One of the things I love most about medicine is that it is constantly changing and improving, especially as new evidence sheds more light on a subject. I have doctors in my group who have been trained in diagnostic peritoneal lavage, but that was just a historical footnote to me.
I was fascinated as a medical student in the 2000s and a resident in the early 2010s by the phenomenon of drug research. I remember finding excellent articles in the literature describing the behaviors of so-called addicts and carefully monitoring these behaviors in my patients. I broached the subject as a resident, publishing two articles trying to quantify how often these drug-seeking behaviors actually occur. (J Med Urgent. 2012;42:15; West J Emergency Med. 2012;13:416; https://bit.ly/3K5ewSm.)
I thought I really understood how to deal with drug-seeking behaviors based on my research and review of the literature: these patients had to be cut off from any drug they asked for because they were clearly addicted, and a lot of of them needed special notes in their chart to alert my colleagues that I had caught them looking for drugs.
The only problem with my understanding and approach to drug-seeking behavior is that I haven’t fully understood the subject. My treatment plans at the time helped move patients from prescription drugs to illicit drugs. Like many of you, my cutting approach has not taken into account that drug addict patients suffer from addiction and withdrawal. By not managing these conditions, I forced patients to buy their substances on the street to avoid withdrawal because I was unwilling to help them. I was part of the shift of the opioid epidemic in the United States from prescription painkillers to heroin.
Fast forward to the late 2010s, and I had finally learned about addiction and withdrawal. I got a buprenorphine waiver and now take pride in treating drug addict patients by addressing their drug addiction and withdrawal and referring them to a treatment program for their substance use.
Last month, I received a text from an ER staff member with a photo from an emergency medicine lecture showing that my drug research was still being used for educational purposes. My colleague was impressed that my research was the centerpiece of the educational module, but I was worried: Who still uses the term drug research?
On my next shift, I was reviewing my next patient’s chart and saw the diagnosis of drug-seeking behavior in her chart. She received this diagnosis during her last visit to the emergency room and was quickly discharged. Any ideas why she came back to the ER? You guessed it – withdrawal. I saw her in opioid withdrawal and was able to induce her on buprenorphine and refer her to a local treatment program.
Despite my early passion for drug-seeking behavior, I now realize that drug-seeking is not a condition or a diagnosis but rather a symptom of many conditions. Because “drug seeking” evokes judgment and prompts providers to abruptly stop all treatment, the term should be removed.
I will soon be certified in addiction medicine in addition to emergency medicine, and I have a much better understanding of what drug-seeking behavior is – a symptom of conditions that need to be investigated:
- Substance use disorder. A patient with an active substance use disorder (also called dependence) may exhibit drug-seeking behavior toward their substance of choice due to cravings and psychological changes due to the disorder , such as benzodiazepine use disorder or opioid use disorder.
- Drug addiction. A drug-addicted patient may exhibit drug-seeking behavior towards a substance they are addicted to for a variety of reasons, from fear of rebound symptoms (such as anxiety and benzodiazepines) when the drug runs out fear of withdrawal.
- Withdrawal. A patient in acute withdrawal may exhibit drug-seeking behavior during acute withdrawal to relieve their discomfort (such as opioid-seeking for opioid withdrawal).
- Severe uncontrolled symptoms. A patient with severe, uncontrolled symptoms such as anxiety or pain may exhibit drug-seeking behavior to obtain relief from these symptoms.
- Two or more of them.
Drug-seeking behavior used to be very easy for emergency doctors. We called all drug-seeking behavior an addiction, didn’t investigate further, told the patient they wouldn’t get the drug they were looking for, and sometimes even said they weren’t welcome in our emergency department. We really missed the mark on this because drug-seeking behavior is much more complex, and these patients are in desperate need of assessment and treatment more than a discharge of judgment.
Just as we don’t tell a nauseous patient that they’re nauseous and then send them home without further workup or treatment, we need to start calling drug-seeking behavior what it is – a symptom. of a condition that needs to be evaluated to determine the right treatment.
The next time you find yourself using the term “drug-seeking behavior,” take the next step and dig deeper into the patient’s story and find out what’s really going on. As physicians, we have already tried to eliminate drug-seeking behavior with judgment and rapid discharge. This has led to the worst epidemic of substance use and overdoses in our country’s history, with more than 100,000 overdose deaths in the past year. Our patients are ready for us to do better.
Dr Groveris an emergency physician at Monterey Peninsula Community Hospital, where he serves as Chair of Emergency Medicine and Vice Chief of Staff. He hosts and produces the “Addiction in Emergency Medicine and Acute Care” podcast, which can be found onanchor.fm/casey-grover/.