Millions of Opioid Prescriptions Go to 'Doctor Shoppers'

Nancy A. Melville

July 23, 2013

Nearly 2% of all US opioid prescriptions, totaling an estimated 4.3 million prescriptions each year and 4% of all opioids by weight, are purchased by patients presumed to be "doctor shoppers," according to a new study.

In the first national estimate of opioid medications obtained in the United States by the doctor shoppers — patients who receive painkiller prescriptions from multiple doctors without informing the doctors of their other prescriptions — researchers found that they obtained, on average, 32 opioid prescriptions per year from 10 different prescribers.

The results are from evaluation of 146.1 million opioid prescriptions dispensed during 2008 by 76% of retail pharmacies. The findings were published online July 17 in the journal PLoS One.

According to lead author Douglas McDonald, PhD, principle researcher with Abt Associates, of Cambridge, Massachusetts, the results showed 3 basic categories of prescriptions, with about 1 in 143 patients appearing to be doctor shoppers.

"For opioid prescribing, we found the vast majority of prescriptions were a matter of 1 doctor and 1 prescription," he told Medscape Medical News. "In the second category, there would be a patient receiving a few prescriptions from a few doctors, but these looked to me like patients in the chronic care population.

"And then in about 1 out of 143 were the outliers who looked different from the rest, with an average of 32 different prescriptions from 10 different prescribers."

Although the prescribers' exact intentions cannot be confirmed, Dr. McDonald said other factors that suggested doctor-shopping included the fact that the patients paid disproportionately in cash — a tactic used to avoid being detected by their insurers, and many were in their 20s and 30s, a group that has been shown in the substance abuse literature to have the highest rate of abuse.

"Exponentially" Increasing Problem

The exponentially increasing problem of prescription opioid abuse is evidenced by the 4-fold increase in opioid overdose deaths, from 4000 in 1999 to 16,651 in 2010. The overdoses are now twice as common as heroin and cocaine overdose deaths combined, the authors note.

Opioid prescriptions meanwhile skyrocketed during the same general period: while the US population increased by just 16% between 1997 and 2011, the amount of oxycodone sold by retail pharmacies increased by 1259%.

The US Department of Justice took action to try to curtail the problem by making federal assistance available in 2002 for the computer-based prescription monitoring programs (PMPs) that collect data from pharmacies regarding dispensed prescriptions from certain drugs, including all schedule II drugs and several others.

But those programs have not caught on with physicians, and currently only Kentucky and West Virginia legally require prescribers to access patients' prescription histories in the databases before prescribing certain drugs.

Among the key challenges in using PMPs is simply convincing physicians that they are worth the effort, Dr. McDonald said.

"One of the problems of the PMP is it does require jumping through some hoops, such as password creation, and then looking up a prescription history, and that can take a significant amount of time and effort."

"My primary care provider, for instance, has 3000 patients, and if he were to use PMPs for even a 10th of those patients, that would be a lot of additional work in the scope of the traditional 15-minute appointment," he said.

"Furthermore, reimbursement rates don't offer much incentive for spending the time to evaluate someone for the risk of abuse and then take even more time to make referrals to treatment and find a treatment provider if they are a risk. So unfortunately, the easiest thing to do is to write a prescription and send them home."

Holes in the System

Yet another problem is that PMPs only provide information for a particular state, which is a significant restriction, said Stuart Gitlow, MD, president of the American Society of Addiction Medicine.

"I'm based in Rhode Island, for instance, but a patient could easily drive to Connecticut, Massachusetts, Vermont, or New Hampshire in no time at all and get multiple other prescriptions," said Dr. Gitlow, who practices in Woonsocket. "The more you look at it, the more you realize there are holes in the system.

"I do think prescription monitoring programs are way overdue, but we have to realize they have very significant limitations at the moment, and we need to solve that before they are as useful as promised," he added.

The study's authors and Dr. Gitlow agreed that the ideal situation would be for PMPs to be integrated into electronic medical records so that patients' prescription histories would be as easily accessible as their medical histories, but efforts toward that type of universal integration are only in the early stages.

In the meantime, Dr. Gitlow suggested that physicians keep their eyes open for key clues that may suggest a patient is doctor-shopping.

"The typical concern is the individual who comes in asking for a drug specifically and says something like, 'I'm here for my Vicodin,' because the majority of patients do not want to take medication if they can avoid it," he said.

"Another thing is if you try to prescribe a particular drug and they say, 'No, not that one, I want this other one instead. I can only take Oxycontin and not Percocet,' for instance," he said. "If they have that much familiarity, that's a sign of a potential doctor shopper."

Physicians should also keep track of how much time has passed since a patient's last prescription.

"Follow along over the course of time," he said. "If they do come in before they're really out of their medication and give excuses such as the medication is lost, it fell down the drain, or someone took it, those are big signs of problems."

The study was funded by the National Institute on Drug Abuse. Dr. McDonald and Dr. Gitlow have disclosed no relevant financial relationships.

PLoS One. Published online July 17, 2013. Full article

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