How to Tell If a Patient Is Faking Pain

Opioids, a mainstay of pain management, have become a serious problem as more people abuse analgesics and come to medical offices and emergency rooms seeking drugs.

Practitioners can’t just treat symptoms as described; they first need to determine if patients are faking pain or really hurting. It’s a difficult proposition,” said Edward Michna, MD, an American Pain Society board member, director of the Pain Trials Center at Brigham and Women’s Hospital in Boston, and an assistant professor at Harvard Medical School in Boston. 

Johnny Williamson, MD, medical director of Timberline Knolls Residential Treatment Center in Lemont, Illinois, said when effectively treating patients in pain, physicians should monitor and evaluate and keep an eye out for any inappropriate use, whether recreational use or divergence. "Patients can put a lot of pressure on the physician, and some of them can be pretty convincing,” Williamson said. If you are not vigilant about these things, it is easy to miss them.

Red Flags A Patient Is Faking Pain

Several behaviors may point to a patient who is faking pain rather than being in real distress. These patients may present as well-organized and informed.

However, a patient who aggressively complains about the need for a drug, often being very specific about the drug or saying they are allergic to similar drugs, are warning signs for Williamson.  Asking for a brand-name drug is another behavior to watch for, as is someone saying he took a friend’s drug and it worked and he wants more. That immediately should alert the prescriber that the patient is willing to share prescription medications.

As you drill down closely about their symptoms and concerns, it provokes an emotion,” Williamson said. “They get angry or irritable because they start to anticipate you will refuse them. That can be a tip-off.” If the patient says he has taken more of the pain medication than ordered or used it for other purposes or in a different form, these are signs of misuse, Williamson added. Opioid-seeking patients may call the physician’s office often, including during off-hours, and show up without an appointment.

Drug-seeking patients who are faking pain often resist diagnostics or referrals to specialists, Williamson said. The patient may cite objections about paying co-pays or deductibles. Michna cautioned that no method of screening patients will be 100 percent infallible.

Communicating with the patient, obtaining a good history, performing a physical exam, and discussing the case with past treating physicians can help the physician determine the best course of action, he said.  

Additionally, clinicians can use the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) to assess the risk of opioid abuse in chronic pain patients, Michna said.

This validated tool asks about tension at home, mood swings, prior medication use, impatience with physicians, medication cravings, and more. It takes about five minutes to complete the tool.  “For the well-meaning prescriber, it is very challenging, because you are working with the information the patient is telling you,” Williamson said. 

Treatment options  “In non-acute situations, you have to do conservative things prior to prescribing opioids,” Michna said. “Opioids should not be the first thing or the second or third thing for chronic back pain.”

In an office or clinic setting, over-the-counter analgesics, muscle relaxants, physical therapy, and time should be tried first, never opioids, Michna explained. When a patient presents saying he needs a certain opioid medication refill, the clinician’s answer should be no.

That should not happen anywhere, but I know it does,” Michna said. “The use of opioids has to be for medically recognized reasons and in the right person without high-risk factors and who you have fully vetted by speaking to prior treating physicians.” Physicians should use their state’s prescription monitoring program to check for prior prescriptions for this patient. But a drawback is that the information does not include access to data from other states, Williamson warned.

Before starting someone on an opioid, the clinician should educate the person about the risks, Williamson advised. Then the prescriber should closely monitor the patient.

Vigilance has to be applied to every patient, every visit,” Williamson said, explaining that patients taking opioids appropriately for pain relief can become addicted. “I have the same evaluation with every patient who takes these drugs every time I see them.”

Referrals and Comprehensive Care

Some primary care physicians have stopped prescribing opioids, in part due to the additional paperwork required, and are referring to pain specialists. Michna indicated this was not a sustainable solution for the specialty practice, due to a lack of reimbursement for the required paperwork.

The best approach is a multidisciplinary approach, with the primary care [physician] involved and expert recommendations, monitoring, [dealing with] the psychosocial things,” Michna said.

The pain management team should include mental health counselors, physical therapists, and alternative therapy providers; however, Michna reported that insurers may not cover many of these modalities. “Comprehensive care is expensive, but through many decades, we have known that is the best way to care for these patients,” Michna said. “In the end, it’s about treating the individual.

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