Commentary on Jung and Reidenberg's "Physicians being deceived": aberrant drug-taking behaviors: what pain physicians can know (or should know).

Jung and Reidenberg have once again touched a nerve in their piece: Physicians Being Deceived. Always with a knack for highlighting key controversies in the medico-legal arena, they are to be applauded for this contribution that brings data to bear on an issue that has heretofore been subject to changing legal and regulatory currents without being informed by science. Physicians have more and more been given back the responsibility for ferreting out addicted and drug dealing patients. Early intractable pain laws offered pain physicians protections when they prescribed opioids, but limited these protections by excluding known substance abusers or those who should be known to be substance abusers [1]. It was considered progress by the pain management community when the wording of such laws began changing, coinciding with the recognition that pain management with opioids in those with substance abuse is feasible, can be safe, and is an ethical imperative in some situations. However, with the growth of prescription drug abuse, the pressure to detect lying has been rising for prescribing physicians. And these patients do lie. Jung and Reidenberg point out that this lying is nearly impossible to detect given most physicians' truth bias. Physicians are taught that patients come in seeking help and are approaching them in a good faith fashion to enlist such help. When people lie to doctors to obtain more opioids, not all lying is created equally nor are they equal in terms of the bad faith they represent. To our observation, addicted patients lie in a fashion that is somewhat distinct from diverters. Addicted patients engage not just in other-deception but also in self-deception (i.e., volitional on the one hand and almost dissociative on the other). The act of lying to their physicians is often an extension of lies they tell themselves (i.e., " I am not overusing; I am not out of control; It is all pain related and if I only had more relief I wouldn't use like this "). They lie while their life spirals out of control; they run out early and lie about why. The diverter, on the other hand, lies without self-deception. Diverters lie to procure drugs for sale and are motivated by profit. Unless greed gets the better of them, they will not run out early. They will often abide by the rules while secretly doctor shopping. Both can be skilled actors and experts at hiding their …