Detecting deception on the part of patients.

The tragic death of actor Heath Ledger from an apparent overdose of drugs known to be dangerous in combination raises the question of how he obtained them.

Details are still unfolding, and there is much that we might never know. We must be careful about speculating on the role of Mr. Ledger or that of his physician(s), if any, in what happened. Regardless of the specifics, this case serves as a reminder that patients sometimes deceive physicians to obtain drugs. Even those of us who are forensic psychiatrists know that our ability to recognize lies is limited.

Despite knowing that the desire to obtain drugs motivates many patients to lie, we want to trust our patients and must devote our limited time and resources to diagnosis and treatment--rather than to determining whether the patient is being honest. Still, we serve our patients better if we can uncover efforts at deception with some strategies that might contribute to better care.

The possibility of attempted deception to obtain drugs should be considered when the patient does any of the following:

* Remembers suddenly, near the end of the evaluation, a hypnotic that he or she has been taking and wants continued.

* Reports adverse reactions to all nonaddictive drugs for a given indication.

* Tells you that only one drug works, and that drug turns out to be a benzodiazepine.

* Tells you atomoxetine and bupropion were ineffective for attention-deficit hyperactivity disorder, or that methylphenidate works better when snorted.

* Reports that he needs higher than usual doses of a benzodiazepine or psychostimulant.

* Objects to a trial of a nonaddictive alternative.

Even when you do not suspect drug seeking, obtaining information from other sources can help you provide better care. Include family or friends in part, but not necessarily all, of the evaluation.

Patients might not want to tell you the whole story in front of family, but sometimes only a family member will provide critical information. Require the patient to authorize release of records of prior treatment. Telephone contact might suffice when receipt of records is delayed.

It is important to approach questions about substance use as though you assume the patient has used and you really believe addiction is just another disease.

If you ask, "Do you abuse alcohol or take any street drugs?" the patient might interpret such a perfunctory approach as evidence that he can fool you. Instead, review all the major drugs and groups, starting with caffeine. Nonsmokers tend to avoid "harder" drugs, but many smokers abuse them.

When a patient tells you, "I don't drink," look impressed and ask why, or, "Oh, are you a recovering alcoholic?"

Always cover marijuana, opiates (heroin and pharmaceuticals), lysergic acid diethylamide (LSD or acid), phencyclidine hydrochloride (PCP or angel dust), psilocybin mushrooms, mescaline, [gamma]-hydroxybutyrate (GHB) and other sedative-hypnotics, 3,4-methylenedioxymethamphetamine (MDMA or ecstasy), and cocaine and other stimulants, including those prescribed for ADHD.

Patients who do not feel judged and who believe you will find them out anyway might provide more information.

When your inability to trust a patient interferes with your work to the extent that you feel you cannot help him or her, say so, and consider discharging the patient. This might be just the intervention that helps the patient "hit bottom" and get help for addiction.

Ultimately, the physician's role is to diagnose and treat--not to uncover dishonesty. The patient who lies to obtain drugs should be held responsible for any damage that results.

DR. EDWARDS practices adult general, addiction, and forensic psychiatry near Seattle. He also publishes www.behavenet.com.

BY H. BERRYMAN EDWARDS, M.D.