In almost every dentist’s practice, there are difficult patients. There is no simple solution to resolve the problems these patients present because each situation is unique. This first installment of How to Effectively Treat A Difficult Patient will attempt to describe some of the more common situations and provide recommendations for treating such patients.

Patients Who Demand and/or Abuse Narcotics

Patients who abuse narcotics present a dilemma for dentists. The patient may come to the office with complaints of severe pain and, as pain is often subjective, the dentist must rely on what the patient tells him/her. Some patients may demand a specific narcotic, or even a specific dose. Other patients may claim that non–narcotics have not been effective and ask the dentist to prescribe a narcotic. Before the dentist prescribes narcotics, he/she must check the I-STOP registry, which will tell the dentist if the patient has a history of seeking narcotics from multiple providers and if a narcotic has already been prescribed by another provider.

If it is contemplated that a patient is going to be treated with narcotics over a long period of time, it is recommended that the patient sign a pain management agreement. The agreement sets forth the expectations for the treatment relationship and spells out the consequences for failure to adhere to the agreement. Consequences include discontinuing the prescription for narcotics, requiring drug testing and/or discharging the patient from the practice.

Once a dentist decides to prescribe a narcotic, other issues may arise. A patient who is given medication that is intended to last for a specific number of days may call the office requesting a refill before the next refill is due. The patient may claim the prescription was lost, the medications were stolen or something atypical such as “the dog ate my pills.” Substance abusers will generally have a myriad of excuses. After a few visits, the dentist may begin to question the legitimacy of the patient’s need for narcotics and become wary of the patient’s excuses. This is particularly true when the pain has no obvious cause and/or no objective signs and symptoms of pain are manifested.

Obvious signs of substance abuse include: (1) the dentist learning that the patient has been obtaining narcotics from multiple sources; (2) the patient making frequent visits to an emergency department or another covering dentist to seek narcotics; and (3) a new patient demanding narcotics for pain control but refusing to authorize the release of treatment records of a prior dentist. Dentists must always be alert to the fact that patients abuse, and may even sell, the narcotics prescribed to them. The patient may intentionally divert the medication, or a family member or friend may be stealing drugs the patient legitimately needs for pain.

If a dentist reasonably believes that a patient is a habitual user or abuser of narcotics, is the victim of the theft of narcotics by a third party or has stolen narcotics, the dentist must contact the New York State Department of Health Bureau of Narcotic Enforcement (BNE) and notify them of that information. The dentist may also consider discharging the patient from care. If the patient has an existing appointment or cannot be discharged due to his or her condition, the dentist should advise the patient that narcotics will no longer be prescribed and refer the patient to a pain management clinic. If the patient resists, the dentist must take steps to wean the patient from the narcotic medication. In addition, all covering dentists must be advised not to refill narcotic prescriptions for that patient.

If the patient alleges that a family member is stealing the medication, a toxicology screen must be ordered to confirm that the patient is not taking the prescribed narcotic. Theft of drugs by a third party is a crime and should be reported to the police. Advise the patient that the police will be contacted.

Situations involving abuse of narcotics do not lend themselves to easy solutions. Read our Risk Management Checklists for Dentists: Opioid Management for more tips. If you have a concern in this area, you should contact legal counsel at Mercado May-Skinner.

Patients or Family Members Who Are Rude, Hostile, Abusive or Threatening

Some patients, or their family members, have a low flash point. If they are given bad news or are inconvenienced, they may become angry or abusive. Others may make threats or become physically intimidating. When a patient makes a threat, the dentist must immediately determine how serious the threat is, including whether the individual could potentially carry out any threat of violence. If the threat appears to be legitimate, and if it rises to the level of a criminal act, it should be promptly reported to the police. Criminal acts include trespass, disorderly conduct, harassment, aggravated harassment, stalking and menacing.

Law enforcement authorities should also be immediately notified of any criminal conduct that takes place on the premises, or any criminal acts committed against the dentist and/or staff. If an individual is hostile and threatening to staff and refuses to leave after being asked to do so, the police may be contacted. If criminal charges do get filed, the dentist and/or staff member may even request the court to issue an Order of Protection, which mandates that the patient refrain from menacing conduct or that the patient stay away from an individual’s home or office. In these extreme cases, the patient (and perhaps his or her entire family) should be discharged from the office practice and referred to the emergency department for follow-up care or to the local dental society for the name of other providers.

If the conduct is less severe, such as rude or disruptive behavior, the dentist has several options. Sometimes, a direct conversation with the patient or family member will result in a change of behavior. The dentist can plainly state that the behavior is unacceptable and, if it occurs again, will result in discharge from the practice. This conversation can occur either by telephone or at the time of a visit, and it should be documented. Often, this will achieve the desired result. If a discussion with the patient is not an option, then the patient should be seen for the immediate condition and then discharged. The dentist/group also may wish to discharge other family members, such as siblings or in-laws, if it would be uncomfortable continuing to care for them under the circumstances.

The Noncompliant Patient

Noncompliant patients are some of the most difficult patients a dentist may encounter. These patients fail to comply with recommendations for treatment, testing and referrals. Others routinely fail to keep appointments. Although these patients may be nice individuals, they can be extremely risky to the dentist’s legal health. Noncompliant patients should be counseled and warned about the consequences of failing to adhere to treatment recommendations, and these discussions should be documented in the dental record. The consequences of failure to comply should also be reiterated in writing to the patient. If the noncompliance persists, he/she should be discharged from care. Although patients legally have the right to refuse treatment, the dentist also has the right to discharge the patient for noncompliance. The reason for discharge must be thoroughly documented, both in the patient’s record and in the discharge letter, as noncompliance with recommendations for care and treatment.

In summary, all patients, even difficult ones, must be evaluated and treated by their dentists until and unless they have been formally discharged from care.

In the next installment of How to Effectively Treat the Difficult Patient, we will examine Patients Who Fail to Pay Bills, The Intoxicated/Impaired Patient and Patients Who Lack Capacity, as well as discuss the proper way to discharge a patient from care.

In the meantime, you can stay up to date on the latest risk management guidance and alerts by monitoring the MLMIC Dental blogThe Scope: Dental Edition, Dental Impressions and on our Twitter and LinkedIn pages.