October 26, 2011
The medical records of witnesses or parties who abuse substances usually contain classic clinical findings. Clinicians sometimes miss the significance of these findings. Attorney awareness enhances litigation planning, client control, assessment of case value, and handling expert witness testimony about pain or other symptoms.
Abused substances include: prescription and non-prescription drugs, street drugs, and alcohol. The number of the following clinical signs that are present in an individual correlates with the likelihood of having a substance abuse problem.
Any of the following tactics appearing repeatedly in the medical records are a strong sign of drug seeking. The patient:
1. Alleges severe pain that cannot be objectively assessed (e.g., chest pain, migraine, or back pain), demanding narcotics.
2. Calls back after an office visit claiming the pills were lost.
3. Calls a prescriber at home in the evening, gives a fictitious history, and demands a prescription be called in to a pharmacy
4. Claims only one specific drug works for the symptoms.
5. Fakes laboratory results (e.g., claiming a kidney stone, the patient pricks a finger and puts blood into a urine sample).
6. Refuses diagnostic studies and non-narcotic treatments.
7. Sees multiple prescribers and fills prescriptions at different pharmacies.
History patterns associated with substance abuse.
1. Disagreement between the patient and separate interviews of family or friends.
2. Knowledge of drugs is extensive.
3. Medical history is vague, or the patient lists textbook symptoms.
4. Need for narcotics fails to decrease after about two months following acute injury.
5. Pain or impairment is anatomically inconsistent with the possible causes.
6. Pain is constant in intensity all day and night.
7. Psychiatric disorder diagnoses, especially: depression, severe anxiety, progressive dementia, sleep disorders, and excessive mood swings.
8. Untruthfulness/fabrication, shown by inconsistent medical histories.
Clinical signs associated with substance abuse
2. Blood or urine toxicology screen positive.
3. Bruises, cuts, abrasions, or cigarette burns on extremities.
4. Conjunctiva (eyes) frequently inflamed.
5. Disorientation, confusion, or inappropriate responses.
6. Falls or “accidents” with minor injuries, repeatedly.
7. Fatigue, chronic.
8. Hypertension, “labile” (intermittent).
9. Liver enlarged and tender.
10. Liver function tests abnormal.
12. Needle marks or abscesses on the extremities (“track marks”).
13. Nasal mucosa inflamed (rhinitis).
14. Nausea and vomiting.
15. Pain responses on physical examination are exaggerated.
16. Pains, multiple and chronic.
17. Physical examination findings are inconsistent (e.g., point tenderness, joint ranges of motion, abnormal gait, abnormal posture).
18. Pupils strongly constricted or dilated.
19. Serum lipase elevated (opiates).
20. Tests for functional or non-organic disorders produce inappropriate responses. See Attorneys Medical Deskbook, 4th, § 18: 3.
21. Thrombosed varicose veins.
22. Tremor, mild.
For a discussion of clinical signs suggesting substance abuse, see Attorneys Medical Deskbook, 4th, §§ 33: 2, 8, 9, 10.30, 10.40 and 10.60. For detailed questionnaires to detect substance abuse in a client or witness, or to prepare for deposition, see the companion volume Medical Questionnaires for Clients or Witnesses §§ 26–29.