Marcelina Behnam, MD and Mark Rogers, MD
Introduction
Over the past several years,
prescription drug abuse has
become a problem of epidemic
proportions for urgent
care centers and emergency
departments around the
country. There has been an increase
both in visits related to
the acquisition of these medications,
and in emergency department
visits related to the misuse
of prescription drugs.1,2
In response to this epidemic,
new government legislation
has been enacted and
intervention and treatment
centers developed.
This review article discusses
the current problems of prescription
drug abuse and substance use disorders (SUDs),
as well as measures being implemented to address them.
Rise of Prescription Drug Abuse
Within the past decade, there has been a substantial rise
in prescription drug use and abuse.
Drugs of abuse are classified both by abuse potential
and pharmacologic action, the latter of which is broken
down into three main categories: stimulants, opioids,
and CNS depressants. Each of these categories has seen
a rise in use and abuse in the past several years, with opiates
being the most commonly
abused.1
According to a 2004 national
survey on drug use and
health published by the Substance
Abuse and Mental
Health Services Administration
(SAMHSA), 19.1 million
Americans were current illicit
drug users. Among those 19.1
million, the largest segment
(2.4 million) was populated
with those engaging in nonmedical
(i.e., recreational) use
of prescription pain relievers.
In 2005, according to the
National Survey on Drug Use
and Health (NSDUH), 6.4 million
Americans over the age
of 12 reported using a prescription
drug for a non-medical purpose within the past
month. Of those:
4.7 million used narcotic pain relievers
1.8 million used tranquilizers
1.1 million used stimulants (including methamphetamine)
272,000 used sedatives.2
Opiate abuse accounts for more than 50% of prescription
drug abuse. Between 2004 and 2005, the Drug
Abuse Warning Network (DAWN) reported that emergency
department visits involving non-medical use for
opiate pain meds increased 24% overall.2
The Drug Enforcement Agency (DEA) diversion drug
trend report identified hydrocodone as the most commonly
diverted and abused controlled substance in the
United States.
Hydrocodone is also one of the most commonly used
drugs in the U.S., period. In 2004, this country used 99%
of the global hydrocodone supply.1 In 2005, hydrocodone
outpaced Lipitor to be the most-prescribed
drug here.1,2
Compounding the situation, there has been an increase
in deaths and ED visits related to misuse and
abuse of opiates. Opioid-related deaths increased 91%
between 1999 and 2002, and by the end of 2002 opioidrelated
deaths outnumbered deaths related to heroin or
cocaine.3 In 2004, according to DAWN, there were 1.3
million ED visits related to opioid misuse and abuse. It
all added up an estimated $181 billion in healthcare and
social costs.1
Why EDs and Urgent Care?
Lack of patient-provider continuity makes it relatively
easy for drug seekers to obtain prescriptions; hence,
abuse of prescription drugs tends to be more prevalent
in the emergency and urgent care settings.
In fact, prescription drugs are relatively easy to abuse
in most practice settings for a variety of fairly logical reasons.
Among them:
Prescription drugs are perceived to
be more socially acceptable and
easy to obtain than other illicit
drugs like heroin or cocaine.
There is good quality control in
their production.
They are often paid for by insurance
companies and are sold on the
Internet.
There may also be a mistaken impression
among the general public
that prescription drugs are less dangerous
than other drugs of abuse; in
2005, the NSDUH showed that 60% of
prescription drugs were given to the
user by a friend or relative for free.2
And in June 2006 the national Center
on Addiction and Substance Abuse
(CASA) report found 185 Internet sites
selling prescription drugs, 89% of
which did not require a prescription.2
Other factors that may contribute to
the rise of prescription drug abuse include the perception
by both physicians and patients that pain is undertreated.
Patient advocates have voiced concerns that the
war on drugs has made physicians afraid to treat pain.4
Paradoxically, this may facilitate drug seekers playing on
a physician’s sympathies to get prescriptions for pain
medications.
Striking a balance between good pain treatment and
facilitating SUDs is difficult. The Joint Commission’s regulations
mandate the monitoring and relief of pain.
Physicians are challenged with demands for pain control
and the feasibility of chronic pain management.3
Overall, the ready availability of prescription drugs in
the U.S. has led to increased popularity compared with
their illegal counterparts. Abusers of prescription drugs
have developed various modes of diversion through
which to obtain medications. Doctor shopping, Internet
sales, theft, improper prescribing on the part of the
physician, and sharing among family and friends are
some of the most-often cited.3
Characteristics of a Drug-seeking Patient
Familiarity with some of the characteristics common
among drug-seeking patients is particularly important
in urgent care and other acute-care settings, where clinicians
often encounter patients with whom they have
no previous experience.
For example, drug-seeking patients:
are often described as exhibiting
“coercive behavior” and may request
a specific drug for their
pain, with some experts believing
that coercive behavior may be
pathognomonic of drug-seeking
patients
are often noted to have escalating
use of the drug
often report that they “lost” their
prescriptions
may partake in “doctor shopping”
may report multiple drug allergies,
especially to analgesics with
low abuse potential.
A call to the patient’s primary care
physician’s office may reveal multiple missed appointments,
more reports of lost prescriptions, and deceptive
behavior. However, drug-seeking patients are often reluctant
to identify a primary care physician or may
claim that their physician is out of town.
Such patients may also falsify symptoms, as well as
medical examination tests, in order to deceive
providers.5
One example is a patient who was known to repeatedly
visit the emergency department with complaints of
kidney stones, and who had a history of particularly manipulative
behavior. Despite multiple negative CT scans,
this patient often received narcotics based on complaints
of flank pain and hematuria—that latter of
which, as eventually witnessed by a nurse, was manufactured
by the patient pricking his finger in order to
contaminate the urine sample.
Drug-seeking patients are likely to have a history of
substance or alcohol abuse. Look for cutaneous signs of
drug abuse, such as needle tracks. They are also more
likely to suffer from mood disorders.
A 2005 study looked at characteristics of drug-seeking
patients and found that opioid abusers were characteristically
more likely to be young men who have a past
history of alcohol abuse, cocaine abuse, or have a previous
drug or DUI conviction.6
Approach to the Drug-seeking Patient
Assessment of drug addiction/abuse
It is important to evaluate the patient on a clinical basis
and not to dismiss complaints of pain out of hand.
Key steps in this evaluation include establishing the initial
diagnosis, the medical necessity for pain medication,
and weighing the risk-benefit ratio of prescribing pain
medications in the evaluation of a suspected drug
abuser.3
Patients should be evaluated for signs and symptoms
of drug abuse and withdrawal. A discussion with patients
regarding past or present alcohol and recreational
drug use should always take place whenever one considers
prescribing a potentially addictive medication.
The CAGE questionnaire (Table 1) is useful for determining
alcohol abuse and SUDs, which is a useful predictor
for prescription drug abuse. It can also be modified
to query patients about prescription drug addiction
and abuse.
Other surveys have been devised, such as the prescription
drug use questionnaire, which consists of 39 items
evaluating five different domains. This tool is helpful in
identifying addiction risk.5,7
One major limitation to extensive questionnaire use
is the feasibility in an urgent care setting. Other modes
of evaluating for SUDs and abuse of prescription drugs
include a review of the patient’s chart and, in certain
states, a prescription monitoring program.
Alternatives to drugs of abuse
If SUDs or recreational use of prescription drugs is suspected
with a particular patient but you still feel that patient
has a legitimate need, consider prescribing something
other than a medication that could be abused by
the patient (Table 2).
Drugs with partial opiate receptor activity such as tramadol,
for example, have become a popular alternative
to opiate analgesics. These agents are commonly believed
to be non-addictive and are often prescribed to addiction-
prone patients, though there have been multiple
reports of addiction to these substances, as well, with an
increased prevalence in their abuse. A 2004 survey by the
NSDUH found that 1.3 million Americans used tramadol
for non-medical purposes. The DAWN 2004 study
cited 2,984 ED visits related to tramadol overdose.1
When prescribing these medications, consider the
possibility for abuse in those patients with a history of
SUDs or drug abuse.
Strategies for dealing with difficult patients
Practice caution when dealing with coercive patients.
Avoid feeling compelled to oblige the patient’s requests.
If discussion of treatment options escalates to a confrontation
with a patient who is requesting
a controlled substance, try
to do the following:
Remain calm.
Explain to the patient that what he
or she requested is not an option.
Say no.
Offer the patient an alternative.
Demonstrate genuine concern for
the patient’s distress, and avoid raising
your voice. Also, try to avoid using
judgmental phrases or tones.
Create room for discussion by
showing concern and interest for
the patient’s wellbeing.
Documentation
From a medical/legal standpoint, it is
important to document these discussions
with the patient in the patient
chart.5 In addition, if you suspect that
the patient has exhibited repetitive
drug-seeking behavior, doctor shopping,
or other modes of diversion, make
notes of this in the patient’s chart.
This should be done with caution,
however, to avoid “labeling” the patient
and causing undue harm and
bias between the patient and future
providers. For this reason, objective
language should be used with specific
situational references.
Cite in a patient note the nature of
the visit, the past prescriptions obtained,
what the interaction with the patient was, and
an objective description of the patient’s behaviors. It is
also important to cite what alternative treatments have
been offered to the patient.
Treatment
Finally, if feasible and deemed appropriate in your opinion,
direct the patient toward resources to aid in treatment.
Current treatment for SUDs is multifaceted. Medical
therapy usually involves a combination of pharmaceuticals
aimed at reducing the side effects of opiate withdrawal
(e.g., clonidine [Catapres], loperamide [Imodium])
and others reducing the craving for the drug itself (e.g.,
methadone, buprenorphine hydrochloride/naloxone
hydro chloride [Suboxone].
There are a variety of resources available for treatment
(Table 3). For example, SAMHSA offers
an online Substance Abuse Treatment
Facility Locator covering more
than 12,000 treatment centers.9 Other
resources include the National Institute
on Drug Abuse (NIDA) and the
Office of National Drug Control Policy
(ONDCP).
Preventive Strategies
Prevention of prescription drug abuse
is a multidisciplinary task which involves
both public and physician
awareness. Education through the media,
government agencies, and local
campaigns combine to raise public
awareness of prescription drug abuse.
As clinicians who are likely to see
our fair share of drug-seeking patients,
urgent care practitioners are in a good
position to contribute to public awareness
by educating patients and patients’
families on the dangers of addiction
and the potential for overdose
of controlled substances.
Awareness of which drugs are most
likely to be abused helps to facilitate
education.
Medications with high potential for
abuse tend to have several properties
in common, notably:
rapid onset
high potency
brief duration
The formulation of the substance also affects its abuse
potential. Water-soluble medications are prone to intravenous
use; volatile substances may be smoked.
Also, some controlled substances that are manufactured
for a slow, time-release delivery may be tampered
with (e.g., crushed) so that the entire amount of
the active ingredient is absorbed immediately upon ingestion.
Prescriber responsibility and training
There is also concern that the abuse of prescription
drugs is due to overprescribing on the part of the prescriber.
This may be due, in part, to the fact that many
clinicians lack education and training on drug-seeking
patients. They may not know how to identify drug-seeking
behaviors, or they may be unaware of the signs and
symptoms of SUDs. They also may not have strategies
to deal with coercive patients, which may lead to trouble
saying “no” to patients.3
Research indicates that, as a whole, physicians lack education
on prescription drug abuse. For example:2
Only 19% of physicians report receiving training in
prescription drug diversion.
An underwhelming 40% had any previous medical
school training in identifying prescription drug
abuse and SUDs.
As many as one third do not regularly call or obtain
records from the patient’s previous physician before
prescribing controlled drugs on a long-term basis.
Educational seminars and training designed to increase
awareness among physicians and patients is
needed. ONDCP, NIDA, DEA, SAMHSA, and the Department
of Health and Human Services (DHHS) all offer education
on prescription drug abuse.
Institutional Policies
In many instances, institutional policies are overshadowed
by state and national regulations. In some
institutions, hospital committees can help to identify
drug-seeking patients and assign these patients to a
primary provider.
Other institutions have developed “patient alert
lists.” A community-wide system in Calgary, Canada
encompasses a group of local hospitals toward this
end. Such institutional surveillance may not be feasible
in the U.S. due to HIPAA and other federal regulations,
however.
Private insurers and Medicaid have adopted policies
to combat prescription drug diversion, as well.
Private insurance companies use drug utilization reviews
to address whether drugs are being prescribed
appropriately.
Medicaid has an abuse drug audit system that identifies
doctor shoppers and assigns a single primary care
physician and pharmacy to these patients.
Prescription monitoring programs
On both state and federal levels, there are programs
which monitor the distribution of prescription
drugs.
The Kentucky All Schedule Prescription
Electronic Reporting (KASPER) system,
developed in 1998, archives relevant
information into a database that
can be accessed in real time by practitioners.
The limitations to this system
are that drug-seeking patients can go to
bordering states that do not use a prescription
monitoring system.
In an attempt to remedy this problem,
in 2003 the Department of Justice
initiated the Harold Rogers Prescription
Drug Monitoring Program, sponsored
by the DEA and Congressman
Harold Rogers (R-KY). This initiative
was aimed at improving prescription
drug monitoring programs among individual
states.
Two years later, the National All
Schedules Prescription Electronic Reporting
Act (NASPER) passed, continuing
the funding of state monitoring
programs and authorizing spending
to improve the communication between
the different state programs.
While funding has been an issue for these projects, as of
2006 there were 27 states with prescription drug monitoring
programs, of which 18 monitored schedule IV
drugs and 20 monitored schedule III drugs.2
Prescription drug monitoring programs are a benefit
in the states that have these programs. However, at this
time there is little communication between neighboring
states, and work still needs to be done to make this
a national system.
Doctor shopping laws
The National Alliance of Model State Drug Laws is a resource
for legislators and other professionals to help develop
laws with the intent to address alcohol and drug
abuse. Specifically, they cite the number of individual
states with doctor shopping laws.
As of 2006, only 10 states had specific laws against
doctor shopping (Table 4).
Treatment legislation
Congress passed the Federal Controlled Substance Act,
the government’s initial response to the abuse of prescription
medications, in 1970. This act classifies drugs
of abuse and provides criminal statutes for inappropriate
use of controlled substances.
Under the Federal Controlled Substance Act, it is illegal
for physicians to prescribe controlled substances to
individuals who are known to have an abuse or addiction
problem - including those for the treatment of
withdrawal symptoms.
The Drug Addiction and Treatment Act of 2000 addressed
the issue of treatment of individuals who are
addicted to controlled substances. Currently,
buprenorphine HCl (Subutex) and buprenorphine
HCl/naloxone HCl (Suboxone) are the only Schedule
III, Schedule IV, or Schedule V drugs with FDA approval
to treat individuals who are addicted to controlled
substances with opiates, or agents with partial
opiate receptor activity. This treatment is facilitated
through specialty clinics.
Summary
With the implementation of strategies aimed at reducing
the diversion of controlled substances, the abuse of prescriptions
drugs can decrease. One study identified frequent
users in an emergency department, denied them
narcotic prescriptions, provided supportive and addiction
counseling, and limited them to one pharmacy. This resulted
in a 72% decrease in the use of the emergency department
by these frequent users without increased use
of other hospitals.4
Prescription drug abuse has grown
to epidemic proportions in the past 10
years. One of the challenges in the
identification and prevention of prescription
drug abuse is the fear of inadequately
treating someone's pain. It is
often difficult to discriminate between
true disease pathology and drug-seeking
behavior.
However, with increased awareness
and experience, urgent care providers
can help to control prescription drug
abuse by identifying drug-seeking patients
through the recognition of their
behaviors and diversion techniques.
This will allow the provider to treat all
patients appropriately and responsibly.
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Drug Abuse Warning Network, 2004: National Estimates of Drug-Related Emergency Department
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