Physicians a Leading Source of Opioids for Illicit Users

Deborah Brauser

March 06, 2014

Although access to prescription opioids by abusers is commonly thought to come primarily from friends or family members, physicians are just as likely to be the source ― especially for high- risk, high-use individuals, according to the Centers for Disease Control and Prevention (CDC).

A national survey study of more than 11 million participants showed that 27% of those who reported nonmedical use of opioids on 200 or more days in the past year got the drugs from their own prescriptions, while 26% got them free from a friend or family member, and 23% bought them from a friend or family member.

Although the percentage of those who received opioids from prescribers dropped as the frequency of use decreased, nearly 20% of those who used the drugs in a nonmedical capacity for just 1 to 28 days still reported getting them from a physician.

"People who are using these drugs on a daily or near-daily basis need a much larger volume of medication to keep up with their habit," coinvestigator Leonard Paulozzi, MD, MPH, a medical epidemiologist at the National Center for Injury Prevention and Control at the CDC, told Medscape Medical News.

"So it seemed intuitive that they would eventually exhaust all their friends and people's medicine chests and would have to seek other sources," he said.

Therefore, many of these high-use abusers often go directly to physicians for their drugs, said CDC director Tom Frieden, MD, MPH, in a release.

"Healthcare providers need to screen for abuse risk and prescribe judiciously by checking past records in state prescription drug monitoring programs. It's time we stop the source and treat the troubled," said Dr. Frieden.

The study was published online March 3 in JAMA Internal Medicine.

New Prevention Target

The investigators note that previous research has shown that most individuals who use opioids nonmedically get them free of charge from family and friends. So prevention efforts have focused on this group with programs such as take-back events for unused medications.

However, these programs do not target individuals who are at the highest risk for overdose.

"We did this study to dig a little farther into the subpopulation of the heaviest nonmedical users of opioid pain relievers at 200 to 365 days a year. Basically, they're daily users," said Dr. Paulozzi.

Dr. Leonard Paulozzi

For the current study, the investigators examined data for the period 2008 to 2011 from the Substance Abuse and Mental Health Service Administrations' National Survey on Drug Use and Health for 11,018,735 weighted participants older than 12 years (55.5% male) who reported any past-year nonmedical use of opioids.

Nonmedical use was defined as "use without a prescription or use with a prescription for the feeling or the experience caused by the drug."

The patient population was split into 4 subgroups representing frequency of use and included those who used the drugs 1-29 days in the past year (n = 7,037,205), those who used them 30-99 days (n = 2,110,122), those who used them 100-199 days (n = 1,103,312), and those who used them 200 or more days (n = 768,096).

In addition, types of sources for providing opioids for the participants' last use were categorized into the following groups: obtained from a friend or family member for free or for money; stolen from a friend or family member; prescribed by 1 or more physicians; bought from a drug dealer or a stranger; or obtained from another source.

Results showed that the biggest source of opioids for the entire group was from a friend or relative for free (54.4%), followed by from a prescription from 1 or more physicians (19.7%) and from a friend or relative for money (11.3%).

"In other words, a majority of the time, the source was a pill given to them by a friend or relative for free. This could be someone at school or even a parent giving a drug for some kind of headache or pain. And that has been the dominant message from recent years," said Dr. Paulozzi.

"However, the source varied significantly by frequency of nonmedical use," report the investigators.

Judicious Prescribing

In fact, obtaining for free from friends or family dropped significantly as the frequency of use increased (61.9% for the lowest use group vs 26.4% for the highest; P < .05 ), as did stealing from friends or family (5.3% vs 2.9%, respectively).

The order was reversed for obtaining the opioids from a physician. This source was reported by 27.3% of the highest use group, 26.5% of the 100-199 days use group, 19.5% of the 30-99 days use group, and 17.9% of the 1-29 days use group (P < .05 for the 2 lowest use groups vs the highest use group).

As the days of nonmedical use increased, the percentage of participants also increased for those who reported obtaining opioids through purchasing from a friend or relative (7.6% of the lowest use group vs 23.2% of the highest group, P < .05) and purchasing from a drug dealer or other stranger (2.1% vs 15.2%, respectively; P < .05).

Overall, the highest-risk group was "more likely than those with the lowest frequency of use to obtain opioids from a physician's prescription or from a drug dealer. This pattern is similar to that of patients in opioid treatment programs, who cite dealers and physicians as frequent sources," write the researchers.

"These results underscore the need for interventions targeting prescribing behaviors, in addition to those targeting medication sharing, selling, and diversions."

The investigators add that going forward, it is important that clinicians include "judicious prescribing" and use of screens and drug monitoring programs before prescribing opioid pain relievers to any patient.

"Prescribers have to think of the population of nonmedical users as not all the same kinds of people. They'll hear a lot about people sharing their medication and feel that they can't really have any control over that," said Dr. Paulozzi.

"But they should also realize that the people who are coming to them seeking drugs to be used in this way are likely to be the highest risk group. As such, they are likely to have some record in the prescription drug monitoring program. And they may have a pattern of getting multiple opioids and going to multiple pharmacies," he added.

Higher Level of Diligence Needed

Edward Michna, MD, board member with the American Pain Society, told Medscape Medical News that the study's results were not really surprising.

Dr. Edward Michna

"An addict will do whatever they can do. If someone is chronically using [this type of drug], there's going to be a higher risk that he's going to feign medical illness to get prescriptions from the doctor," said Dr. Michna.

"These users need a more stable supply than they can get from family and friends. And whatever is the easiest way for them to achieve it is what they'll do, whether it's getting it from multiple doctors, doctor shopping, or buying it on the street," he said.

Dr. Michna, who was not involved with this research, is also director of the Pain Trials Center at Brigham and Women's Hospital in Boston, Massachusetts, and an assistant professor at Harvard Medical School.

"All of this being said, we can't be police officers or lie-detecting everybody. But certainly a higher level of diligence helps," he said.

He noted that he has reviewed many malpractice cases that involve inappropriate opioid prescribing.

Much of the time he said these situations arise because doctors do not ask about abuse, do not look at prior medical records, or do not talk to prior treating physicians or that they ignore tests that indicate abuse, such as urine drug screens.

"Obviously, it's a multifaceted thing. There's been dramatic improvement in the number of people educated in terms of monitoring and evaluating patients for appropriate use. But we have a long way to go."

Still, he admitted that it can be difficult to identify and deal with a savvy patient determined to fool a clinician.

"Despite our best efforts, these things are still going to happen. The problem really is that there's the disease of addiction. And the bottom line is we need to better understand it and put resources behind it instead of just blaming drugs or clinicians or whoever for the problem," said Dr. Michna.

"I think it's more complicated than just doctors prescribing, although that is certainly part of the whole problem."

The study authors have reported no relevant financial relationships.

JAMA Intern Med. Published online March 3, 2014. Abstract


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