Medical Mutual Insurance Company of Maine

Physician » Risk Management » Practice Tips

Drug Diversion and the Drug-Seeking Patient

In the U.S., prescription drug abuse has become an epidemic. According to a report by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, 15.1 million Americans, or 6 percent, admit to abusing prescription drugs – more than all other forms of drug abuse combined. The most frequently abused drugs include pain relievers such as OxyContin and Vicodin; depressants such as Valium and Xanax; and stimulants such as Ritalin and Adderall.

Among the report's findings:

• Between 1992 and 2003, when the US population increased 14 percent, the number of people abusing controlled prescription drugs jumped 94 percent.
• Between 1992 and 2003, the report found a 212 percent increase in the number of adolescents ranging from 12 to 17 years old who abused prescription drugs. In 2003, the report found that 2.3 million in this group – 9.3 percent – reported abusing a controlled prescription drug in the year before.
• About 43 percent of physicians – who often have little time to spend with patients – do not ask about prescription drug abuse when learning about patients' health history.
• From 1992 to 2002, prescriptions for controlled drugs increased more than 150 percent.

1. In the Physician Office Practice:
   Distinguishing a legitimate patient from a drug abuser is not easy. If there is any concern that a patient may be inappropriately asking for drugs, consider the following questions:
   
   • Does the patient present to the office frequently?
   • Has the patient recently moved, but refuses to give you the name of his previous physician?
   • Is the patient paying with cash?
   • Have you experienced difficulty contacting the patient between office visits?
   • Are prescription pads absent and unaccounted for after certain patients visit the office?
   • Does the patient state that only a particular drug is effective?
   • Does the patient refuse to see one physician?
   • Does the patient frequently report losing medications?
   • Is the patient demanding, especially of drugs that hold a high street value?
   • Does the patient regularly visit multiple physicians or have prescriptions filled at multiple pharmacies?
   
   If many of the answers to these questions are yes, the provider should be aware that drug-seeking patients often exhibit these types of behaviors.
   
   Most patients who take prescribed narcotic analgesics, sedative-hypnotics, or stimulants use them responsibly. However, in addition to the medical standards and treatment issues involved, physicians should be cognizant of the fact that these classes of drugs generate scrutiny from the Drug Enforcement Agency (DEA) and other authorities because of their potential abuse. Therefore, physicians treating patients with chronic pain should closely adhere to pain management guidelines and take special care with documentation. Each of the following principles is an essential element in the treatment of patients with chronic pain:
   • Perform a comprehensive evaluation and document a clear treatment plan.
   • Document informed consent and agreement for treatment. If a trial of controlled substances is selected, consider having the patient sign a pain management agreement.
   • Refer the patient for consultation or to a pain clinic if needed.
   • Perform and document a periodic review of the treatment efficacy.
   • Specifically document drug treatment outcomes and the rationale for medication changes.
   If a patient appears to exhibit drug seeking behaviors, do not be confrontational. Treat the patient with respect when indicating that you intend to prescribe only non-narcotics or minimum quantities, if appropriate for the patient’s treatment. Resist the temptation to prescribe a small quantity of narcotics in hopes of avoiding a confrontation with the patient. This strategy usually backfires, because the patient may now believe that you can be pressured into prescribing narcotics. If the patient protests and you are not the primary care provider, offer to contact their treating physician or to confer with a pain specialist.
   
   As a healthcare professional, you share responsibility for minimizing prescription drug abuse and drug diversion. You can also protect yourself and your practice by adopting the following procedures:
   
   
   • Never sign an incomplete prescription.
   • Use tamper-resistant prescription pads that cannot be photocopied.
   • Write the quantity and the strength of drugs in both letters and numbers. If only a number is on the prescription, it is easy to alter.
   • Be wary of patients who are not interested in having a physical examination, are unwilling to authorize release of prior medical records or have no interest in a diagnosis or a referral, saying they want the prescription immediately.
   • Be cautious if a new patient has an unusual knowledge of controlled substances or when a new patient requests a specific controlled drug and is unwilling to try another medication.
   • Don’t take short-cuts, particularly when drug abuse is suspected; take a complete history and perform a thorough physical examination.
   • Look for signs of drug abuse, such as inflamed nares, skin tracks, and perforated nasal septum.
   • Refer to Practitioner’s Manual: An Informational Outline of the Controlled Substance Act prepared by the United States Department of Justice.
     
     
2. In the Hospital Emergency Department:
   In the Emergency Department, the following is suggested when addressing a person who is exhibiting drug seeking behavior:
   • Be assured that this is a drug seeking patient, i.e., a patient who requests a prescription for a legal drug for resale or non-medical use, often manifested as a fraudulent presentation of disease to multiple physicians in an attempt to obtain prescription drugs. In Maine, use of the Prescription Drug Monitoring Program is helpful in identifying this type of patient. In Vermont, the Prescription Monitoring Program can be used to identify these patients.
   • It is important to differentiate the true “drug-seeker” from the patient with chronic or reoccurring pain who has unmet healthcare needs and poorly controlled pain management. This patient may need a pain management plan developed by the primary care physician, ED provider and the patient. In addition, education about pain management and adjunct therapy should be a part of the treatment plan. For this patient, the prescribing of narcotics may be appropriate.
   • If a patient presents to the ED with a complaint of pain, an assessment of the patient needs to occur. It is important that all patients presenting to the ED receive an Emergency Medical Screening (EMS). Not offering an EMS is a violation of EMTALA regulations. If this assessment does not correlate with the complaint, the physician needs to offer a treatment plan commensurate with his assessment which may be a non-narcotic prescription. It is important to document the thorough exam and the physician’s conclusion.
   • When a patient requests narcotics and the ED physician does not feel it is appropriate based on the assessment, then the physician needs to explain to the patient that narcotics will not be prescribed. In addition, if the physician has information regarding the multiple prescriptions obtained (in Maine, the Prescription Drug Monitoring Program, in Vermont, the Prescription Monitoring Program), the physician may confront the patient with this.
   • It is important that the physician be firm with his/her decision. Consistency in not prescribing the narcotics is the key to discouraging the patient from using the ED as a way to obtain drugs for non-medical or illegal use. However, the ED physician is obligated to assess the patient each time he presents in order to determine if the pain is legitimate.
   • There are several potential ramifications associated with noting “drug seeking behavior” in the medical record. These are a defamation claim, a patient claim of interference with insurance coverage, the possibility of a misdiagnosis and the accusation of “labeling” the patient.  Medical Mutual generally discourages documenting “drug seeking behavior” unless the provider’s rationale is clearly reflected. For example, the provider should document the patient’s presenting complaint of pain; the request for a specific narcotic; statements that the patient has presented to other hospitals with the same complaint; refusal by the primary care physician to refill narcotic prescription for these pain complaints, etc.
     
     
3. Reportable Acts:
   Questions frequently arise regarding what constitutes a reportable act and when law enforcement should be notified about a patient’s possible illegal activity. Information gained as part of the physician/patient relationship, including disclosure of possible criminal acts, remains confidential. However, a patient who attempts to use a physician or healthcare provider to perpetrate illegal acts, such as illegal acquisition of drugs or the selling of those drugs, should be reported to the Drug Enforcement Agency (DEA) or local law enforcement agency.
   
   If the Medicaid program insures a patient engaging in questionable conduct, a report on the matter should be provided to Medicaid Surveillance.
   Be aware that Health Information obtained through a Substance Abuse Treatment Program falls under Federal Law, CFR 42 Part 2. Under this law it is a crime to disclose health information obtained from a Substance Abuse Treatment Program. Prior to disclosing this information to authorities, take steps to assure that your program or practice does not meet the Federal definition of a Substance Abuse Treatment Program.  
   
   Consult with an attorney or state medical association for further recommendations on reporting of illegal behavior.

Medical Mutual Insurance Company of Maine's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.