American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tips to spot patients who abuse prescription drugs

From the April ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Jason van Steenburgh

When a Florida court earlier this year sentenced a physician to 30 years in prison for illegally prescribing the drug OxyContin to hundreds of patients, it sent a chill through the medical community.

The doctor had written more prescriptions for the powerful painkiller than anyone else in the state. Four of his patients died after overdosing on the drug.

While that physician was clearly an outlier—prosecutors described him as a common drug dealer—his crime and punishment may be a warning of sorts to doctors everywhere. Across the country, the furor over OxyContin is driving new legal precedents that are forcing doctors to take more responsibility for their prescribing practices.

If you think you're safe because you tread carefully when prescribing commonly abused drugs, think again. H. Westley Clark, MD, director of the Center for Substance Abuse Treatment, said that all too often, physicians fall prey to drug-seeking patients because they don't know the signs. And the patients may not be looking for the drugs you think. The center, which is part of the Substance Abuse and Mental Health Services Administration, seeks to expand the availability of effective treatment and recovery services for individuals with alcohol and drug problems.

In a recent interview, Dr. Clark gave some pointers about how to spot drug-seeking patients—and how to avoid becoming entangled with them.

ACP-ASIM Observer: How do physicians need to change their thinking about drug abuse?

Dr. Clark: Physicians should remember that any drug can be abused, and that physicians who facilitate that abuse could face extreme consequences. Instead of letting the Controlled Substances Act schedules dictate which drugs you should worry about, physicians should focus on patient behaviors that indicate a problem.

With psychoactive drugs, you're always dealing with the risk of misuse or abuse. These substances require medical licenses because they are deemed too powerful for over-the-counter consumption. Practitioners in busy offices tend to forget that.

On the other hand, becoming preoccupied with the prospect of being snookered by someone with ulterior motives can paralyze us. We should err on the side of the patient, but at some point we should begin asking questions.

Q: What trouble signs should physicians look for?

A: Always ask first, Why am I seeing this patient? Be wary of those who've been in the community a while who see you for the first time and say, "Give me drug X," which is a scheduled drug, as opposed to, "I've got this problem."

Specific questions can often help uncover inappropriate behavior. Ask what happened to their old doctor, and whether they have changed health plans. (For more questions, see "10 questions to identify drug-seeking patients".)

Q: When should doctors re-evaluate treatment?

A: You should not give patients scheduled drugs in perpetuity. At some point, you should stop and re-assess. Ask yourself, When does the legitimate therapeutic purpose expire? Consider how often the patient presents. Be suspicious of a departure from normal behavior in these situations.

Q: Are too many physicians prescribing out of their realm of expertise?

A: The burden on primary practitioners is substantial. Our code is, "First, do no harm." As a result, doctors have to ask themselves some simple questions, such as: Why am I writing endless prescriptions for Ritalin? How many patients with attention deficit hyperactivity disorder do I see? If I see only a few, then I'm probably not the appropriate person to be prescribing this drug.

Q: What are some common scams?

A: Most scammers try to get the doctor to write a prescription or gain access to a prescription pad so they can write a script themselves.

Patients will sometimes say they're from out of state and the pharmacy won't fill their prescription. They try to evoke the practitioner's compassion to continue the medication.

Other times, a patient you've never seen before will present with a prescription, ask you to refill it and promise to schedule an appointment next week. If you fill that prescription, you've been had.

Some patients will misrepresent their medical condition to induce you to write a prescription. Others will use the old standby excuses: "I lost my prescription," or "I didn't have enough money to fill the prescription and it expired."

Drug abuse is a developing phenomenon. It starts with patients losing prescriptions, not being able to track the amount of prescriptions or claiming that the doctor wrote the wrong prescription.

A concatenation of events often indicates abuse rather than serendipity or accident. A single transaction by itself does not mean abuse. But if your record shows repeated violations, you are not only denying what's going on, but also making yourself vulnerable to DEA or even patient litigation.

Q: What should physicians do if they suspect abuse?

A: If you have been prescribing benzodiazepines, for example, and you suspect the patient is behaving oddly, the first step is accepting responsibility for what you've done.

Remember that it's not just a matter of losing your medical license for a diversion. Many patients sue physicians for misprescribing when they become addicts.

Patients can sue you for contributing to their addiction because you failed to pick up on obvious behavior. That's why at some point, you need a follow-up evaluation, if only to protect yourself. You should consult or refer to addiction specialists or psychiatrists who have addiction expertise.

Q: When you refer patients to addiction specialists, are there subtle ways to address addiction without blatantly calling them addicts?

A: You don't have to be terribly subtle. There are many things you can say.

Tell the patient that because their medication use is escalating, you need a re-evaluation to calculate the appropriate dose and determine if you need to change medications.

You could also say something like, "Your care is becoming more complicated than we first realized. I need to know that these meds are not harming you."

If you feel a need to refer a patient to someone else, tell her that her progress with the current therapy is not sufficient, so you want another practitioner to evaluate her case.

You could also explain that you want the patient to see the other physician because you are dealing with a biobehavioral phenomenon. Explain that when anxiety and pain enter the equation, the problem isn't strictly biological or psychological—it's a combination of the two.

Finally, you can explain that you want to refer the patient to an addiction psychiatrist who can explore both the medical conditions and the medication. Tell the patient that second opinions are helpful because sometimes conditions change and you are not a specialist.

Remember that practitioners get sued all the time for failing to discern subtle changes in patients' conditions. In these kinds of complex situations, you should routinely get a second opinion.

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