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Searching for answers: proper prescribing of controlled prescription drugs.

The number of prescriptions being written by medical professionals has increased dramatically over the past decade. The nonmedical use or abuse of these prescription drugs is now seen as a serious and growing public health problem, with an estimated 52 million people having used prescription drugs for nonmedical reasons in their lifetimes (NIDA 2011). This represents around 20% of those aged 12 or older in the United States. The DEA (DEA 2011) reports that in 2009 there were seven million Americans aged 12 years and older who abused controlled prescription drugs for nonmedical purposes within the past month. This is a 13% increase since 2008.

Three classes of controlled prescription drugs are most commonly abused: opiates, such as oxycodone (OxyContin[R], Percocet[R]), hydromorphone

(Dilaudid[R]) or hydrocodone (Vicodin[R]); sedative-hypnotics including benzodiazepines (such as Xanax[R], Ativan[R], Klonopin[R], Valium[R]), and stimulants (such as Adderall[R], Dexedrine[R], Ritalin[R], amphetamine, Concerta[R]). Currently, of these three classes of medications, the most commonly diverted and abused medications are the opiate drugs. The rapidly increasing distribution of prescription opioids (whether from legitimate prescriptions or Internet pharmacies) has helped increase the abuse of these medications, as well as the threats posed by diversion of the medications (ONDCP 2011).

The statistics on prescription drug abuse are startling: in 2009, an average of 6,027 individuals per day abused prescription pain relievers for the first time, and 2,500 teens daily use prescription drugs to get high for the first time (DEA 2011). One in seven teenagers has admitted to abusing prescription drugs in the past year to get high. Many of the teenagers have the misconception that prescription drugs are easier to get than illicit drugs, that they are safer than illegal drugs, and that they are not addictive (DEA 2011). Substance abuse, including controlled prescription medication, has become one of the nation's primary health problems, now affecting millions of individuals. The rate of controlled prescription drug abuse almost doubled from 7.8 million to 15.1 million in the years 1992 to 2003 (Manchikanti 2007). The CDC reports that opioid prescription painkillers caused more drug overdose deaths than cocaine and heroin combined, while the number of individuals abusing prescription drugs is larger than the number of individuals abusing cocaine, hallucinogens, heroin, and inhalants combined (CDC 2011).

BATTLING DIVERSION WITH NASPER

"Pill mills" have received the most attention in the ongoing battle to prevent misuse, abuse, and diversion of controlled prescription drugs. The lure of financial gain at the expense of individuals who have addiction problems is being fought by state and federal law enforcement. Dishonest professionals who are prescribing excessively without legitimate reasons are being investigated and arrested. One of the tools that have aided law enforcement has been the prescription monitoring programs (PMP) developed in many states. The SAMHSA National All Schedules Prescription Electronic Reporting (NASPER) Act of 2005 provided for the establishment of a controlled substance monitoring program in each state (Manchikanti, Whitfield & Pallone 2005). This law requires that dispensers of drugs report to their state within one week of dispensing a controlled substance. It also required that a searchable database be developed in each state containing the reported information that would be accessible by other states. The Alliance of States with Prescription Monitoring Programs currently lists 48 states having legislation authorizing the creation and operation of a prescription monitoring program (Alliance of States with Prescription Monitoring Programs 2012). Only 40 states, however, have a PMP that is operational and currently collecting data from prescribers and dispensers, while reporting information from the database to authorized users.

TYPES OF MISPRESCRIBING PROFESSIONALS

Unfortunately, addressing the illegal procurement and diversion of controlled prescription drugs is only part of the problem. Professionals more often misprescribe for other reasons than financial gain. Misprescribing can be broadly defined as prescribing scheduled drugs in quantities and frequencies inappropriate for the patient's complaint or illness. This may include prescribing controlled substances in large quantities or at frequent intervals and progression to multiple medications in the same medication class. Other misprescribing issues include prescribing controlled substances for family members or for friends and colleagues without a true physician/patient relationship. Often in the above situations, inadequate records are kept by the prescribing professional. Many medical boards have adopted the philosophy that "it is not what you prescribe, but how well you manage the patient's care, and document that care in legible form, that is important" (Minnesota Board of Medical Practice 1990). The types of medical professionals who have prescribing privileges allowing them to write prescriptions for controlled substances are varied. Physicians, dentists, nurse practitioners, and physician assistants can all prescribe prescription medications for patients. The professionals who misprescribe can fall into several different categories. The four D's--dated, disabled, duped, and dishonest--were first outlined by Wesson and Smith (1990) and then adopted by the American Medical Association (AMA). Within the CME program at the Center for Professional Health, Spickard and colleagues (1999, 1998) built onto this model by adding dismayed and dysfunctional in order to enhance the understanding of the role of physician wellness and levels of training in prescribing.

The dated professional often fails to keep current for many different reasons. Multiple new medications and treatments are discovered yearly, making the task of keeping up with the pace of medical knowledge daunting, particularly if the professional is practicing in a primary care field where a wider variety of disorders are treated (rather than in a narrowly defined specialty). At times, there is a lack of knowledge about other effective treatment options simply because the professional does not attend ongoing continuing medical educational courses, feeling they know the "best way to treat a particular problem."

The disabled professionals may have their own impairment issues, which may impact their judgment. Professionals are no different than the general population, in that they suffer the same type of impairment problems at a similar and possibly, at times, a higher prevalence. One of the most common issues is alcohol and other drug problems. If a professional has a problem with alcohol and/or drugs, it makes the professional more likely to be in denial about the issues occurring with the patient or to be "more generous" in their prescribing of controlled medications. Of equal concern is that the professional's judgment is impaired to the point that they see their ability to prescribe as an easy way to get drugs for themselves in order to continue their own addiction problems. However, it is not just alcohol and other drugs that may cause impairment issues in professionals. Misprescribing can occur when the prescriber has problems with psychiatric disorders such as depression, bipolar disorder, and anxiety as well as medical problems that can cause decreased concentration or cognition problems. There is also the issue of dementia in some aging professionals, which affects their ability to practice and may lead to misprescribing and medical errors.

The lack of substance abuse education both in the training professionals receive and in the continuing medical education required throughout their careers leads to the professional who is duped, as the professional fails to detect deception by their patient. In one study, only 19% of physicians had received any medical school training in identifying prescription drug diversion and only 40% received training on identifying prescription drug abuse and addiction (CASA 2005). At the same time up to 43% of physicians do not even ask about controlled prescription drug abuse when taking a patient's health history (CASA 2005). Currently, there appears to be a lack of substance abuse training in many medical schools. Few medical schools require a mandated clerkship in substance abuse such as the one offered in the Department of Psychiatry at the University of Florida (Gold & Teitelbaum 2010). Professionals through their own denial or lack of understanding of impairment problems often do not recognize the possible warning signs of addiction in their patients or themselves. The professional may believe their patients are always telling the truth about their symptoms, how they "lost" their prescription medication, or why they need early refills. This is particularly true when the patient does not fit the preconception the professional has of how someone with substance abuse problems presents.

At times a professional gives a prescription as a quick fix due to time constraints. The professional may be dismayed secondary to time constraints, too many patients scheduled, emergencies in the practice, or any number of other practice issues. The professional may feel the only way to get everything done is by taking the "easy way out." This may mean prescribing what the patient asks for or wants, rather than risking a possible confrontation. A commonly recited example is when a busy physician prescribes a controlled substance for a new patient requesting the drug but fails to complete a full screening and background check due to time and patient flow. The physician may simply give a prescription rather than taking time to explore the alternative treatment options available for that patient and thus avoids any conflict. It is much easier for the medical professional to give the prescription than to complete a thorough investigation and expend the time to provide other treatment options. They are avoiding the critical discussions and interactions with the patient in order to keep their office on schedule and prevent a patient complaint to the board while feeling as if they have provided "appropriate" care of their patient.

At times a professional is dysfunctional, finding it hard to say no to any request from a patient, family member, friend, or colleague. Many professionals when asked a favor by someone they closely know have a difficult time setting an appropriate professional boundary. The issue of treating oneself or a close family member/friend often was not addressed in the professional's education. The American Medical Association (AMA 1993) in their Principles of Medical Ethics (Policy E-8.19) states that physicians should not generally treat themselves or their family members for multiple reasons. The reasons include that their objectivity may be compromised; their personal feeling may unduly influence their medical judgment; they may fail to probe sensitive areas when taking a medical history; or they may be inclined to treat problems beyond their expertise or training. It is also felt that it is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members (AMA 1993). Although the guidelines were developed in June 1993, professionals have often continued to prescribe controlled prescription drugs to family, friends, and themselves.

UNDERSTANDING SUBSTANCE ABUSE

Since prescription drug abuse is this nation's fastest growing drug problem (ONDCP 2011), it is important to understand the larger picture of substance abuse. The Drug Abuse Warning Network stated that in 2005 there were 816,696 emergency department visits involving an illicit drug (Manchikanti, Whitfield & Pallone 2005). This represents 2,200 opportunities every day in emergency departments alone for physicians and other healthcare workers to screen and refer patients to appropriate substance abuse treatment (Manchikanti, Whitfield & Pallone 2005). Whether it involves legal substances such as tobacco, alcohol and prescription drugs or illicit drugs, substance abuse is a major patient safety issue. As noted above, a CASA (2005) study reported that only 40% of physicians surveyed received training on identifying prescription drug abuse and addiction. Additionally, physicians often fail to offer treatment to addicted patients and only 55% routinely recommended addiction treatment (Friedman, McCullough & Saitz 2001).

One of the ways a professional can avoid inappropriately prescribing for a patient is to understand the risk factors for substance abuse or dependency. Substance abuse is defined by the American Psychiatric Association (2000) in the DSM-IV-TR as "a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances." Problems may manifest themselves as failure to fulfill major role obligations in their lives, recurrent use of substances in physically hazardous situations, recurrent legal problems related to their substance use, or recurrent problems in social or interpersonal settings secondary to substance use. If a patient is substance dependent their disease may be manifested by tolerance, withdrawal, taking larger amounts of the substance, unsuccessful efforts to cut back on their use, a large amount of time spent trying to get the substance, important personal activities given up because of substance use, or continued use despite recurrent problems related to or caused by the substance (APA 2000).

Professionals should screen for risk factors, as well as warning signs of drug addiction in their patients. There are a number of screening questionnaires for alcohol and/or drug use that can be used in the medical setting, many of which the patient can fill out themselves before seeing the medical professional. Screening and brief interventions can make a difference in identifying more patients with substance abuse problems, as well as decreasing risky behaviors (Anderson et al. 2008).

Professionals should be aware that many risk factors exist for developing a substance abuse problem, including a positive family history of addiction, a past history of sexual or other type of abuse, history of risk-taking behaviors, chronic pain syndromes, etc. Additionally, professionals should suspect drug-seeking behavior in their patients who demonstrate any of the behaviors listed in Table 1 (DEA 1999).

EDUCATING HEALTHCARE PROFESSIONALS

Vanderbilt University's Center for Professional Health (CPH) has been training and educating physicians about proper prescribing practices for over a decade (Spickard 1999, 1998). In collaboration with CPH, Martha E. Brown, M.D. at the University of Florida and her colleagues have offered a misprescribing course for almost seven years. Based on experiences in both courses, it appears most course participants were never trained in substance abuse identificaiton or proper prescribing practices around substance abuse (Swiggart, Ghulyan & Dewey In press). These experiences verify what has been reported in the literature, that routine screening for substance use or abuse (particularly in primary care and emergency department settings) is not commonplace (Hettema et al. 2009). Barriers to screening and brief interventions include physicians' doubts regarding treatment efficacy, lack of self efficacy, lack of knowledge (Holland, Pringle & Barbetti 2009), as well as, low confidence and lack of training in medical school and residency (McEwen 2009). Screening, brief intervention, and referral to treatment (SBIRT) is a well-studied screening and intervention procedure that has been shown to improve patient's short-term health outcomes and reduce healthcare costs (Babor et al. 2007). Over the past 20 years, many research studies have focused on the value of SBIRT as a harm reduction model for at-risk alcohol use with significant impacts on patient safety and health care costs (InSight Project Research Group 2009; Madras et al. 2009; Saitz 2008; Babor et al. 2007; Bien, Miller & Tonigan 1993). SBIRT has been clearly described and is teachable; however, it is not widely implemented (Estee et al. 2009; Bernstein et al. 2007).

Continuing medical education (CME) can be an effective tool to remedy this lack of training and education. Educational strategies involving training and practice have a much better chance of changing practitioner behavior when focusing on the process of learning (Davis et al. 2011). The three-day CME course currently offered by the Center for Professional Health at Vanderbilt (http://www.mc.vanderbilt.edu/cph) and at the University of Florida Addiction Medicine Division (www.drmarthabrown.com) titled "Prescribing Controlled Drugs: Critical Issues and Common Pitfalls" was developed to teach new skills and substance abuse identification, teach appropriate prescribing practices, and facilitate the physician's and other professional's understanding of his/her personal motivations in the patient encounter (Swiggart, Spickard & Dodd 2002; Spickard et al. 1999, 1998). The majority of the physician participants are mandated or sanctioned to attend by their individual state medical board or physician's health program. A major reason for such sanctions is inadequate records around pain management or other scheduled drug use. The following is a checklist of chart entries that should be noted. While states may vary in their approach to an investigation, an adequate chart is the physician's most valuable defense. The chart should minimally contain the following:

1. Diagnosis/problem list

2. Number of office visits

3. Controlled prescriptions

4. Contracts/agreements

5. Medical monitoring history/PMP

6. Urine drug screens

7. Step prescriptions (try non-narcotics first)

8. Adjuncts

9. Referrals

10. Comprehensive medical therapy

11. Diagnosis evidence

Dewey (2011) suggests a four-step approach for every patient. Step one is history taking and screening for substance abuse using SBIRT, including individual and family substance abuse history, and asking "have you ever used or do you currently use" tobacco, alcohol, marijuana, street drugs, prescription drugs, or other recreational drugs. Substance use should be identified and quantified with the rest of the patient's presenting and past history. If the screen is negative no further substance use intervention is needed. If that screen is positive, then the physician would proceed to step two and provide the remaining components of SBIRT: the brief intervention using motivational interviewing techniques and the referral to treatment if warranted based on the patient's issues. Step three is to determine an appropriate plan of care by developing a treatment plan that includes nonaddictive pharmaceutical and other treatment modalities and referrals, determining criteria for success and failure of treatment, providing informed consent relative to risk/benefits of any scheduled drug prescribed and scheduling regular monitoring of patient condition, laboratory results, side effects, etc. Step four involves documenting the patient's history, physical and supporting evidence (labs, radiographs, etc.), informed consent given, any plans developed, medications prescribed, compliance, and follow up (Dewey et al. Under review). Practice procedures that the medical professional can use to avoid being cited for misprescribing are delineated in Table 2.

Educational programs for physicians should include teaching about the biological underpinnings of substance abuse including the interaction of reward pathways in the brain, the efficacy of treatment, and the necessary competency to treat or make informed referrals. Barriers and risk factors are important to address. Data from the Vanderbilt CME course demographics and assessments inform us that physicians referred to the CME courses usually have one or more of the following five risk factors: (1) family of origin patterns that interfere with the physician's ability to ask appropriate questions or deal with certain behaviors because of familial taboos of discomfort; (2) core personality issues such as conflict avoidance or passivity and acquiescing to patient demands; (3) patient type problems such as having a large numbers of drug seeking patients or other challenging patient types in their practice; (4) pharmacological knowledge issues where the physician is out of date regarding newer drugs or particular interactions; and (5) professional practice system problems such as poor charting, as well as, sloppy administrative practices allowing drug diversion within the office system. (Spickard et al. 1998).

Physicians most at risk for complaints appear to be family practice and general internist physicians practicing in solo practices in small communities (Spickard et al. 1998). Often access to pain clinics and substance abuse referral resources are limited in these circumstances, placing extreme pressure on the individual physician to solve a multitude of patient problems. Preventative education needs to occur at all levels of training and be reinforced for the practicing physician.

CONCLUSION

Controlling prescription drug abuse has rapidly become one of the nation's most pressing problems in healthcare. The lack of substance abuse education and training of healthcare professionals has added to the problem. The proper prescribing of prescription drugs needs to be emphasized not only in medical training, but by the licensing boards, requiring continuing medical education on the issues prior to being licensed or renewing one's license.

Healthcare providers need to recognize that even brief interventions by providers have proven effective in reducing substance abuse in patients. Medical professionals need to understand and incorporate appropriate prescribing guidelines into their practices in order to: (1) not be afraid to treat pain and other conditions with controlled prescription drugs when necessary and (2) screen, identify, and intervene with patients who have or are at risk of developing substance abuse or dependency problems.

Additionally, they need to talk with their patients about the benefits versus risks of using the medications, helping them to make informed decisions about their medical care, while minimizing the risk of abuse and addiction. Prescription monitoring programs need to be fully functional in every state so they can help healthcare professionals begin to recognize those patients who may already have addiction problems. It would be wise to take a lesson from Franz Kafka who wrote in A Country Doctor, "To write a prescription is easy but to come to an understanding with people is hard" (Manson 2005). By educating themselves and their patients, physicians can help them make informed decisions about prescription drugs, while curbing their own desire to try and relieve all of their pain and suffering with a prescription.

DOI: 10.1080/02791072.2012.662081

REFERENCES

Alliance of States with Prescription Monitoring Programs. 2012. PMP Status Map. Available at www.pmpalliance.org.

American Medical Association (AMA). 1993. Principles of Medical Ethics (Policy E.-8.19). Available at http://www.ama-assn.org/adcom/ polfind/Hlth-Ethics.pdf

American Psychiatric Association (APA). 2000. Diagnostic and Statistical Manual of Mental Disorders. Fourth Ed., Text Rev. Washington, DC: APA.

Anderson, P.; Aromaa, S., Rosenbloom, D. & Enos, G. 2008. Screening & Brief Intervention: Making A Public Health Difference. Boston, MA: Join Together, with support from the Robert Wood Johnson Foundation.

Babor, T.F.; McRee, B.G.; Kassebaum, P.A.; Grimaldi, P.L.; Ahmed, K. & Bray, J. 2007. Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse 28 (3): 7-30.

Bien, T.H.; Miller, W.R. & Tonigan, J.S. 1993. Brief interventions for alcohol problems: A review. Addiction 88 (3): 315-35.

Bernstein, E.; Bernstein, J.; Feldman, J. et al. 2007. An evidence based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Substance Abuse 28 (4): 79-92.

Center on Addiction and Substance Abuse (CASA). 2005. Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the US. New York: The National Center on Addiction and Substance Abuse (CASA).

Centers for Disease Control and Prevention (CDC). 2011. Drug overdose deaths--Florida, 2003-2009. Morbidity and Mortality Weekly Report 60 (26): 869-72.

Davis, D.A.; Prescott, J.; Fordis, C.M.; Greenberg, S.B.; Dewey, C.M.; Brigham, T.; Lieberman, S.A.; Rockhold, R.W.; Lieff, S.J. & Tenner, T.E. 2011. Rethinking CME: An imperative for academic medicine and faculty development. Academic Medicine 86 (4): 468-73.

Dewey, C. 2011. Protecting You, Protecting Patients: Clinical Vignettes. Program: Prescribing Controlled Drugs: Critical Issues and Common Pitfalls. Session 7. Nashville, TN: The Center for Professional Health.

Dewey, C.M.; Swiggart, W.H.; Brown, M.E. & Ghulyan, MV. Under review. The proper prescribing of controlled prescription drugs: What every doctor needs to know about the rules governing prescribing practices.

Drug Enforcement Administration (DEA). 2011. Fact Sheet: Prescription Drug Abuse--A DEA Focus. Availalble at http://www.justice.gov/ dea/concern/prescription_drug_fact_sheet.html

Drug Enforcement Administration (DEA). 1999. Don't be Scammed by a Drug Abuser. Availalble at www.deadiversion.usdoj.gov/pubs/ brochures/drugabuser.htm

Estee, S.; Wickizer, T.; He, L.; Shah, M.F. & Mancuso, D. 2009. Evaluation of the Washington state screening, brief intervention, and referral to treatment project: Cost outcomes for Medicaid patients screened in hospital emergency departments. Medical Care 48 (1):18-24.

Friedmann, P.D.; McCullough, D. & Saitz R. 2001. Screening and intervention for illicit drug abuse: A national survey of primary care physicians and psychiatrists. Archives of Internal Medicine 161 (2):248-51.

Gold, M. & Teitelbaum, S. 2010. Personal Communication with Martha E. Brown, MD.

Hettema, J.E.; Sorensen, J.L.; Uly, M. & Jain, S. 2009. Motivational enhancement therapy to increase resident physician engagement in substance abuse education. Substance Abuse 30 (3) 244-47.

Holland, C.L.; Pringle, J.L. & Barbetti, V. 2009. Identification of physician barriers to the application of screening and brief intervention for problem alcohol and drug use. Alcohol Treatment Quarterly 27: 174-83.

InSight Project Research Group. 2009. SBIRT outcomes in Houston: Final report on InSight, a hospital district-based program for patients at risk for alcohol or drug use problems. Alcoholism: Clinical and Experimental Research 33 (8): 1374-81.

Madras, B.K.; Compton, W.M.; Avula, D.; Stegbauer, T.; Stein, J.B. & Clark, H.W. 2009. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence 99 (1-3): 280-95.

Manchikanti, L. 2007. National drug control policy and prescription drug abuse: Facts and fallacies. Pain Physician 10: 399-424.

Manchikanti, L.; Whitfield, E. & Pallone, F. 2005. Evolution of the National All Schedules Prescription Electronic Reporting Act (NASPER): A public law for balancing treatment of pain and drug abuse and diversion. Pain Physician 8: 335-47.

Manson, A. 2005. A theology of illness: Franz Kafka's "A Country Doctor." Literature and Medicine 24 (2): 297-314.

McEwen, S. 2009. Substance abuse screening and brief intervention in primary care. North Carolina Medical Journal 70 (1): 38-42.

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Office of National Drug Control Policy (ONDCP). 2011. Epidemic: Responding To America's Prescription Abuse Crisis. Available at http://www.whitehouse.gov/sites/default/files/ondcp/issues-content/ prescription-drugs/rx_abuse_plan_0.pdf

Saitz, R. 2008. Poor care, not poor protocols, for alcohol withdrawal. Mayo Clinic Proceedings 83 (6): 725-26; author reply 728-730.

Spickard, W.A.; Dodd, D.; Dixon, G.L.; Pichert, J.W. & Swiggart, W. 1999. Prescribing controlled substances in TN: Progress, not perfection. Southern Medical Journal 92 (1): 51-54.

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Swiggart, W.; Spickard, A. & Dodd, D. 2002. Lessons learned from a CME course in the proper prescribing of controlled drugs. Tennessee Medicine 95 (5): 192-93.

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Martha E. Brown, M.D. (a); William H. Swiggart, M.S., LPC/MHSP (b); Charlene M. Dewey, M.D., M.Ed., FACP (c) & Marine V. Ghulyan, M.A. (d)

(a) Associate Professor of Psychiatry, UF College of Medicine, Department of Psychiatry, Addiction Medicine Division, Gainesville, FL.

(b) Assistant in Medicine, Co-director, Center for Professional Health, Vanderbilt University Medical Center, Nashville, TN.

(c) Associate Professor of Medicine, Co-director, Center for Professional Health, Associate Professor of Medical Education and Administration, Vanderbilt University Medical Center, Nashville, TN.

(d) Research Analyst II, Center for Professional Health, Vanderbilt University Medical Center, Nashville, TN.

Please address correspondence to Martha E. Brown, M.D., Associate Professor of Psychiatry, University of Florida College of Medicine, Department of Psychiatry, Addiction Medicine Division, 8491 NW 39th Avenue, Gainesville, FL 32606; phone: (352) 265-5300; email: marthabrown@ufl.edu or www.drmarthabrown.com
TABLE 1

Suspected Drug Seeking Behaviors in Patients

Possible drug seeking behavior in a patient may include:

* Manipulative behavior

* Assertive personality, often demanding immediate
 action

* Pressures the professional for a particular
 medication

* Has no interest in diagnostic tests

* Refuses to see a consultant for a second opinion

* Resists attempts to verify history or get old
 records

* Fails to keep their appointments

* Feigns physical or psychological problems

* Self diagnoses

* Will not accept alternative medications

* Rapid increases in amount of medication used

* Frequent, early refill requests

* Utilizes a child or an elderly person when seeking
 controlled substances, particularly stimulants

TABLE 2

Practice Procedures For Prescribing Professionals

Helpful strategies for the treating professional include:

* Require all patients to sign a patient informed consent agreement

* Require all pain patients to sign a pain contract

* Do frequent urine drug screens on all patients receiving controlled
 substances on an ongoing basis (no patient should be excluded
 including the 80-year-old grandmother)

* Require the patient to use only one pharmacy

* Keep meticulous records, documenting reason for prescribing,
 presenting complaint, impression, and treatment plan

* Make sure your workup is sufficient to support your diagnosis

* Strongly consider noncontrolled medication options or alternative
 procedures

* Protect prescription pads

* Explain the risk versus benefit with the patient and document this

* Do not prescribe controlled substances to your family, friends, or
 yourself

* Have clear office procedures on drug refills, pain contracts, lost
 medication, and phone prescriptions

* Listen to your pharmacist

* Learn to say no

* Review the ongoing need of the patient for controlled substances at
 each visit
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Author:Brown, Martha E.; Swiggart, William H.; Dewey, Charlene M.; Ghulyan, Marine V.
Publication:Journal of Psychoactive Drugs
Geographic Code:1USA
Date:Mar 1, 2012
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