Pharmacology

Doctor shopping and prescription substance use disorders: A nursing response

drug-seeking

Prescription substance use disorders (SUDs) have a serious impact on society. In 2013, 6.5 million adults admitted to illicit use of prescription medications. The annual cost of prescription SUDs is estimated at $72 billion. Additionally, annual deaths from opioid overdoses have quadrupled from 1999 to 2011 and nearly surpass the rate of accidental traffic deaths.

People with SUDs may engage in “doctor shopping” to obtain multiple prescriptions for controlled medications from multiple prescribers. People who doctor-shop often present to outpatient healthcare settings and emergency departments and may seek hospitalization to receive controlled substances.

Studies have shown people who doctor-shop often have a significant SUD, which also may involve intravenous (IV) prescription drug use. They may try to obtain a variety of controlled prescription medications and take them simultaneously with other medications, or they may sell or trade controlled drugs.

It can be difficult to identify a SUD and doctor-shopping behavior. When in doubt, prescribers may err on the side of compassion and prescribe medication, but there are evidence-based methods that help identify doctor shopping and ensure people with SUDs get the treatment they need. Nurses can make a big impact on this complex issue by promoting the following strategies.

Taking universal precautions

SUDs are not rare and occur in approximately 10% of the population, according to Dr. Kima Joy Taylor, director of the Closing the Treatment Gap Initiative. Opiates are the largest class of prescription medications that are misused, but benzodiazepines, stimulants, and other controlled medications also are misused.

To address this issue, it is important to take a universal precautions approach similar to that used for infectious diseases. Nurses and healthcare providers need to understand that patients at risk of having or developing a prescription SUD can be of any race, gender, or socioeconomic status. Most patients with SUDs will remain unidentified or inadequately treated if interventions are implemented only with patients who raise red flags or behave suspiciously.


Additionally, patients who engage in doctor shopping report that healthcare providers are easy to fool through manipulation and deception. Unfortunately, the rate of a person’s ability to determine if someone is lying is only 54%, just slightly better than flipping a coin, according to a review of over 206 studies. Taking universal precautions when assessing patients can improve the odds of identifying and treating SUDs.

Assessment of SUDs and drug-seeking behavior

Begin by taking a thorough history with all patients. Studies have shown that people who have prescription SUDs have a higher incidence of using more than one substance, a prior history of a SUD, a mental health disorder, and/or a history of trauma. All patients should be screened for an SUD on intake and annually.

Nurses can advocate for the use of screening instruments in their workplaces. Following are some examples:

  • The Drug Abuse Screening Test (DAST) is a reliable and commonly used screening instrument for drug use. Patients can complete it along with other paperwork.
  • The Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R) can help identify abuse of prescription pain medication.
  • The Addiction Behavior Checklist, completed by healthcare professionals, assesses drug-seeking behaviors associated with controlled prescription medications.

In addition, all patients who are prescribed controlled medications should be asked detailed questions about their use of these medications. This includes the amount and frequency, and what other substances are being taken or prescribed from other providers.

Nurses also can identify a possible SUD in patients through observation and physical assessment. Notify the prescriber and document if a patient appears to be under the influence of a substance or has withdrawal symptoms. Symptoms warranting further assessment and intervention include:

  • slurred speech
  • sedation
  • hypervigilance (being tense or on guard)
  • mydriasis (pupil dilation)
  • piloerection (elevated hair follicles on skin)
  • diaphoresis (sweating).

To detect IV drug use, routine skin assessment for needle marks on the arms, legs, and feet should be performed on all patients who are prescribed controlled medications.

Nursing’s role in educating prescribers

Prescribers, including physicians, dentists, physician assistants, and advanced practice nurses, may be unaware of or underutilize steps that need to be taken when prescribing controlled drugs. Nurses can provide education to prescribers and assist in implementing the necessary measures in their workplaces.

Here are five steps for which nurses can advocate in their practice or facility:

  1. Verify identification. People who doctor-shop use various tactics, such as falsifying identification, sharing diagnostic imaging results, paying cash, and traveling long distances to seek care.

Implement standard measures to verify patient identification, diagnostic imaging reports, and prior records, and to increase scrutiny of patients who pay cash and travel from out of town. A photo ID should be required and kept in the patient’s record. Identification should be further verified with a utility bill or other documentation.

  1. Obtain informed consent and a treatment contract. This should be done any time controlled drugs are prescribed. The consent should include a treatment contract stating that the medication should be taken only as directed and should not be obtained from other prescribers.

Treatment contracts can reduce problems with prescription medication use by 7% to 23%, according to a systematic review by Starrels. They should include an agreement about the measures taken with all patients who are prescribed controlled medications.

In large organizations or practices, records of patients prescribed controlled drugs should be monitored to detect prescribing by more than one provider. A release also should be signed allowing communication with a reliable family member or friend who can provide information about areas of concern regarding substance use.

  1. Require urine drug screens. Urine drug screens should be part of the routine care of patients who are prescribed controlled substances. They will detect if the prescribed medication or other controlled substances are already being used.

Recommendations include performing a urine drug screen once or twice a year on low-risk patients and three to four times a year for patients at moderate risk. High-risk patients should have a urine drug screen at every visit.

It is best to use urine tests that are sent to a lab for analysis rather than the urine dipstick tests, which can be easily falsified by patients. In addition, witnessed urine drug testing can reduce the incidence of inaccurate results by 25% according to a study by Mallya published in the American Journal of Addictions.

  1. Count pills. Pill counts can help detect if a patient is taking more of a controlled medication than prescribed. Patients are called at random and asked to come to the office within a certain period with their prescribed medication. The number of pills remaining should match the prescriber’s directions and number of days since filling the prescription.

Although people who engage in doctor shopping report sharing medications to falsify pill counts, they are not always successful in obtaining the required amount and type of pills.

  1. Resister with drug monitoring programs. Individual states participate in prescription drug monitoring programs (PDMPs). These programs provide electronic databases that collect data on controlled drugs filled at pharmacies. Prescribers can register with these programs and log on to check what controlled medications their patients have had filled.

Many states allow the prescriber to designate another healthcare professional to conduct searches for them. Nurses who are designated to do this could check the PDMP upon admission or the day before the patient is seen in an outpatient setting.

Problems with the databases include delayed availability of information and the lack of a nationwide database. This allows patients to cross state lines to obtain prescription drugs from numerous prescribers. Despite this, this program is the single best method available to detect when patients are obtaining prescriptions from multiple prescribers. It should be checked every time a controlled drug is prescribed.

Managing doctor shopping and prescription SUDs

Detection of a prescription SUD should be addressed using motivational interviewing (MI) techniques, which includes a nonjudgmental and nonconfrontational attitude. MI is a conversational approach that addresses ambivalence to change, where the goal is to provide opportunities for patients to identify their desire and plan for change in their own words.

Screening brief intervention and referral to treatment (SBIRT) is an evidence-based program that uses MI and other techniques to identify and manage SUDs. Online training in SBIRT is offered from a variety of sources, including the University of Pittsburgh. It provides continuing education training for nurses at a minimal cost.

Nurses can recommend using SBIRT in their workplaces. It also is important to have a list of referrals for local SUD treatment programs on hand.

Studies have shown that when patients are informed of problematic PDMP reports, or told that they will not be prescribed a controlled drug, they may react with a variety of emotions. These include becoming distraught or exhibiting denial or anger. Healthcare professionals should expect these types of reactions and should establish protocols to manage these situations.

Selected references

Amari E, Rehm J, Goldner E, et al. Nonmedical prescription opioid use and mental health and pain comorbidities: a narrative review. Can J Psychiat. 2011;56(8):495-502.

Babor TF, McRee BG, Kassebaum PA, et al. Screening, brief intervention, and referral to treatment (SBIRT): toward a public health approach to the management of substance abuse. J Life Learn Psych. 2011;9(1):131-40.

Back SE, Payne RL, Simpson, AN, et al. Gender and prescription opioids: findings from the national survey on drug use and health. Addict Behav. 2010;35:1001-7.

Bond CF, DePaulo BM. Accuracy of deception judgments. Pers Soc Psychol Review. 2006;10(3):214-34.

Butler SF, Fernandez K, Benoit C, et al. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9(4):360-72.

Chen LH, Hedegaard H, Warner M. Quick stats: number of deaths from poisoning, drug poisoning involving opioid analgesics – United States 1999-2010. MMWR. 2013;62(12):234-5.

Department of Justice. Facts about prescription drug diversion and abuse. 2009. http://www.justice.gov/dea/pubs/pressrel/pr052009.html.

Gourley DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-12.

Green TC, Bowman SE, Ray M, et al. Collaboration or coercion? Partnering to divert prescription opioid diversion. J Urban Health. 2013;90(4):758-67.

Hildebran C, Cohen DJ, Irvine JM, et al. How clinicians use prescription drug monitoring programs: a qualitative inquiry. Pain Med. 2014;15(7):1179-86.

Irvine JM, Hallvik SE, Hildebran C, et al. Who uses a prescription drug monitoring program and how? insights from a statewide survey of Oregon clinicians. J Pain. 2014;15(7):747-55.

Jamison RN, Butler SF, Budman SH, et al. Gender differences in risk factors for aberrant prescription opioid use. J Pain. 2010;11(4):312-20.

Lundahl BW, Kunz C, Brownell C, et al. A meta-analysis of motivational interviewing: wenty-five years of empirical studies. Resour Sch Soc Work. 2010;20(2):49-54.

Mallya A, Purnell AL, Svrakic DM, et al. Witnessed versus unwitnessed random urine tests in the treatment of opioid dependence. Am J Addict. 2013;22(2):175-7.

McLarnon ME, Monaghan, TL, Stewart SH, et al. Drug misuse and diversion in adults prescribed anxiolytics and sedatives. Pharmacotherapy. 2011;31(3):262-72.

Owen GT, Burton AW, Schade CM, et al. Urine drug testing: current recommendations and best practices. Pain Physician. 2012;15(3 Suppl):ES119-33.

Partnership for Drug Free Kids. (2010). New data show millions of Americans with alcohol and drug addiction could benefit from health care reform. http://www.drugfree.org/new-data-show-millions-of-americans-with-alcohol-and-drug-addiction-could-benefit-from-health-care-r/ 

Rigg KK, Kurtz SP, Surratt H L. Patterns of prescription medication diversion among drug dealers. Drugs: Ed, Prev and Policy. 2012;19(2):145-55.

Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152(11):712-20.

Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Overview and Findings. The NSDUH Report. Sept 4 2014.

Tracy EM, Laudet AB, Min MO, et al. Prospective patterns and correlates of quality of life among women in substance abuse treatment. Drug Alcohol Depend. 2012;124(3):242-9.

Worley J. Prescription drug monitoring programs, a response to doctor shopping: purpose, effectiveness, and directions for future research. Issues Ment Health Nurs. 2012;33(5):319-28.

Worley J, Hall JM. Doctor shopping: a concept analysis. Res Theory Nurs Pract. 2012;26(4):262-78.

Worley J, Thomas SP. Women who doctor shop for prescription drugs. West J Nurs Res. 2013;36(4):456-74.

Wu SM, Compton P, Bolus R, et al. The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain. J Pain Symptom Manage. 2006;32(4):342-51.

Julie Worley is an assistant professor at Rush University College of Nursing and a clinician at Haymarket Center, a substance abuse treatment facility in Chicago, Illinois.

http://www.drtepp.com/pdf/substance_abuse.pdf

 

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