The Journal of Emergency Medicine, Vol. 42, No. 1, pp.

1521, 2012
Copyright 2012 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2011.05.065

Original
Contributions

QUANTIFYING DRUG-SEEKING BEHAVIOR: A CASE CONTROL STUDY

Casey A. Grover, MD,* Reb J. H. Close, MD, Erik D. Wiele, BA, Kathy Villarreal, RN, and Lee M. Goldman, MD
*Stanford/Kaiser Emergency Medicine Residency, Stanford University Medical Center, Stanford, California, Division of Emergency Medicine,
Community Hospital of the Monterey Peninsula, Monterey, California, and University of California at Berkeley, Berkeley, California
Reprint Address: Casey A. Grover, MD, Stanford University Medical Center, Division of Emergency Medicine, Alway Building, M121, 300
Pasteur Dr MC: 5119, Stanford, CA 94305

, Keywordsdrug; seeking; behavior; emergency

, AbstractBackground: Drug-seeking behavior (DSB) is

common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of
anecdotal evidence. Study Objectives: To perform a casecontrol study examining the relative frequency of DSB in
suspected drug-seeking patients as compared to all ED
patients. Methods: We performed a retrospective chart review of 152 drug-seeking patients and of age- and gendermatched controls, noting which of the following behaviors
were exhibited during a 1-year period: reporting a nonnarcotic allergy, requesting addictive medications by
name, requesting a medication refill, reporting lost or stolen
medication, three or more ED visits complaining of pain in
different body parts, reporting 10 out of 10 pain, reporting
> 10 out of 10 pain, three or more ED visits within 7 days,
reporting being out of medication, requesting medications
parenterally, and presenting with a chief complaint of headache, back pain, or dental pain. Results: The odds ratios for
each studied behavior being used by drug seeking patients as
compared to controls were: non-narcotic allergy: 3.4, medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different
parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits
in 7 days: 30.8, out of medication: 26.9, headache: 10.9,
back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated
odds ratio of infinity for these two behaviors. Conclusions: Requesting parenteral medication and reporting greater than
ten out of ten pain were most predictive of drug-seeking,
while reporting a non-narcotic allergy was less predictive of
drug-seeking than other behaviors. 2012 Elsevier Inc.

INTRODUCTION
Pain is a common problem for which patients seek care in
the emergency department (ED), accounting for up to
42% of all ED visits (1,2). Despite this, pain control in
the ED can be challenging, with inadequate pain
control occurring frequently (2,3). There are many
reasons why pain control may be problematic in the
ED, such as variability in emergency physician (EP)
prescribing practices and difficulty in assessing
a patients level of pain (35). Additionally, EPs may
be reluctant to administer analgesia out of concern that
a patient complaining of pain may be trying to obtain
medications for non-therapeutic purposes (24). These
patients, often labeled as drug seeking, represent
a difficult group of patients to manage in the ED. They
often present with conditions that may be easily feigned
and are difficult to evaluate, such as headache, back
pain, and dental pain (6,7). They also are known to
engage in deceptive behavior in an attempt to fool
clinicians into giving them additional medication. Such
behaviors include prescription forgery, seeking care
from multiple providers, reporting allergies to nonopioid analgesics, complaining of lost or stolen medications, requesting refills, exaggerating symptoms, and
using multiple aliases (611). These patients are also
noted to have an extensive knowledge about pain

RECEIVED: 24 October 2010; FINAL SUBMISSION RECEIVED: 3 February 2011;

ACCEPTED: 29 May 2011
15

16

C. A. Grover et al.

medication, request to receive medications parenterally,

request medication by name, and may exhibit
threatening or even violent behavior when denied the
medications they want (6,1012).
Drug-seeking patients are common in the ED,
accounting for as many as 20% of all ED visits, and are
also known to consume large amounts of medical
resources (9,12). As a result, many EDs have created
habitual patient files and case management programs in
an attempt to track the use patterns of these patients
and minimize the amount of narcotics and other
medications that they receive (5,7,10,1315).
Despite the magnitude of the problem and the familiarity of physicians from all specialties with these patients,
there is still much to learn about them. A review of the
medical literature reveals that there are many publications on the subject, including several screening tools
(Screener and Opioid Assessment for Patients with Pain
- Revised [SOAPP-R]; Opioid Risk Tool [ORT]; Current
Opioid Misuse Measure [COMM]; Diagnosis, Intractability, Risk, and Efficacy score [DIRE]; and Addiction
Behaviors Checklist [ABC]) developed by pain management clinicians to assess for problematic medication use
in chronic pain patients (1623). However, few of these
studies present any quantitative data on drug-seeking
patients in the ED, and these studies are limited to small
numbers of patients (6,7,24,25). With this in mind, we
chose to perform a case-control study on a large number
of patients referred to a case management program for
suspected narcotic abuse. To the best of our knowledge,
this is the first study to date that provides quantitative
data as to the relative frequency of drug-seeking behaviors in all patients suspected of non-therapeutic ED use
as opposed to controls.
The goal of this investigation was to perform a casecontrol study to determine the relative frequency of
drug-seeking behaviors in suspected drug-seeking
patients as compared to all ED patients. Given the difficulty in studying this group of patients, we are aware
that finding the exact frequency of any given behavior
is very unlikely. However, we hope to provide practicing
EPs with information as to which drug-seeking behaviors
are more commonly used by drug-seeking patients. We
feel that, from a clinical standpoint, knowing that one particular behavior is strongly associated with drug-seeking
behavior while another is not as strongly associated
would be helpful in evaluating a patient suspected of
drug seeking.
METHODS
This observational retrospective study was performed at
a 205-bed community hospital in central California that
has approximately 45,000 visits to the ED each year.

This study was given institutional review board exemption by the hospital committee on research.
The hospital has an existing case management program that was developed by the ED staff to adequately
meet the needs and improve the overall care of patients
recurrently seeking care in the ED for chronic medical
problems, particularly narcotic addiction. The program
is chaired and operated by an ED nurse, who oversees
a committee consisting of ED physicians, a chemical
dependency physician, pain management clinicians, behavioral health physicians and nurses, and social service
providers. Patients are enrolled in the case management
program if they are identified as having a large number
of visits to the ED in the months before enrollment.
Patients can also be enrolled if nursing staff or physicians
request a case management evaluation for a particular
patient based on patient use patterns suspicious for
drug-seeking behavior. Additionally, patients can be
enrolled if one of the EPs receives a letter from the
California prescription monitoring program (Controlled
substance Utilization Review and Evaluation System
[CURES]) regarding a patient. As a part of the management of these patients in the case management program,
each patients ED visits are analyzed, and the chronic
problem or reason for recurrent use is determined.
Finally, a plan, such as a chemical dependency evaluation
or limitation of narcotic refills for chronic problems, is
developed by the case management team to manage the
chronic underlying problem for each patient in the outpatient setting.
Inclusion criteria for patients in our study group were
the following: any patient enrolled in the case management program that was given a referral to chemical
dependency and any patient enrolled in the case management program that had a care plan involving limitation of
narcotics, benzodiazepines, or muscle relaxants.
Exclusion criteria for patients in our study group were
the following: all patients enrolled in the case management program whose care plans did not involve either
a chemical dependency evaluation or limitation of narcotics, benzodiazepines, or muscle relaxants.
Patients in the control group were randomly chosen
from the hospitals medical record system by their medical record number. Each patient is randomly assigned
a five- or six-digit medical record number when they first
receive care at the hospital. For each patient in the case
group, the medical record number was cut down to four
digits. This four-digit medical record number was then
entered into the hospitals database of patients, and the
first patient that was found that was the same age and gender as the case patient was chosen as a control patient.
Any patients with zero ED visits in their medical record
were excluded, and a new control was found with at least
one ED visit in their medical record.

Quantifying Drug Seeking

Table 1. List of Studied Behaviors
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Presenting to the ED and reporting an allergy to a nonnarcotic pain medication

Presenting to the ED with a chief complaint of headache
Presenting to the ED with a chief complaint of back pain
Presenting to the ED with a chief complaint of dental pain
Presenting to the ED and asking for narcotics,
benzodiazepines, or muscle relaxants by name
Presenting to the ED with a chief complaint of medication
refill for narcotics, benzodiazepines, or muscle
relaxants
Presenting to the ED and reporting that narcotic,
benzodiazepine, or muscle medications had been lost
or stolen
Presenting to the ED on three or more separate
occasions with pain-related chief complaints in
different parts of the body
Presenting to the ED and complaining of 10 out of 10 pain
Presenting to the ED and complaining of >10 out of
10 pain
Presenting to the ED for any reason three or more times
in a 7-day period
Presenting to the ED and reporting being out of narcotic,
benzodiazepine, or muscle relaxant medications
Presenting to the ED and requesting to be given narcotic,
benzodiazepine, or muscle relaxant medications
parenterally

ED = emergency department.

17

reported in the literature (612). Whereas certain

behaviors, such as headache and reporting a nonnarcotic allergy, are easy to assess in a chart review,
behaviors such as exaggeration of symptoms and high
frequency of use are more difficult to measure. We thus
chose to make some measurable equivalents for the
behaviors that were more difficult to measure. In trying
to assess exaggeration of symptoms, we chose to look
for complaining of 10 out of 10 and > 10 out of 10 pain.
Also, in trying to assess for frequent use of medical
services, we chose to look for presenting to the ED for
more than three pain-related complaints and presenting
to the ED three times within 7 days.
Once collected, the data were analyzed using Excel
(Microsoft Corporation, Redmond, WA) and Dimension
Research statistical software (Dimension Research,
Drums, PA, 2010). For each of the 13 data parameters collected, the percentage of patients in each group exhibiting
each behavior was calculated, and a 95% confidence interval for each was calculated. Also, an odds ratio was calculated comparing the study group to the control group, as
were 95% confidence intervals for the odds ratios.
RESULTS

For the study group, all visits to the ED 1 year before

enrollment in the case management program were reviewed. For the control group, all visits to the ED during
a 1-year period were reviewed as well. As many of the
control patients had few ED visits, the majority of the
patients in our control group did not have visits to the
ED during the 1-year period of review of their corresponding case patient. As such, for each of our case
patients, we reviewed the most recent ED visit in the
medical record as well as the year preceding that visit.
The hospitals electronic medical record system was implemented in 2004, and we conducted our review in 2010.
As such, the largest possible separation in time between
the time periods of review for the two groups was 6 years.
For the majority of case-control pairs, the separation
between time periods of review was < 3 years.
Patient medical records were accessed using the hospitals medical record system, Horizon Patient Folder
(McKesson, San Francisco, CA), and all physician and
nurse documentation for each visit was carefully
reviewed. For each study patient and each control patient,
it was recorded whether or not patients exhibited any of
the behaviors listed in Table 1 at any point during the
1-year time period of study. We did not count the number
of times each behavior was exhibited by a particular
patient; our focus in this analysis was to assess which
behaviors are used by drug-seeking patients rather than
the frequency with which they are used by individual
drug-seeking patients. These 13 behaviors were chosen
for assessment as they represent drug-seeking behaviors

Review of the patients in the case management program

identified 152 patients meeting inclusion criteria. Demographically, the average age of this patient group was 43.4
years, and the group was composed of 65.8% females.
In the 1 year before enrollment in the case management program, these patients accounted for 2203 visits
to the ED, which is an average of 14.5 visits per patient
per year. In the 1 year of study for the control group, these
patients accounted for 315 visits to the ED, which is an
average of 2.1 visits per patient per year.
The number of patients exhibiting each of the studied
behaviors can be found in Table 2. The calculated odds ratio comparing each of the studied behaviors between the
study group and the control group can be found in Table 3.
DISCUSSION
To the best of our knowledge, these data and analysis represent the largest group of ED patients suspected of drug
seeking studied to date. Additionally, to the best of our
knowledge, this is also the first time that drug-seeking patients in the ED have been compared to controls for all
chief complaints in an attempt to quantify and compare
different behaviors attributed to drug-seeking patients.
One major difficulty in studying patients exhibiting
drug-seeking behavior is that it is nearly impossible to
definitively determine whether or not a patient is truly
seeking care in an attempt to obtain medications for
non-therapeutic reasons. Pseudoaddiction is a condition

18

C. A. Grover et al.

Table 2. Number and Percent of Patients Exhibiting Studied Behaviors

10 out of 10 pain
Out of medication
Back pain
Request by name
Over 3 pain complaints
Headache
Three visits in 7 days
Chief complaint of refill
Requesting parenteral
Non-narcotic allergy
>10 pain
Dental pain
Lost or stolen medication

Case Group
n = 152

Percent

95% CI

Control Group
n = 152

Percent

95% CI

114
91
88
85
83
70
69
60
46
27
21
17
13

75.0
59.9
57.9
55.9
54.6
46.1
45.4
39.5
30.3
17.8
13.8
11.2
8.6

68.181.9
52.167.7
50.065.7
48.063.8
46.762.5
38.154.0
37.553.3
31.747.2
23.037.6
11.723.8
8.319.3
6.216.2
4.113.0

27
8
14
7
6
11
4
5
0
9
0
3
1

17.8
5.3
9.2
4.6
3.9
7.2
2.6
3.3
0.0
5.9
0.0
2.0
0.7

11.723.8
1.78.8
4.613.8
1.37.9
0.97.1
3.111.4
0.15.2
0.56.1
N/A
2.29.7
N/A
0.04.2
0.02.0

95% Confidence intervals (CI) are for the percentages of patients exhibiting each behavior.

resulting from inadequate pain management, in which

patients exhibit drug-seeking behaviors to obtain medication so as to relieve their pain. This condition generally
resolves once the pain is treated. The behaviors exhibited
by patients suffering from pseudoaddiction are difficult to
differentiate from those of true addiction, especially in
the acute care setting (9). In our analysis, we did not
make any attempt to determine motivation for the drugseeking behavior; rather, we only chose to examine the
different behaviors associated with drug-seeking, regardless of cause.
As this pertains to our study patient population, many
of the patients referred to the case management program
for problems with prescription medications had underlying chronic pain issues. As an example, a significant
proportion of the patients complaining of headaches
and back pain reported histories of migraines and chronic
low back pain, respectively. It would seem that the inclusion of these patients in our study group would be a complicating factor, in that these patients would be more
likely to be suffering from real pain from their chronic
pain condition. However, in the large community surrounding our hospital, there are undoubtedly more people
Table 3. Odds Ratios for Studied Behaviors

Requesting parenteral
>10 pain
Three visits in 7 days
Over 3 pain complaints
Out of medication
Request by name
Chief complaint of refill
Lost or stolen medication
10 out of 10 pain
Back pain
Headache
Dental pain
Non-narcotic allergy
CI = confidence interval.

Odds Ratio

95% CI

N
N
30.8
29.3
26.9
26.3
19.2
14.1
13.9
13.6
10.9
6.3
3.4

N/A
N/A
10.8487.30
12.1870.33
12.2858.72
11.5459.86
7.4249.52
1.82109.37
7.9824.19
7.1725.60
5.4821.85
1.7921.81
1.557.57

that suffer migraines than the 70 patients in our case management program that repeatedly presented to the ED
complaining of headache. It stands to reason, then, that
the patients in our case management program are a different patient population than other chronic pain patients.
They choose to frequent the ED for pain-related complaints in an attempt to obtain prescription medication
rather than seek regular care from a primary care physician or specialist. It is perhaps possible that the patients
in our case management program are simply those
patients with the most severe disease, and their visits to
the ED reflect a desperate effort to control severe pain.
However, in reviewing many of the medical records, an
interesting pattern can be seen in a large number of the
patients in the case management program that suggests
a different explanation. Most of the patients begin with
a significant disease process, such as migraines, a severe
trauma, rheumatoid arthritis, or a work-related injury. After multiple ED visits and likely multiple visits to other
providers for pain-related complaints, patients develop
tolerance for and dependence on the medications they
are taking. Soon, these patients begin presenting to the
ED in withdrawal and request larger and larger doses of
the medications upon which they now are dependent.
With this in mind, as much as they truly do have underlying pain, chemical dependency becomes a major motivating factor for these patients to seek emergency care to
obtain medication. This has been described previously
as a transition in the lives of those with chronic pain
from being pain centered to being both opioid centered
and pain centered (9).
We observed in this study that patients in the drugseeking group complained of 10 out of 10 pain more
than patients in our control group. Furthermore, our study
group patients occasionally complained of > 10 out of 10
pain, an event that was not observed at all in the control
group. This could be explained by the fact that chronic
narcotic use has been shown to increase chronic pain

Quantifying Drug Seeking

and can induce long-term changes in the brain that alter

pain perception (26). Perhaps the chronic narcotic use
has made these patients more sensitive to pain, and they
truly are suffering from the most severe pain possible.
However, this must be considered carefully, as patients
with narcotic abuse and dependency are known to exaggerate pain complaints in an attempt to obtain desired
medication (6,8). It is nearly impossible to determine
which of these two explanations is correct, and the
patients in our study group likely chose to repeatedly
seek ED care to obtain medication for a combination of
both reasons.
In reviewing the confidence intervals listed for the calculated odds ratios in Table 3, there are two main points
that should be noted. First, as a result of the fact that zero
patients in the control group requested parenteral medication or reported greater than 10-out-of-10 pain, the odds
ratios for these behaviors were calculated as infinity.
We interpret this to mean that odds ratios for these behaviors were significantly higher than all others, and are most
predictive of drug-seeking behavior. Second, for reporting a non-narcotic allergy, the odds ratio is only 3.4,
and the upper end of the 95% confidence interval for
the odds ratio is below the lower end of the 95% confidence interval for the odds ratio of most other behaviors.
Thus, we interpret this to mean that reporting a non-narcotic allergy is less predictive of drug-seeking behavior as
compared to other behaviors. However, it is important to
note that the odds ratio for a non-narcotic allergy is >1,
and is still a behavior that is more commonly used by suspected drug-seeking patients than controls.
Limitations
Our study had several limitations. First, as much as this is,
to our knowledge, the largest study on drug-seeking patients to date, it remains a small study. Second, we chose
to use a retrospective observational study design, which
has inherent limitations. As our data come from chart
review, we are dependent on nurse and physician charting, which is not always uniform or accurate. In particular, there may have been documentation bias on the part
of treating physicians and nurses. In patients suspected
of drug-seeking, treating providers may have been more
likely to document behaviors associated with drug seeking, such as being out of medication, as compared to
patients not suspected of drug seeking.
Third, the analysis of the data in our study is limited by
the low frequency of our studied behaviors in the control
group. This is one of the reasons why our confidence
intervals are so large and why we could not calculate
odds ratios for two of our studied behaviors. Fourth, as
much as all of the patients in our study group were exhibiting drug-seeking behavior, it would be nearly impossi-

19

ble to assess whether or not our patients were suffering

from addiction or pseudoaddiction, as both groups exhibit
drug-seeking behavior. Fifth, our study population consists of patients exhibiting drug-seeking behavior who
are also frequent users of the ED. Our study may thus
be poorly applicable to patients presenting to an ED for
a single visit or patients frequenting multiple EDs.
Finally, there was a large disparity between the number
of visits between the case group and the control group.
Given that two of our studied behaviors (three visits
within 7 days, three or more pain-related visits) were in
part dependent on the number of visits by a patient, this
may have inappropriately biased our data on these two
behaviors towards being more common in drug-seeking
patients.
Directions for Future Research
Despite the fact that drug-seeking patients are common,
research on such patients is difficult. The current literature on these patients consists of small studies; a study
with a large number of patients could prove to be insightful. Furthermore, few of the existing studies on drugseeking patients are prospective; additional studies of
this design could also provide needed data on this group
of patients. Also, because it is challenging to assess
whether or not a patient is seeking care only to obtain
medication for secondary gain, a study of patients who
have confessed to pure drug seeking would be helpful.
Finally, in this study we chose to look at whether or not
patients exhibited certain behaviors at any point during
a 1-year period. We plan to review all visits in our case
group to assess the number of times each behavior was
exhibited to gain insight into the frequency of these behaviors in drug-seeking patients.
CONCLUSIONS
In this study of patients referred to an ED case management program for drug-seeking behavior, requesting parenteral medication and complaining of >10 out of 10 pain
were most predictive of drug-seeking behavior. Reporting
a non-narcotic allergy was the least predictive of drugseeking behavior, but was still more common in suspected drug-seeking patients than in controls. For the
remainder of the behaviors studied, the confidence intervals were too wide to allow for meaningful interpretation
of the data, and further research is needed.
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Quantifying Drug Seeking

21

ARTICLE SUMMARY
1. Why is this topic important?
With prescription drug abuse at a national all-time high
and drug-seeking patients making up a significant percentage of all emergency department (ED) visits, dealing
with patients suspected of drug-seeking behavior is something that every emergency physician must face frequently. Unfortunately, drug-seeking patients are
difficult to study, as there are no tests that can be used
to confirm or refute whether or not a patient is drugseeking. As such, the literature on drug-seeking patients
in the ED is limited, and consists of predominantly anecdotal evidence describing drug-seeking behaviors. Thus,
practicing emergency physicians have little evidencebased information to use when trying to assess whether
or not a patient is drug-seeking.
2. What does this study attempt to show?
This study attempts to quantify how frequently a particular set of drug-seeking behaviors is used by drug-seeking
patients, as compared to controls. The goal is to demonstrate which behaviors are most likely to be predictive
of drug seeking behaviors.
3. What are the key findings?
The behaviors with the highest odds ratios predicting
drug-seeking behavior were complaining of > 10 out of
10 pain and requesting narcotic, benzodiazepine, or muscle relaxant medication to be given parenterally. Conversely, the behavior with lowest odds ratio was
reporting an allergy to a non-narcotic pain medication.
4. How is patient care impacted?
When caring for patients in the ED, a patient that either
complains of > 10 out of 10 pain or that requests narcotic,
benzodiazepine, or muscle relaxant medication to be
given parenterally should alert the physician of the potential for drug-seeking. Although reporting a non-narcotic
allergy is more common in drug-seeking patients than
all-comers to the ED, it seems to be less predictive of
drug-seeking behavior than other behaviors and should
not be used alone to determine whether or not a patient
is drug-seeking.