How would you treat a patient whose recurrent headaches have been labeled as “possible migraine” but whose problem is drug-seeking behavior? He believes he is allergic to sumatriptan (Imitrex) and will not accept ketorolac (Toradol). An earlier referral to the pain clinic made the situation much worse. The patient does not accept psychiatric counseling or antidepressants. — Ed Reveiz, MD, Webster City, Iowa

This is a challenging case. If you believe he is truly drug-seeking, then it makes sense to have a “heart to heart,” refer for counseling/treatment, and avoid use of any pharmacologic intervention. If the patient is what pain specialists refer to as a “pseudoaddict,” driven to desperate and seemingly deceitful behavior by the need to control his severe pain, then I would use the standard headache approach by starting preventive agents and trying serial use of other triptans for abortive effect. If he is like so many of my own patients, i.e., “not clear how much is drug-seeking,” then I would recommend approaching him as a complicated chronic headache patient and diligently trying serial combinations of nonopiate and opiate medications using “contracts” until he has some improvement or leaves the practice. Signing a contract means the patient understands that if he repeatedly demonstrates that he is incapable of controlling his use of opiate pain medications, it will be necessary to stop them for his long-term safety. — Karen E. Brown, MD (150-9)


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