What is the best way to differentiate between a patient who has legitimate back pain and someone who is looking for a drug prescription or workers’ compensation? — MAUREEN SHEA, PA-C, Swormville, N.Y.

Pain is a subjective symptom and must always be assumed to be a legitimate complaint. But there are clues to drug-seeking or secondary-gain behavior. Does the severity of reported symptoms match your physical exam? Are there inconsistent physical findings (positive straight-leg raising test when lying but not when seated, patient finds it hard to bend over during exam but later puts on shoes with relative ease) that suggest malingering? Is there a history of substance abuse, including abuse of prescription medicines? Does the patient ask for a specific brand of painkiller by name, telling you that another brand doesn’t work? Patients who lose the same prescription repeatedly are obviously suspect, and a phone call to a few local pharmacies may clinch your suspicion. A thorough social and occupational history can be very helpful but may be quite time-consuming. — Reuben W. Zimmerman, PA-C (144-7)

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