Opioids

1. PAIN MEDICINE
Volume 8 • Number 5 • 2007
© American Academy of Pain Medicine 1526-2375/07/$15.00/433 433–437 doi:10.1111/j.1526-4637.2007.00315.x
Blackwell Publishing IncMalden, USAPMEPain Medicine1526-2375American Academy of Pain Medicine? 200785433437
Original ArticlesPhysicians Being DeceivedJung and Reidenberg
Reprint requests to: Marcus M. Reidenberg, MD, Depart-
ment of Pharmacology, Box 70, Weill Medical College
of Cornell University, 1300 York Avenue, New York,
NY 10021, USA. Tel: 212-746-6227; Fax: 212-746-8835;
E-mail: mmreid@med.cornell.edu.
FORENSIC PAIN MEDICINE SECTION
Physicians Being Deceived
Beth Jung, EdD, MD, MPH,* and Marcus M. Reidenberg, MD†
*Department of Pharmacology, Joan and Sanford I. Weill Medical College of Cornell University, New York, New York;
Schering-Plough, Springfield, New Jersey; †
Departments of Pharmacology, Medicine, and Public Health, Joan and Sanford
A B S T R A C T
I. Weill Medical College of Cornell University, New York, New York, USA
ABSTRACT Objective. In several high profile prosecutions of physicians for prescribing opioids, prosecutors
claimed that the doctors should have known the individuals were feigning pain solely to obtain the
prescriptions. This study was to determine how readily physicians can tell that patients lie.
Methods. A literature search was done for studies of standardized patients used to evaluate physi-
cians’ practices. Standardized patients are actors taught to mimic a patient with a specific illness.
The papers were then reviewed for the frequency with which the physician correctly identified
which office visits were by the standardized (lying) patients.
Results. Six studies of practicing physicians using standardized patients reported the frequency with
which these actors were identified as the standardized patients. This occurred around 10% of the
time. Some real patients were erroneously identified as the actors.
Conclusion. Deception is difficult to detect. In the current legal climate surrounding prescribing
opioids, accepting patients’ reports of pain at face value can have significant legal consequences for
the doctor. While doctors must make every reasonable effort to confirm the diagnosis and need for
opioid therapy, allowance must be made for the fact that conscientious doctors can be deceived.
Key Words. Deception; Prosecution; Opioids; Standardized Patients
Deceiving Physicians
barrier to prescribing opioids for patients in
pain is physicians’ fear of being investigated
by a governmental agency and punished for pre-
scribing this treatment [1–8]. A survey of prose-
cutors in four states found that many would
recommend a police investigation when given a
scenario of a patient with nonmalignant pain
treated with opioids [9]. Our review of Drug
Enforcement Administration (DEA) actions
against physicians who prescribed opioids found
that some of these actions were based on prescrip-
A
tions given to undercover agents [10]. In several
high-profile prosecutions of physicians for pre-
scribing opioids, prosecutors claimed that the doc-
tors should have known the individuals were
feigning pain solely to obtain the prescriptions
[11–13]. How responsible is a physician for being
deceived?
The responsibility for being deceived can be
viewed in the context of factitious disease, Mun-
chausen’s Syndrome, either directly or “by proxy,”
and frank malingering. But a physician can only
be subjected to criminal penalties if the deception
leads to prescription of a controlled substance.
Because of this possibility, some physicians are
reluctant to prescribe adequate doses of opioids
for some patients with pain. Thus, the conse-
quences of a doctor’s fear of being deceived affects
patients with pain much more than other kinds of
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2. 434 Jung and Reidenberg
patients. For this reason, we focused on the spe-
cific problems of being deceived by patients who
say they are in pain.
Physicians operate with what Burgoon et al.
[14] call a truth bias. That is, they presume that
patients’ presentations of themselves are true,
complete, and accurate. Their assessment of
patients’ pain complaints are based both on cur-
rent information (obtained in the interview and
physical examination) and on the starting point,
or anchoring point [15] for the assessment. Doc-
tors assume that patients come to see them
because they have a problem for which they want
treatment.
Law enforcement personnel appear to have a
different assumption when they interview some
people. Yet, in a study of police, judges, and federal
law enforcement personnel,* only the Secret Ser-
vice agents were better than chance at detecting
lying [16]. Thus, law enforcement personnel who
presume physicians can discern lies cannot recog-
nize lies themselves.
Can physicians tell when patients lie? Studies
with standardized patients can address this ques-
tion. Standardized patients are individuals (includ-
ing actual patients) who have been trained to
present accurate, reproducible history and physi-
cal examination findings of a particular clinical
problem. They are increasingly used in teaching
[17], evaluation [18–22], and research [23,24].
They have been used since 1998 to evaluate for-
eign medical graduates applying for American
medical licenses and, since 2004, as part of the US
medical licensing examination [25,26]. They per-
mit assessment of skills and behaviors essential to
medical practice but which are poorly measured
by paper-and-pencil tests.
Standardized patients provide a new way to
consider the question of deceiving doctors by
patients not telling the truth. Standardized
patients have been used in the community to study
resource utilization [24], risk factor determination
and counseling [22,23], and diagnosis, recognition
and management [18,19,27]. All studies involved
training individuals to present an overall scenario
(history, physical examination findings, responses
to physicians’ questions, expressing pain) consis-
tent with a disease or condition. For these studies,
the individuals would then go to the doctor
*Federal law enforcement personnel included Central
Intelligence Agency, Federal Bureau of Investigation,
Secret Service, Drug Enforcement Agency, etc.
pretending to be a real patient and right after the
visit, accurately record the physician’s questions
and interventions. The standardized patients were
trained in how to present themselves to office staff,
and to handle payment for the visit in order not
to be perceived as standardized patients. All phy-
sicians tested with standardized patients had vol-
unteered to be studied in this way, and were asked
to report any patient visit they believed was made
by a standardized patient. Six studies reported on
the rate at which physicians detected standardized
patients when they appeared for their office
appointment.
The first [18] was a study of how well Austra-
lian general practitioners managed depression.
Twenty-five physicians were each visited by two
standardized patients. None of these were identi-
fied as such by the physicians.
The second study was used to evaluate and
develop the methodology of standardized patients
for evaluating primary care [28]. Eight different
standardized patients visited 11 doctors. The stan-
dardized patient was detected seven times (13%)
and was suspected of being the standardized
patient eight times (15%) in the 55 visits in non-
painful illness. The actor portraying a patient with
vascular headache was detected twice (18%) and
suspected once (9%).
Another study included pain (headache for one
case and back pain for another) as the presenting
symptom in two of 10 scenarios. Twenty-six of 263
visits by standardized patients were detected as
such. The frequency of detection of each scenario
was not reported [21].
In a study of 59 doctors visited by an older
woman for a periodic health exam she was
detected as the standardized patient by two doc-
tors [22]. In another study of 51 other doctors
visited by a woman in her 50s for a periodic health
exam only two doctors detected her as the
standardized patient [23]. A study to evaluate
nonsteroidal anti-inflammatory drug (NSAID)
therapeutics by family and internal medicine prac-
titioners had standardized patients portray chronic
hip pain of osteoarthritis and epigastric pain of
NSAID gastropathy. Thirty-six of the 312 visits
(12%) were identified as being the standardized
patients [24,29].
In one study, two real patients were identified
as fakes [24,29] and another article indicated some
real patients were considered imposters but no
numbers were presented [28]. There was no men-
tion of assessing “false positive” identification in
any of the other articles.
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3. Physicians Being Deceived 435
When a patient complains of pain, doctors
apply their experience of how people with pain
appear and respond. Often, different people assess
the same patient’s pain intensity differently [30].
The correlation between subjective pain intensity
and facial pain expression is not strong and differs
between men and women [31]. In a study of decep-
tion in pain expressions, Poole and Craig [15] per-
formed experiments on 104 college students. The
students observed videotapes of facial expressions
of people in pain or faking pain. The observers
thought the fakers were in more pain than the true
sufferers. When the observer was warned about
possible deception, the observer estimated lower
pain intensity in subjects with both genuine and
faked pain. Thus, a faked facial expression of pain
can easily deceive an observer.
Both deception and fear of deception have con-
sequences. Patients can get too much medical care
when the doctor is deceived (as in Munchausen’s
syndrome) or insufficient medical care when the
doctor fears deception (disbelieving reports of
pain when it exists). These consequences affect
both the individual patient and society.
The experience with standardized patients
shows deception is difficult to detect. In the natu-
ralistic setting of an office encounter, genuine
patients can be mistaken for fake patients as well
as fake patients accepted as real ones. In the cur-
rent legal climate surrounding prescribing opioids,
accepting patients’ reports of pain can have signif-
icant legal consequences for the doctor. These
consequences must be addressed to improve the
treatment of patients with chronic pain.
What should a conscientious doctor do that is
reasonable to avoid being deceived? The Model
Policy for the Use of Controlled Substances for
the Treatment of Pain by the Federation of State
Medical Boards of the United States says, “physi-
cians (should) incorporate safeguards into their
practices to minimize the potential for abuse and
diversion of controlled substances” [32]. First, “a
physician-patient relationship must exist and the
prescribing should be based on a diagnosis and
documentation of unrelieved pain.” Suggestions
for documenting in the medical record were pre-
sented in [1] and include: history and physical
findings supporting the diagnosis of a painful con-
dition requiring opioid therapy, laboratory and/or
imaging studies as needed to confirm the diagno-
sis, a treatment plan and consultations for addi-
tional evaluations and treatments as indicated.
Regular follow-up visits with documentation are
also required [1]. When more than one doctor is
treating a patient, the one prescribing controlled
substances must keep the other doctors informed
about the regimen and any other medical matters
coming to the prescribing doctor’s attention. The
other doctors certainly should reciprocate so all
are on the same team.
Assuming this is present, what additional issues
should be considered?
One issue is identifying patients with a sub-
stance abuse disorder and differentiating them
from those diverting prescription drugs to the
illicit market. Much of the attention in the Opioid
Guidelines in the Management of Chronic Non-
cancer Pain by the American Society of Interven-
tional Pain Physicians is devoted to detecting
illicit drug use [33]. The purpose of random drug
screening appears to be the detection of unpre-
scribed central nervous system active drugs in the
urine of the patients. This can certainly identify a
patient as a potential substance abuser but does
not necessarily identify diverters. The American
Pain Society, in its the Use of Opioids for Treat-
ment of Chronic Pain [34], states that “known
addicts can benefit from the carefully supervised
judicious use of opioids for the treatment of pain
from cancer, surgery, or recurrent painful illnesses
such as sickle cell disease.” An estimated 9% of the
US population over age 12 years has used cannab-
inoids within the past year [35]. The National
Institute of Drug Abuse (N.I.D.A.) has estimated
that 46% of the US high school seniors had tried
marijuana at some time and that 20% were current
users [36]. Thus, the clinical significance of 18%
or 11% prevalence of marijuana use detected in
urine test of 500 chronic pain patients [37,38] is
not completely clear. N.I.D.A. estimated that 19.1
million Americans, or 7.9% of the US population,
were classified as illicit drug users; 7.1 million of
these were classified as substance abusers or sub-
stance dependant in 2004 [39]. Thus, interpreta-
tion of the 16% or 22% detection of illicit drugs
in the urine of a group of chronic pain patients in
two different studies [37] is also complex, as all of
these people are not necessarily dependent or
abusers of the detected drugs. Certainly, substance
abuse problems present in chronic pain patients
should be addressed. This is needed for proper
medical care.
In conclusion, we agree with the Model Policy
that safeguards to minimize abuse of prescribed
drugs and diversion of them [32] should be part of
medical practice. Determining if a current or prior
substance abuse problem exists is an important
part of the history. It suggests that the patient is
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4. 436 Jung and Reidenberg
at risk of recurrence and this should be addressed.
Portenoy and Payne [40] have prepared a table of
aberrant drug behaviors that are suggestive of a
drug problem, and behaviors of pain patients that
are “less suggestive” of a drug problem. Some sug-
gestive patient behaviors are: multiple dose esca-
lations, other noncompliance with therapy despite
warnings, multiple episodes of prescription “loss,”
seeking prescriptions from multiple sources, and
deterioration in functioning. Patient behaviors less
suggestive of a drug problem in a chronic pain
patient include aggressive complaining about the
need for more drug, drug hoarding during periods
of reduced symptoms, requesting specific drugs,
and occasional nonsanctioned dose escalation [40].
Obtaining a urine test for illicit drug use is appro-
priate for a chronic pain patient with these or
other suggestive behaviors. It may indicate a sub-
stance abuse or dependence problem that should
be confirmed and addressed, as would any other
confounding medical problem.
Building trust between doctor and patient is
an important part of the management of chronic
pain patients. Victor and Richeimer point out
the importance of the patient’s demonstrating
responsibility in the relationship by following
through on the patient’s part of the management
plan [41] and not trying to conceal deviations from
the physician.
Patients who are diverters, on the other hand,
cannot be treated as other chronic disease patients.
Behaviors suggestive of a drug problem can also
indicate a possible diversion problem. Additional
suggestive behaviors in the Portenoy and Payne
article include prescription forgery, stealing or
“borrowing” drugs from others, and learning that
the patient is selling drugs (p. 40). Our review of
prosecutions of doctors for prescribing opioids
[42] found that often it was other parties and not
the doctor that discovered the acts of diversion.
The doctor had been deceived.
We have presented the data on how easily a
doctor can be deceived by a standardized patient
into thinking the standardized patient was a bona
fide patient. We have noted that Munchausen syn-
drome is another example of the ease with which
doctors can be deceived. It should not be surpris-
ing that undercover agents can also deceive con-
scientious doctors. When portions of the medical
press describe cases of physicians accused of
diverting controlled substances because they were
deceived, suspicion of patients with chronic pain
complaints increases. Unscrupulous doctors exist
and they can be clever in masking what they are
actually doing under the guise of practicing med-
icine. They should be caught and dealt with. But
our data show that conscientious doctors can be
deceived. Therefore, while doctors must make
every reasonable effort to confirm the diagnosis
and need for opioid therapy, allowance must be
made for the fact that conscientious doctors can
be deceived.
Acknowledgments
Supported in part by a grant from the charitable founda-
tion of Marilyn Spinoza Weinberg and Robert F. Wein-
berg. Dr. Reidenberg is a member of the Weill Cornell
CERT.
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