Bad Habits with Drugs

Drug-seeking behavior is a term commonly used, although it poorly describes a range of activities directed towards the attainment of sought-after drugs. It requires an approach that is mindful of outcomes for the patient, practice staff, and the community. Healthcare providers can be part of the solution or problem, but it takes a heavy toll on everyone involved. Even the most experienced person can make a mistake or be dealing with an addiction problem themselves. Regardless of the outcome, awareness and educating yourself and the public can hopefully lessen a situation even when it seems hopeless.

Which Drugs Do People Seek?

Benzodiazepines and opioids are the two most common classes associated with drug-seeking behavior. Opioids commonly misused include oxycodone, fentanyl, codeine, and morphine.

Psychotropic drugs producing stimulant effects, euphoria, sedation, or hallucinatory effects are sometimes sought. These include the newer antipsychotics quetiapine and olanzapine, and stimulants such as dexamphetamine and methylphenidate. Anabolic steroids are also increasingly misused.

Over-the-counter combinations of codeine with paracetamol or ibuprofen have caused serious harm when misused. Complications of overdose with the ibuprofen/codeine combinations can be life-threatening and include gastrointestinal bleeding, perforation, hypokalaemia, renal failure, anemia, and opioid dependence.

The Risks of Misuse

Patterns of drug-seeking behavior, intoxication, and withdrawal states can affect patients’ relationships, employment, and finances. Misuse of prescription drugs is associated with crime and consequent incarceration. Harms extend to the wider community and include robbery, theft, identity fraud, extortion, and the manufacture of illicit drugs.

Traffic accidents and disorganized behavior can have consequences for both the patient and the community. Harms associated with the injection of prescription drugs include an increased risk of acquiring blood-borne viruses and other adverse effects of unsafe injecting.

Indicators of Drug Seeking Behavior

Dependency on prescription drugs may occur at any age, within any cultural group, and across any educational class. Health providers should be aware of drug-seeking behaviors, but some patients seeking drugs of dependence may present without these behaviors. Common contexts within which drug-seeking occurs include:

Typical requests and complaints

• Aggressively complaining about a need for a drug
• Asking for specific drugs by name
• Asking for brand names
• Requesting to have the dose increased
• Claiming multiple allergies to alternative drugs
• Anger or irritability when questioned closely about symptoms such as pain

Inappropriate self-medicating

• Taking a few extra, unauthorized doses on occasion
• Hoarding drugs
• Using a controlled substance for non-pain relief purposes (e.g. to enhance mood, aid sleep)
• Injecting an oral formulation

Inappropriate use of general practice

• Visiting multiple doctors for controlled substances (doctor shopping)
• Frequently calling the clinic
• Frequent unscheduled clinic visits for early refills
• Consistently disruptive behavior when arriving at the clinic
• Consistently calling outside of clinic hours or when a particular doctor who prescribes controlled substances is on call

Resistant behavior

• Unwilling to consider other drugs or non-drug treatments
• Frequent unauthorized dose escalations after being told that it is inappropriate
• Unwilling to sign a controlled substances agreement
• Refusing diagnostic workup or consultation

Manipulative or illegal behavior

• Claiming to be on a waiting list for, or unable to afford dental work and needing to manage dental pain
• Obtaining controlled drugs from family members (including stealing from older relatives)
• Using aliases
• Forging prescriptions
• A pattern of lost or stolen prescriptions
• Selling drugs
• Obtaining controlled drugs from illicit sources

Other typical behaviors

• Being more concerned about the drug than a medical problem
• Deterioration at home or work or reduction of social activities because of adverse drug effects

Controlled Prescribing Strategies

• Controlled quantities: Prescribe what is needed and safe. You can prescribe smaller quantities (e.g. 10 tablets) than the standard packaging quantities that automatically come up in the prescribing software. Discuss this with the pharmacist.
• Controlled dispensing: Consider setting up arrangements with the patient’s local pharmacy so that a small quantity can be dispensed at an interval agreed with the patient. For example, arrange for the patient to attend once or twice a week, or daily. You will need to contact the pharmacist to arrange this and write these dispensing instructions on the prescription.
• Private scripts or authority scripts for increased quantities: These should only be used for patients with cancer-related pain or those receiving palliative care.
• Request patients to obtain their prescriptions from one pharmacy: This encourages an open and communicative approach to management and improves the safety of prescribing.
• Inform patients that they will need to see the same PCP for all reviews associated with their prescription: No telephone requests for extensions or ‘lost’ scripts will be given.

–NIH (an Australian journal article)

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Combating Prescription Drug Abuse in Your Practice

When internist Juliet Mavromatis answered a phone call from a nearby pharmacy a few years ago, she was greeted with some unexpected news. One of her patients was attempting to fill a prescription, and the pharmacist had some concerns.

“She had been my patient for probably two or three years, and she and I had a good relationship,” says Mavromatis, who was at the time practicing at The Emory Clinic in Atlanta. “I didn’t think she was doing anything illegal — certainly not forging prescriptions.”

Mavromatis had been prescribing the woman narcotics for chronic pain, and as she and the pharmacist compared notes, to her dismay she realized the woman had been copying her prescriptions and attempting to fill them more often than directed.

Still, when the pharmacist asked Mavromatis if she wanted to press charges, she refused. “This is a woman who became addicted to drugs and who had an illness and wasn’t going out on the street and selling drugs,” she says. “She didn’t intentionally create her addiction. She became addicted and then was acting like an addict and broke the law.”

Later that day, Mavromatis received her second unexpected phone call. This time, the woman was on the other end of the line, asking to come into the office for a visit. “She came in and was tearful and apologetic,” says Mavromatis, who is now a solo physician in Atlanta. After speaking with the woman, Mavromatis decided to continue treating her, with the caveat that she would no longer prescribe the woman pain medication. “Saying ‘I’m not going to see you anymore’ is just basically sending her to the next doctor, and it’s not really a solution for her,” says Mavromatis, noting that the woman successfully came off the medication on her own. “The most compassionate solution is to work with patients, help them recognize when they have a problem, and then help them use medications appropriately or get off the medication.”

All Too Common

For most of you, this scenario is a familiar one, though it plays out in different ways. Patients become addicted to prescriptions and start abusing them, and then their behavior changes in ways you would never expect. Worse, prescription abuse sometimes leads to tragedy. About eight years ago, Mavromatis lost a patient — a young mother of five — to an accidental overdose. Unbeknownst to Mavromatis, the woman had visited another clinic and obtained a prescription for a longer-acting narcotics, which she was taking in addition to the medications Mavromatis was prescribing her.

Part of the challenge in dealing with prescription-abusing patients is identifying when a patient is experiencing a problem and/or when a problem is escalating. Anyone can become vulnerable to abusing prescriptions because anyone can become addicted, and when patients become addicted, many are adept at hiding it, says Barbara Sullivan, associate director of the Utah Addiction Center at the University of Utah in Salt Lake City.

That’s why it’s essential to have open, honest relationships with the patients to whom you prescribe controlled substances, she says. You should discuss the addictive qualities of medications with patients; inform them that you will be carefully monitoring them when they are taking the medications; express concern if problems crop up; and discuss alternative approaches to treatment. Focus on creating a dialogue with the patient, she says, rather than simply doing all the talking. “In a lot of ways, it’s like being a parent. The better you know your child, then the better you can tell when something is different or something is up.”

A strong physician-patient relationship also increases the likelihood that a patient who is addicted, or feels that he is becoming addicted, will share this with you. In fact, Mavromatis credits the strong relationship she had with the female patient who copied her prescriptions as a key reason why the woman contacted her after the pharmacy scare. “She didn’t feel like she had to run away from me,” says Mavromatis. “She felt like she could come in and be truthful with me and we could salvage the relationship.”

Alarm Bells

When treating a patient with controlled prescriptions, the earlier you can identify a problem the better. Always keep an eye and ear out for changes in behavior, failure to maintain eye contact, slurred speech, ready excuses for inappropriate or problem behaviors, and/or a nervous or jittery manner, says Sullivan.

Also, learn to identify medication-seeking behavior. Patients who compulsively use medication, continue to use medication despite harm, complain they need more medication, horde medication, or request specific medications should raise your concern, says psychiatrist and attorney H. Westley Clark, who serves as director of the Center for Substance Abuse Treatment under the Substance Abuse and Mental Health Services Administration in Rockville, Md.

Also, learn to differentiate between “yellow flag” and “red flag” behavior, says Cleveland-based internal and addiction-medicine physician Theodore Parran. Yellow flag behavior indicates a patient may be abusing prescriptions and you should proceed with caution when treating him. Red flag behavior indicates a patient’s health or safety is threatened, and you should immediately stop prescribing the medication, says Parran, who is also a professor at Case Western University School of Medicine in Cleveland.

Examples of Yellow Flags

• A patient asks for one or two early prescription refills.
• A patient takes all of his prescriptions but marijuana shows up in his toxicology screening.
• A patient reports that her spouse had a migraine so she gave him a bit of her own medication.

Examples of Red Flags

• You receive information from others that a patient is diverting or selling his medication.
• A patient alters, forges, or rewrites prescriptions.
• A patient suffers an accidental overdose.
• A patient threatens you or your staff.
• A patient continually raises yellow flags despite your warnings and attempts to reorient her.
• A good prescription drug monitoring program makes it easier to identify when yellow and red flags are raised, says Parran.
• Also, Parran says, require all of your patients to whom you prescribe controlled substances to sign informed consent forms.

Careful Approach

As soon as you begin to suspect a patient may be abusing prescriptions, express your concerns to him, says Sullivan. Do not, however, accuse him of abuse or approach him in a judgmental manner, says Clark. “Make sure that we don’t take our suspicions and make them facts without exploring what’s going on with the patient,” he says. Instead, explain your concerns, describe why it may be risky for him to continue taking the medication as he is taking it, and reinforce your commitment to work with him.

If the patient recognizes the problem: Speak to him about a treatment plan. This plan will vary, of course, depending on the type and extent of the problem. For instance, in a non-emergency situation (perhaps a few yellow flags have been raised) consider a slow taper off the medication, says Parran.

If you believe it is necessary to stop prescribing immediately (perhaps a red flag has been raised) educate him about withdrawal symptoms, and attempt to refer him to a formal addiction-treatment provider, says Parran. If he refuses, do your best to help him manage the withdrawal and continue to try to talk him into a referral.

If the patient is in denial or refuses to recognize the problem: Try to get the patient to acknowledge the issue by discussing how his behavior has changed due to his medication consumption, says Clark.

If the patient continues to deny a problem, document your attempts to treat him, and document his reactions and resistance. Then, recommend evaluation by someone more skilled in addressing addiction issues, says Clark. If the patient refuses, tell him you cannot continue to write pain medications for him.

At this point, many prescription abusers will “fire” you, says Parran. If your patient does not, however, that does not necessarily mean you must discharge him. Consider continuing to treat him without prescribing him controlled substances.

Sticky Situations

When a prescription abuser has committed a felony to gain prescriptions, not only will you need to determine if you will continue treating him, you also need to determine if you want to press charges.

For Parran, reporting the crime comes down to how you define your role as a physician. “My only advice to physicians is to be very clear in their own minds what their job is,” he says. “Is it to stick with purely being a physician to this patient, in which case taking the patient off the controlled substances and dealing with the withdrawal is really as far as their job goes? Or, does the physician consider part of their job to be the so-called civic professionalism aspect of trying to notify the public health or the criminal justice authorities about somebody who is committing felonies?”

Be careful, however, when facing such a difficult dilemma. In some jurisdictions, you may be legally obligated to report such an incident if certain conditions are met, says Clark. Your state medical board may also issue a reprimand for failing to report an incident.

-Physicians Practice

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…and Don’t Ignore These Red Flags

All health care professionals are required by law and ethics to help prevent prescription drug abuse.

But there is a delicate balance between deterring individuals who may be seeking controlled substances for illegitimate reasons and helping patients who need these prescriptions to manage pain and in pursuit of improved quality of life.

As the opioid epidemic in the United States continues to spiral out of control, physicians and other prescribers have been held criminally liable for overdose-related deaths. Pharmacists are not exempt from liability in this setting and have been held legally and criminally liable for patients’ overdose deaths. The Board of Pharmacy in states such as California has been increasing the number of investigations against pharmacies, pharmacists, pharmacy technicians, intern pharmacists, and associate staff members for not carrying out “corresponding responsibility” or addressing “red flags.” In 2013, the California Pharmacy Board revoked the licenses of Pacifica Pharmacy and pharmacist Thang Q. Tran for multiple failures to address red flags. In 2015, the West Virginia Supreme Court ruled that substance abusers, even those who knowingly engage in illegal activities, such as doctor shopping and misleading providers, can sue the prescriber and pharmacists who dispensed the medications. A bill was subsequently approved by the West Virginia governor in 2016 to prohibit anyone engaging in illegal activities from suing prescribers and pharmacists.

Pharmacists have an important legal and ethical role in addressing prescription drug abuse. Under Title 21 Code of Federal Regulations Part 1306.04 (21 C.F.R. § 1306.04), “the responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription.”2 The extent and magnitude of the “corresponding responsibility” remains largely misunderstood and undefined. There have been several cases where pharmacists and pharmacies were held criminally liable for failing to exercise their corresponding responsibility.

With pharmacists and pharmacies susceptible to investigations and corresponding liability, it is important that pharmacies establish due diligence policies, which include checking state prescription drug monitoring programs (PDMPs) and identification of red flags. Red flags are warning signs that may indicate a controlled substance prescription is not being obtained for legitimate medical purposes but rather for diversion or abuse. It is the pharmacist’s job to evaluate and interpret the seriousness of these warning signs.

Listed below are the red flags that pharmacists should recognize based on a document released by the National Association of Boards of Pharmacy titled, “Stakeholders’ Challenges and Red Flag Warning Signs Relate to Prescribing and Dispensing.”3

Presentation of the Prescription

• Patients travel in groups and/or have unexplainable common factors in their relationships with each other. For example, groups of patients present prescriptions for the same controlled substance(s) from the same prescriber or multiple family members or patients living at the same address present similar controlled-substance prescriptions to the pharmacy on the same day.
• A patient presents prescriptions for controlled substances written in the names of other people. This does not apply to designated caregivers presenting prescriptions for patient.
• A patient presents a prescription for a controlled substance that the pharmacist knows or reasonably believes that another pharmacy refused to fill.
• A handwritten prescription is presented at the pharmacy, looking altered or flawlessly thorough (contains patient address, quantity spelled out, patient’s date of birth, multiple provider identifiers, lacks common abbreviations, etc.).
• The pharmacist becomes aware that the prescriber’s Drug Enforcement Agency (DEA) registration has been previously suspended or revoked or is pending suspension or revocation.

Patient Behavior

• The patient pressures the pharmacist to dispense the controlled substance by making implied or direct threats.
• The patient shows physical signs associated with controlled-substance abuse, such as appearing sedated, confused, intoxicated, or exhibiting withdrawal symptoms.
• The patient obtains the same or a similar controlled-substance prescription from multiple health care practitioners without disclosing those existing controlled-substance prescriptions.
• The patient obtains controlled-substance medications from 1 pharmacy, while having received the same or similar controlled substance(s) from another pharmacy or other pharmacies, without disclosing those existing controlled-substance prescriptions.
• The patient presents prescriptions for highly abused controlled-substance medications, which may vary by region. The pharmacist should be aware of abuse trends in their area.
• The patient presents several prescriptions written for controlled and non-controlled substances but only wants the controlled-substance medication(s) dispensed.
• The patient has a history of untruthfulness when filling controlled-substance prescriptions.

Medication Taking/Supply

• The patient presents prescriptions for large quantities or large numbers of prescriptions for controlled substances.
• There is therapeutic duplication for 2 or more long-acting and/or 2 or more short-acting opiates.
• The patient presents prescriptions for highly abused “cocktails” (combination of opiate, benzodiazepine, and muscle relaxant) of controlled-substance medications.

Illicit/Illegal

• The patient indicates that drugs will be shared with others or sold.
• The prescriber’s DEA registration or state license has expired or been suspended or revoked.
• The patient presents a prescription from a prescriber who is prescribing outside the scope of his/her practice, as defined by state law.
• The patient alters, forges sell, or rewrites prescriptions.
• The patient is diverting/selling medication or getting drugs from others.

After recognizing red flag(s), pharmacists should begin applying due diligence to the situation. This includes checking the patient’s PDMP report, contacting the prescribing physician for confirmation, and in a respectful manner, asking the patient to explain his or her situation. Documentation of the due diligence applied to prescriptions is a good habit to practice in case of audits or investigations. In the case that a prescription’s legitimacy cannot be verified, taking the time to explain the circumstance to the patient is necessary to avoid miscommunication.

Of late, some community pharmacy chains have changed policies that have been developed around the pretext of patient safety. Such policies include the limited-day supply of opioids for acute pain. However, this may present a bitter inconvenience for patients who legitimately require opioids for a major acute injury and also maximizes the profitability associated with multiple copays and dispensing fees for drugs that cost pennies. To our knowledge, there is no evidence to support that limited supplies for legitimate patients improve safety or mitigate risk. In fact, there is sufficient data to support that placing such barriers, at least for patients requiring long-term opioids, may actually contribute to the heroin epidemic.

Nevertheless, for minor acute injuries, we certainly don’t advocate for large supplies of short-acting opioids. Discretion should be left to the prescriber, based on presumed healing, and the number of units to be dispensed should be based on a responsible assessment with appropriate follow-up. Overshadowing such policies should be a requirement that pharmacists counsel every patient receiving opioids for new fills and renewed prescriptions and should include the attributes, adverse effects, and secure storage. Irrespective of how many times a patient hears these things, counseling should be a repetitive priority similar to the safety checks we hear each time we board an airplane.

In summary, an interdisciplinary approach that works fluidly is imperative to ensure that the right medication ends up in the right hands. All health care professionals share 1 goal, which is to help patients. Prescribers have the duty of appropriate prescribing for a legitimate medical purpose, followed by monitoring to ensure adherence and appropriate continuation of therapy.  Pharmacists have an equal and corresponding responsibility to ensure that patients are receiving controlled substances for a legitimate medical purpose and should engage patients in related counseling conversations routinely. Pharmacists should serve as a continuum of patient care and are some of the most accessible members of the health care team. Pharmacists are the last line of defense in preventing a controlled substance from ending up in the wrong hands and have a duty to patients and the community.

–Pharmacy Times