Game is designed to help doctors spot drug abuse

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http://www.nytimes.com/2012/05/26/us/game-is-designed-to-help-doctors-to-spot-drug-abuse.html?_r=1

A Game to Help Doctors Ask Tough Questions
By DIRK JOHNSON
Published: May 25, 2012

CHICAGO — As Dr. Danielle McCarthy listens to a man beg for a prescription for painkillers, she weighs her possible responses.

A 31-year-old emergency room physician, she listens patiently as the man tells her that “every morning I wake up in pain,” describing the agony he continues to endure, three years after being injured in a car wreck.

He has tried physical therapy, acupuncture and chiropractic treatment, he says. Nothing works except pills, he insists, as his voice grows louder and more demanding.

Their exchange is similar to conversations that take place on almost every shift at Northwestern Memorial Hospital here, Dr. McCarthy said. But it is fiction — part of an interactive video game designed to train doctors to identify deceptive behavior by people likely to abuse prescription painkillers. The patient is an actor whose statements and responses are generated by the program.

The video game was designed based on research by Dr. Michael F. Fleming at the Northwestern University Feinberg School of Medicine and draws on technology used by the F.B.I. to train agents in interrogation tactics. It teaches doctors to look for warning signs of drug abuse, like a history of family problems, and to observe nonverbal signs of nervousness, like breaking eye contact, fidgeting and finger-tapping.

The game, which is in its final phase of testing, is aimed at primary care and family doctors, who often feel uncomfortable and unqualified assessing their patients in this regard.

“This isn’t something medical students have traditionally been trained for,” Dr. Fleming said. “These are hard conversations to have.”

It can be a thorny matter, Dr. McCarthy said, because physicians are trained to help patients, but they do not want to enable drug abuse. “You don’t want people to be in pain,” she said. “And you’re put on the spot. I’ve had patients yell at me. I’ve never been hit, but once or twice I’ve felt physically threatened.”

In 2009, for the first time, the number of deaths from drug overdoses surpassed those from highway traffic accidents, according to Gail Hayes, a spokeswoman for the Centers for Disease Control and Prevention. She said misuse of prescription medication has been largely the cause. About 75 percent of overdoses involved prescription drugs, she added.

So health care professionals are searching for better ways to distinguish patients who can be trusted to use prescription pain medications properly from those out to abuse them. According to the C.D.C., prescription drug abuse is the fastest growing drug problem in the United States, fueled by the use of highly addictive opioid analgesics like OxyContin.

The Web-based interactive video game, which will soon be available online for a fee to medical schools and health care providers, includes about 2,000 statements by the patient, ranging in tone from charming to irate. A doctor can choose from 1,500 questions and responses, selecting one from five to seven options that appear on the screen when it is time to speak to the patient.

The dialogue is drawn from research by Dr. Fleming, based on interviews with more than 1,000 patients who were receiving opioids for pain. “We have 95 percent of what a patient and doctor would say or do,” he said.

Sharp skills are needed to assess a patient’s motives, he said, because an objective measurement, like from a blood test or an X-ray, is not available to gauge pain, and the opioids can be highly addictive.

The game’s software was developed by Dale E. Olsen, a former professor of engineering at Johns Hopkins University. He is the founder and president of Simmersion, a company that has created simulation training programs for the F.B.I. The game’s development was financed by a $1 million grant from the Small Business Administration and the National Institute on Drug Abuse. Dr. Olsen, who has a Ph.D. in statistics, said the game would cost users about $50 an hour. It is designed to be used for 10 sessions of 15 to 20 minutes each. He said customers would most likely include medical schools, as well as private and government health care providers.

The game encourages doctors to adopt a more collaborative and less accusatory approach with patients, Dr. Olsen said. “The goal is to build rapport,” he said.

Dr. McCarthy, wearing headphones and blue scrubs, faces the computer screen, where the patient, named Tom, a trim man with a neatly cropped beard, is asking for pain medication.

The physician asks Tom to describe his pain. Tom points vaguely to his lower back. She asks about whether he has ever had any problems with pills. He acknowledges that he once accidentally took too many pills, but that it was “no big deal.”

When she asks him to submit to a drug screening, he is testy, but agrees to do so if she insists — “and then I want my pills.”

At the end of the interactive portion, the game awarded Dr. McCarthy high marks for communication skills, for asking for a drug test and for declining the request for a prescription. She lost points for not asking enough questions.

Dr. McCarthy nodded at the screen in acknowledgment of her score. She explained that there are time constraints in her work.

“We move pretty quickly in the emergency room,” she said. “We’re not usually going to have time for 60 questions.”

She sometimes has had a hunch that a patient was exaggerating or fabricating pain, she said. She found the training useful, she said, because it offered new suggestions of responses to patients.
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this is very primitive.

Look: we freely prescribe methadone to anyone who claims to be opiate dependent, but methadone programs are highly-structured and uniform (from what I've seen). Why is the pain management industry not progressing toward uniformity?

It'd be nice for doctors everywhere to be able to say: Got pain? There's a program for that! But instead, we allow the FBI to dictate what medical treatment is permissible.

Burn it all.
 
What if someone is anxious because they are in pain? How would you distinguish from pain based anxiety and "oh shit I hope I get these drugs!" anxiety?

What if you're anxious that you're seeking out the drugs, but are also in legitimate pain?

It doesn't really seem possible. This video game sounds like it's training doctors to just make it more difficult for patients to get medication.
 
well maybe this game can get leaked so drug users can learn how to better manipulate doctors. I guess i'll maintain eye contact and not fidget the next time i'm trying to get something. In the end it definitely just makes things more difficult for legitimate users while drug seekers will learn and adapt.
 
Captain.Heroin said:
What if someone is anxious because they are in pain? How would you distinguish from pain based anxiety and "oh shit I hope I get these drugs!" anxiety?

What if you're anxious that you're seeking out the drugs, but are also in legitimate pain?

It doesn't really seem possible. This video game sounds like it's training doctors to just make it more difficult for patients to get medication.
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People really in pain are willing to try a diversity of treatments and are willing to have diagnostic tests done to find out what is really wrong. They emphasized the patients they are screening in the test were adamant that NOTHING except narcotics work for them. This is more than just anxiety. As you know, I have chronic pain and because I was honest with my doctors, tried every test to determine what was wrong and tried every treatment (narcotic or not, pill or not), my doctors knew they could trust me and did so I was able to play a larger role in determining the appropriate drug regimen to find relief.

I think it's great that they are finding better ways to weed out drug abusers. It's true that SOME pain patients may be inaccurately labelled drug seekers but that is already happening anyway and a lot of doctors are under-prescribing for most or all of their patients out of fear of feeding addictions. If doctors were more confident about their own abilities to spot drug-seekers, they are going to be more willing to work with legitimate patients seeking relief.

Drug seekers make it difficult for a lot of patients to find relief and I'm sick of seeing people around here blaming the doctors for hesitancy to prescribe serious medications. If people would stop trying to use doctors as dealers, people who are actually in pain wouldn't have such a hard time getting necessary treatment.
 
Good, how about you?

When you make your first million from doctor shopping, will you kick a little this way? ;)
 
It sounds like a pretty good idea I guess, just not necessarily the most effective...I'm afraid this will stop people who are in legitimate pain from getting the treatment they need and deserve. Plus it won't be difficult for drug addicts to figure out how to appear as if they aren't lying, it really isn't that complicated.
 
IF you have not been in a recent serious accident and are asking for pain meds in the ER/ A + E, you are doing it wrong. Any legitimate pain-patient who may ever need emergency IV intervention in a hospital setting can easily get what is essentially an open prescription for treatment from their Chronic Pain Specialist for pain flare-ups.
Normal people don't go to the ER for pain meds, they make a doctors appointment and speak with their Primary Care Physician.
 
muvolution said:
Normal people don't go to the ER for pain meds, they make a doctors appointment and speak with their Primary Care Physician.
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According to the article:

The game, which is in its final phase of testing, is aimed at primary care and family doctors, who often feel uncomfortable and unqualified assessing their patients in this regard.
Click to expand...
 
“We move pretty quickly in the emergency room,” she said. “We’re not usually going to have time for 60 questions.
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I understand it is "aimed" at pcp'ers, but they are clearly implementing it on ER doctors, and they chose to use this as an example.
 
Captain.Heroin said:
What if someone is anxious because they are in pain? How would you distinguish from pain based anxiety and "oh shit I hope I get these drugs!" anxiety?

What if you're anxious that you're seeking out the drugs, but are also in legitimate pain?

It doesn't really seem possible. This video game sounds like it's training doctors to just make it more difficult for patients to get medication.
Click to expand...

I'm ADHD and I exhibit those traits normally. I do try and avoid basically everything they say when I go to the doctors though. I'd hate to lose my methadone script because I'm fidgety.
 
As the article discusses, the fidgetiness is one aspect of this but doctors don't see someone with a stiff neck and automatically diagnose them with spinal meningitis. To make a diagnosis, they need to see convincing proof which is why they are trying to train doctors to look for signs and determine this when there is sufficient evidence.

A lot of chronic pain patients have anxiety... it's a common reaction to being in pain all the time so they aren't going to cut off pain patients just because they have symptoms of a condition demonstrably linked to chronic pain. They also aren't going to release all of the information the game uses to train doctors for obvious reasons.
 
muvolution said:
I understand it is "aimed" at pcp'ers, but they are clearly implementing it on ER doctors, and they chose to use this as an example.
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Emerg is a primary care specialty, as one usually presents to them directly, rather then being referred by another physician. Er, at least that is how I've always seen it classified.

As for the whole idea on a large scale, I don't think it's a very good approach. In as far as I mean I doubt the utility of a deterministic algorithm on a computer to be a valid approximation to discreet events of a interpersonal, social nature. It would be like writing a computer program to "train" you in how to get your mack on and pick up girls. It is not an accurate model of the real world system in question.
 
This is dumb. It detects nervousness. I am always nervous when I see a fucking doctor/therapist/psych. I dont understand this shit. So if you break eye contact your an Addict? Fucking stupid.
 
The game, which is in its final phase of testing, is aimed at primary care and family doctors, who often feel uncomfortable and unqualified assessing their patients in this regard.
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we're going to end up turning people with legitimate mental health issues away. which we already do anyway..
What if someone is anxious because they are in pain? How would you distinguish from pain based anxiety and "oh shit I hope I get these drugs!" anxiety?
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that
 
are pain patients generally receiving adequate analgesia, or are they systematically under-dosed? I don't hang out at pain clinics so I have no idea.
 
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