utilization of the ED dropped from 15-25 times a month in the months before she was enrolled in our program to 2-3 visits in the 4–5 months after our intervention. She instead relied on the healthcare system we helped her build to continuously evaluate and manage her chronic back pain as well as her depression and anxiety.

Conclusion

This case illustrates a patient who was likely displaying pseudoaddictive behaviors rather than having a more severe substance abuse disorder. Had the patient refused care from the pain clinic, displayed more symptoms of substance abuse disorder or been “fired” from the pain clinic for a breach of contract, substance abuse counseling would have been a more appropriate recommendation. Chronic pain patients are particularly vulnerable to undertreatment for their pain, as caregivers fear making the patient addicted to pain control medication. Lacking relief from other venues, those patients frequently turn to the ED for pain control. Rather than just dismissing them as “drug-seekers,” community paramedics can play a vital role in helping these patients find more appropriate sources of care for their physical and psychological needs.

Bibliography

1. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, www.samhsa.gov/datahttps://s3.amazonaws.com/HMP/hmp_ln/imported/NSDUHresults2012/NSDUHresults2012.pdf.

2. Dumas EO, Pollack GM. Opioid Tolerance Development: A Pharmacokinetic/Pharmacodynamic Perspective. AAPS J, 2008 Dec; 10(4): 537–51.

3. Lee M, et al. A comprehensive review of opioid-induced hyperalgesia. Pain Physician, 2011; 14(2): 145–61.

4. American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. WMJ, 2001; 100(5): 28–9.

5. Hasin DS, et al. DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale. Am J Psychiatry, 2013; 170(8): 834–51.

6. Weissman DE, Haddox JD. Opioid pseudoaddiction—an iatrogenic syndrome. Pain, 1989; 36(3): 363–6.

Jason R. Berman, EMT-P, is a community paramedic with the CONNECT Community Paramedic Program at the Center for Emergency Medicine of Western Pennsylvania.

Dan Swayze, DrPH, MBA, MEMS, is the vice president and COO of the Center for Emergency Medicine of Western Pennsylvania and is widely considered one of the pioneers of the field of community paramedicine.