ABSTRACT & COMMENTARY
Who Is Shopping for You?
By Rahul Gupta, MD, MPH, FACP
Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV
Dr. Gupta reports no financial relationships relevant to this field of study.
SYNOPSIS: In a study of young adults, attempted physician deception to obtain a pharmaceutical drug was found to exist in a limited manner along with general characteristics of those patients who may divert medications.
SOURCE: Stogner JM, et al. Deception for drugs: Self-reported "doctor shopping" among young adults. J Am Board Fam Med 2014;27: 583-593.
Prescription drug misuse and abuse has become not only an epidemic but one of the major public health concerns in the United States in recent years. Overdose deaths, including deaths from prescription pain medications, have more than tripled since 1999 and now outnumber those from heroin and cocaine combined.1 Data show that in 2008, drug overdoses in the United States caused more than 36,000 deaths. This means that in 2008, nearly 100 persons per day died of drug overdoses in the United States. Of the 20,044 overdose deaths resulting from prescription drugs, opioid pain medications were involved in 14,800 deaths (73.8%).2 Emergency department visits for prescription drug misuse more than doubled between 2004 and 2011. In fact, enough prescription pain medications were prescribed in 2010 to medicate every American adult continually for a month. These statistics clearly point to the fact that large quantities of prescription drugs are reaching unintended users. The health and other societal consequences of nonmedical use of prescription pharmaceuticals are significant. Data also demonstrate that most nonmedical users obtain these medications from friends or family, often free of cost.3 However, recent data indicate that as the reported days of nonmedical use increases, opioid pain relievers are obtained from other sources, including prescriptions from physicians and purchases from a friend or a relative or from a drug dealer or a stranger, with greater frequency.4 Additionally, among nonmedical users reporting 200-365 days of use, more than one-fourth of the opioid pain relievers are most often obtained via prescription from physicians. This is especially concerning since the role of physicians serving as the front line of defense in drug diversion is being increasingly recognized. Therefore, it is critical to understand the pervasiveness of those patients who may attempt to deceive physicians and avoid detection in order to obtain such prescriptions.
The goal of the study by Stogner et al was to assess the prevalence of attempted physician deception in a general population, explore common motives, and evaluate risk factors associated with such behavior. The researchers utilized a stratified random sampling to obtain responses to a self-administered paper survey across a locally representative sample of 2349 young adults in the southeastern United States. With a response rate of 80%, the sample population was 48.4% male, 68.9% white, 24.4% black, and 2.8% Hispanic. The mean age of those in the sample survey was 20.06 years, and the median family income category was $75,000 to $99,999. Questions assessing whether respondents had attempted to deceive a physician to obtain a pharmaceutical drug they did not intend to use were able to differentiate between whether participants were attempting to get a prescription for a medication that they intended to abuse and whether they intended to sell.
Researchers found that 93 (4%) of the respondents self-reported having attempted to deceive a physician to obtain a pharmaceutical drug. A significantly larger portion of men (4.8%) than women (3.1%) reported deception. The difference also was seen for both motives (abuse and sell), although it was proportionally larger for selling (2.7% of men, 1.4% of women). Approximately half reported that selling a portion of the prescription was a motivating factor. Authors also noted that attempted deception was more commonly reported by Hispanics, self-identified lesbian/gay/bisexual/transgender individuals, and those at the lowest and highest extremes of the income spectrum. Alcohol use, marijuana use, and pharmaceutical misuse were also each found to be risk factors associated with attempted deception. Additionally, a significantly larger portion of student athletes reported the deception. For the purpose of abuse, twice the percentage of athletes reported attempted deception (7.2% vs 3.3% of nonathletes). To obtain pharmaceuticals to sell, there was a four-fold difference in the reported attempted deception (5.6% vs 1.8% of nonathletes).
COMMENTARY
There has been a striking increase in the misuse and abuse of prescription medications over the past two decades in which prescribed patients either may not adhere to the prescribed regimen, or share with other individuals with or without financial gains. While Pharmaceutical drug diversion can take several forms; regardless of the route, the excess supply of such drugs in the market is ultimately the result of generous prescribing. The nonmedical use of prescription drugs is often perceived to be more socially acceptable than the use of illegal drugs such as heroin or cocaine. Also fueling the epidemic is that the nonmedical use of prescription drugs is perceived by many as being a safer alternative while avoiding the high-risk lifestyle and stigma associated with the use of illegal drugs. From an economic perspective, this epidemic has significant costs in addition to the human health impact. A 2011 study estimated that in 2006, nonmedical use of prescription opioids imposed a cost of approximately $53.4 billion on the U.S. economy — including $42 billion in lost productivity, $8.2 billion in increased criminal justice costs, $2.2 billion for drug abuse treatment, and $944 million in medical complications.5
Preventing pharmaceutical drug diversion will require multilevel changes. While effective statewide prescription drug monitoring programs and prescription claims review programs by health insurers and pharmacy benefit managers may assist, it is the physician practice that remains at the vanguard of ensuring that diversion through deception is minimized or eliminated. Nevertheless, practice interventions to reduce prescription drug diversion must strike a balance between reducing the misuse and abuse and safeguarding legitimate access to treatment.
The study by Stogner et al demonstrates that physician deception may be inescapable for the physician practice and provides an insight into the patient profile. However, physicians should be careful not to generalize these results but remain appropriately vigilant and develop screening criteria as well as protocols for prescribing that avoid inadvertently contributing to the recreational pharmaceutical use problem. It starts by physicians only using opioids in carefully screened and monitored patients when non-opioid treatments have not been sufficient to treat pain, as recommended in evidence-based guidelines.
REFERENCES
- Mack KA; Centers for Disease Control and Prevention (CDC). Drug-induced deaths - United States, 1999-2010. MMWR Surveill Summ 2013;62 Suppl 3:161-163.
- Centers for Disease Control and Prevention. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States 1999-2008. MMWR 2011;60:1487-1492.
- Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, 2012. Rockville, MD: Substance Abuse and Mental Health Services Administration. NSDUH Series H-41; HHS publication (SMA) 2012;11-4658.
- Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA Intern Med 2014;174:802-803.
- Hansen RN, et al. Economic costs of nonmedical use of prescription opioids. Clin J Pain 2011;27:194-202.
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