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With the opioid epidemic in America reaching unprecedented levels, people desperate for prescription painkillers have resorted to a number of methods for securing drugs beyond treatment parameters. While all of these methods entail questionable issues of their own, one particular approach has far-reaching implications. The practice of doctor shopping, and its cost to society, is an example of how the opioid crisis and drug overprescription create problems across the entire spectrum of public health.
Innovations in Clinical Neuroscience describes doctor shopping as “a phenomenon of many themes.” In its simplest form, doctor shopping is the process of one person seeing many treatment providers. This is not an illegitimate practice in and of itself (although it may yet be an inadvisable one); where the topic gets contentious is when a patient sees multiple doctors to unlawfully obtain prescription medications, especially when these medications are classified as controlled substances because of their addictive potential.1 Due to the prevalence of this form of doctor shopping, the legal issues surrounding the practice, and the implications on healthcare and public health, this has become the primary definition of doctor shopping.
In an attempt to put a number to the scope of the problem, researchers writing in the JAMA journal concluded that procuring prescription medications from five or more doctors in a single year was the criteria for doctor shopping. The West Virginia Medical Journal clarified that doctor shopping is not only visiting multiple doctors in a significantly short period of time; patients must have “the explicit intent to deceive [doctors] in order to obtain controlled substances.”2, 3
There are a number of reasons why patients could engage in doctor shopping, some related to mental health conditions (such as substance abuse or addiction), while others may be due to the persistence of symptoms or a dissatisfaction with the first doctor (and/or medical opinion).
But there appears to be an increased rate of doctor shopping among clients who have higher rates of mental illness.4 While the nature of these psychological dysfunctions is varied, a majority of the incidents of doctor shopping is related to substance abuse and misuse. Research published in the Mayo Clinic Proceedings journal noted that “doctor shopping is a traditional method of acquiring drugs illicitly.”5 Not only is doctor shopping “traditional,” it is also easy. The Australian Family Physician journal reported that a number of patients who were receiving treatment in a rehabilitation program told scientists that getting benzodiazepines from multiple doctors was “all too easy.”6
More patients engage in doctor shopping for addictive drugs than for nonaddictive drugs.7 Breaking down the types of drugs frequently procured this way, the Drug and Alcohol Dependence journal found that opioids were the most commonly acquired drugs (12.8 percent), with benzodiazepines (4.2 percent), stimulants (1.4 percent) and weight-loss medications (0.9 percent) following.8How common is doctor shopping?
Research conducted and published in PLOS ONE estimated that one in 143 patients who received a prescription for a painkiller in 2008 seemed to be a doctor shopper. Even though this population represented only 0.7 percent of all patients with a painkiller prescription, they bought approximately 4 percent of all opioids. Doctor shoppers are typically between 20 and 40 years old, seeing 10 doctors a year, receiving as many as 32 different prescriptions, and paying in cash whenever possible to avoid a paper trail of their purchases.9
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Covertly securing addictive and controlled drugs from multiple practitioners is an issue that the legal system takes very seriously. A FindLaw blog points out that every state has some form of fraud-based legislation on the topic of prescription drug based on the Uniform State Narcotic Drug Act. Broadly speaking, the act (and the fraud statutes derived from it) prohibit the acquisition, or attempted acquisition, of a narcotic drug (or the administration thereof) “by fraud, deceit, misrepresentation or subterfuge […] or by the concealment of a material fact.”
Therefore, clients who lie to doctors about their conditions, or deliberately hide that another doctor has already prescribed drugs, are breaking both state and federal law.10
To control the problem, 20 states have passed doctor shopping laws that specifically prohibit patients from intentionally keeping critical information from their doctors regarding the prescription of controlled substances that they received from other healthcare providers.11
Those laws stipulate restrictions and punishments on patients, but doctors themselves can get in trouble for being shopped. Healthcare practitioners who knowingly engage in drug diversion (a medical and legal term referring to the practice of “hijacking” legal, but controlled, drugs and using them illegally) can be held criminally liable. In Kentucky, for example, a dentist was arrested on felony drug charges for being part of a doctor shopping scheme, wherein he “conspired to obtain controlled substances by fraud, commonly referred to as doctor shopping.”12
To ensure due diligence and accountability when it comes to the prescription of controlled substances, more than 20 states have created online databases that compile prescription histories for patients, and doctors are required to check the databases to track what drugs their patients have received, as well as whether other physicians have noted signs of abuse among those patients. This also allows doctors to see whether the prescribing history of another physician (or a healthcare practitioner authorized to prescribe controlled substances) suggests complicity in a doctor shopping scheme.
Drugs being tracked include popular and infamous medications like OxyContin, Percocet, and Vicodin. In California, doctors who prescribe such substances (as well as other serious medications) are required to revisit the database every four months to safeguard against being shopped by their patients. In the past, checking the database was optional; now, anyone in a position to write a prescription (dentists and nurse practitioners, for example) has to monitor the database for signs of abuse, one of which can be the practice of doctor shopping.13
FindLaw cautioned that a database to cut down on doctor shopping (as well as laws against the practice) is a small step in the huge fight against the opioid epidemic, but there is reason to be optimistic: Anti-fraud statutes concerning the illegal procurement of prescription medication can make accessing such drugs far more difficult than it used to be.
Kentucky was the first state to push its doctors to comply with keeping an eye on prescription history. What such a program has done for the Bluegrass state in cutting down on doctor shopping, and the inevitable societal cost, is now being held up as a model for the rest of the country. The Pew Charitable Trusts writes that the ground was broken in 2012, with the formation of the first enforceable prescription drug monitoring program, that allowed (and compelled) doctors to look up a patients’ history before writing an order for opioids, sedatives, or any other drug that could reasonably be expected to trigger an addiction.14
However, the problem of doctor shopping is not limited to Kentucky or any other individual state. Pharmacoepidemiology and Drug Safety noted that nearly 33 percent of people who engage in doctor shopping crossed state lines to obtain fraudulent prescriptions. This practice of doctor shopping is concentrated in the northeastern United States, specifically New England. The cluster of small states allows for people to traverse multiple jurisdictions and counties in a single day, racking up potentially hundreds of pills before the sun goes down, and making it harder for doctors and law enforcement to keep up with them. While a number of states have their own prescription drug monitoring program, the technological infrastructure to track prescriptions across states is still in its infancy.15
Speaking to the Washington Post, one of the authors of the Pharmacoepidemiology and Drug Safety study pointed out that another limitation of state-specific monitoring systems is one state might have a very different setup to that of a neighboring state; in effect, “they’re not interoperable.” This restriction raises another question: legal issues about what medical information doctors and states can share about their patients and residents, even if there is a (suspected) case of substance dependence or a potentially illegal activity like doctor shopping.16
Under pressure to do something in the wake of tens of thousands of people overdosing and dying on opioids (many of them prescribed), different states have vowed to communicate on ways to fight back. In 2014, New Jersey, Delaware, and New York agreed to share information on how their doctors prescribed controlled medication. Governors across New England, where the region has seen some of the highest rates of prescription abuse in the country, have agreed to pool their data.
Doctors themselves are lending their voices to the conversation. The American College of Physicians submitted a policy position paper to the Annals of Internal Medicine journal wherein they called for a nationwide monitoring program.17
Similarly, the American Medical Association has also thrown its support behind doctors using databases to spot the signs of potentially addictive behavior among their patients.18 However, not everyone in the medical community is united; there are fears than requiring mandatory checks of the database could interfere with some of the very essentials of the practice of medicine, such as patient privacy (especially if doctors communicate with other medical professionals across state/county lines, and if doctors are required to report instances of suspected doctor shopping to law enforcement). Some advocates note that doctor shopping is not necessarily a sign of addiction but may be an expression of frustration and/or desperation with a primary care provider. A lawyer based in Dallas observed that a patient subject to prescription monitoring could claim a violation of Fourth Amendment rights (as a form of “unreasonable search”). Furthermore, if a report is made to law enforcement, there are concerns about how police or federal authorities will use that information. For example, there are questions over what steps are authorized, such as whether the patient’s home can be legally subjected to a drug raid.19
In fact, in Missouri (the only state to have never implemented any form of system to monitor prescription drugs), a doctor who serves as a state senator led a group of legislators in blocking the creation of such a program in the state, arguing that the government being allowed to keep and access a record of prescriptions would violate the privacy rights of Missouri patients.20 But in St. Louis County, where the undersheriff said the opioid overdose problem had become “a regional public health crisis,” officials are not willing to wait. In January 2017, the two largest counties in Missouri (St. Louis and Jackson, where more than 26,000 people in a population of 647,158 are struggling with opioid addictions) agreed to pool their resources and partner together in the maintenance of a prescription medication monitoring database.21
The cooperation between St. Louis and Jackson Counties, in the face of the overwhelming numbers of opioid-related overdoses and deaths, speaks to how more and more local governments are willing to get behind online drug tracking. Twenty-nine states have prescription drug monitoring programs, reports the National Alliance for Model State Drug Laws, but the conditions for doctors tracking a prescribing history are different from state to state. Without uniformity of criteria, some doctor shoppers can still slip through the gaps if they understand the limitations of the system well enough.22
For many experts, this is the way to go to cut down on doctor shopping and the tolls it takes on society. The initial results have borne out their confidence; in the states that require doctors to check databases for prescription histories and signs of abuse, The Pew Charitable Trusts notes that the overall rate of opioid prescribing has drastically dropped, as have overdose deaths and hospitalizations related to drug abuse. An analysis conducted by the University of Kentucky’s College of Pharmacy discovered in the first year the state mandated use of the prescription monitoring program, Vicodin prescriptions went down by 13 percent, followed by Percocet at 12 percent and Ultram by 12 percent. The biggest effect was seen in the decline in Opana prescriptions, which reduced by 36 percent. Opana is of particular note to the state of Kentucky; Bowling Green’s BG Daily News notes that “several overdose deaths […] throughout the state” have been traced back to the abuse of Opana (or its generic oxymorphone).23, 24
When doctors discover that their patients are shopping, they refer their patients to treatment, and the states in question have thus experienced an increase in the number of people checking into addiction treatment programs as well. In March 2016, a national advocacy organization promoting prevention and treatment of drug addiction reported that states that require doctors to look at patient prescription histories found a drop in overdose hospitalizations (26 percent) and prescription opioid deaths (25 percent).25
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While doctors are optimistic that prescription monitoring programs can cut down on doctor shopping, implementing such systems takes time, especially when most states do not yet require their physicians to actually use the program. As recently as 2012, only 35 percent of doctors in any given state were signed up to access their local database. Technical difficulties, the “time-consuming nature of information retrieval,” and a lack of understanding of how the data is presented have resulted in most primary care physicians struggling to access and use the information in their monitoring systems, according to Health Affairs.26
Another barrier to implementation is that even when doctors are required and able to look at their databases, they are directed to use their discretion if they suspect that a patient is addicted, doctor shopping, or otherwise misusing their prescription medication. But Van Ingram, Kentucky’s Director of Drug Control Policy, points out that identifying the signs of addiction is not always straightforward; doctors, pressed for time and fearing career-ending lawsuits, might want to err on the side of caution and not accuse patients of such practices. Patients, meanwhile, may be doctor shopping for reasons not related to drug addiction; for example, they may simply be looking for a second opinion after a distressing diagnosis.
However, even patients who are addicted to their opioids and engaging in doctor shopping might put on such a convincing show that their doctors see no need to double-check. People with addictions are more than capable of hiding the truth and misleading their spouses and employers; Van Ingram warns that such people “can definitely conceal the disease from their physician in a 15-minute visit.”
As with the implementation of any new program, there was initial resistance to Kentucky’s prescription monitoring program. However, says Ingram, doctors have been surprised to see the signs of an addiction by patients they’ve known for 20 years. He says that using the database should be an obvious choice for healthcare professionals; a tool that “takes 15 seconds to use and can diagnose a disease,” should be a “no brainer.”
Ingram calling the program a “no brainer” is a step up from the term that was used to describe the status quo of patients who would frequently doctor shop to get their desired mix of opioid painkillers: “the cocktail,” consisting of Xanax and Soma. Kentucky’s prescription drug monitoring program director, David Hopkins, explains that combining the two medications produces a high that is similar to that caused by heroin and, whether users are aware of it or not, just as lethal. However, since the passage of state law that required doctors to check the database, the number of people who received “the cocktail” has dropped by 30 percent. Overall, the number of people attempting to engage in general doctor shopping plunged by 52 percent.
“We cracked down on that big time,” said Hopkins.
One way this happens is when the database alerts doctors when a single patient receives medications from multiple sources where the chemical content of the medications is equal to, or more, than 100 milligrams of morphine per day. To assist doctors, a calculator was added to the system, so doctors could do the math easily and more quickly.
Hopkins told The Pew Charitable Trusts that when doctors raised concerns about the implementation of the database, the state responded by hearing them out and adding some “common sense exceptions” wherever possible. For example, doctors (or any healthcare provider empowered to prescribe medications) do not have to consult the database in an emergency or to prescribe medications to patients who are in hospice care, long-term care, or receiving treatment for cancer. In the event that a patient was prescribed a painkiller by a colleague within the same practice, and the patient needs a refill or a different pain medication, the doctor can skip checking the database.
In the event that a doctor suspects an irregularity with a patients’ prescription history, the doctor can look in the database to find out if any other physicians in the state are addressing the medical needs (as they relate to pain) of similar patients, and the physicians can consult an individual patient’s drug history to determine the likelihood of being doctor shopped. Such a consultation was forbidden under Kentucky’s previous privacy laws.
In order for doctors to be able to better communicate across state lines, Kentucky has joined forces with other states in using reciprocal agreements on the topic of sharing drug dispensing information across different jurisdictions, allowing for pharmacists, physicians, and law enforcement to be on the same page (wherever necessary). Kentucky, for example, is in agreement with 20 states; New Jersey’s prescription drug monitoring program has been linked with those in Connecticut, Delaware, South Carolina, Virginia, and Rhode Island.27 The standard practice when a doctor discovers a patient is engaging in doctor shopping is for the physician to dismiss the patient and refuse treatment.
However, the Kentucky Physicians Health Foundation encourages doctors to be more compassionate. The head of the foundation argues that while prescribers are perfectly within their rights to withhold medication, there are other options, such as referring diversionary patients to treatment. The important thing, says the foundation, is that doctors save lives, one way or another.
To that end, what Kentucky has done to crack down on doctor shopping and the resultant cost “meets the gold standard for prescription drug monitoring programs,” according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Before the implementation of the state’s electronic reporting system, it ranked 31st in the country for the highest nonmedical use of prescription painkillers; afterwards, it fell to second place, “a drop that officials attribute largely to its monitoring program.”
SAMHSA noted that Kentucky’s doctors are in agreement that the database has been instrumental in helping them make better prescription decisions for their patients. A 2010 survey of physicians showed that 70 percent of respondents were confident that the monitoring system assisted them in deciding which drug to prescribe to a patient. As many as 90 percent of doctors responding to the survey felt that they had “refused to prescribe or dispense a controlled substance” because of what a database report told them.28
Even beyond Kentucky, the data provided by prescription drug monitoring programs is of “enormous value” to officials and legislators whose job it is to determine resources for prevention and treatment, said SAMHSA. The federal data of the past could have been out of date by as much as six years by the time the information was processed. The drug databases of today can provide real time information, allowing policymakers to stay abreast of current trends, and, ideally, with doctor shopping and other diversionary practices.
Additionally, Kentucky’s program has allowed local health and policy officials to better track the scope of the state’s opioid epidemic and fine-tune their prevention efforts to reach people in the most affected regions. The branch manager of the Substance Abuse Prevention Program with the state’s Department of Health pointed out that before the drug monitoring system went online, there was no deeper grasp of how and where the prescription drug problem was striking the hardest. “Now,” she says, “we know where it is, we know how much is going on.” Physicians being able to look up prescription histories allows the health community to “pinpoint the hotspots.”
For all the good it has done, Kentucky’s system is still a work in progress, but many in the state’s medical and health community are optimistic about the difference it can make in the future. David Hopkins, the Prescription Drug Monitoring Program Director in Kentucky, told SAMHSA that the database has alerted doctors to the importance of “more review of the potentially addicting substances their patients are receiving,” and for some cases, the database might convince doctors to prescribe fewer controlled substances to begin with.
Kentucky’s success with cutting down on doctor shopping and the toll it takes on society is an example of the results of a study conducted by the Addictive Behaviors journal, which found that states that implement such programs can cut diversionary tactics by as much as 80 percent.29 One of the study’s authors told Fox News that such databases “are a promising component” of a concerted effort to strike back at the opioid epidemic.30
Encouraging as though those figures are, doctors caution that doctor shopping is a symptom of the larger opioid crisis running across America. Dr. Stephen W. Patrick, a pediatrician at Vanderbilt University’s School of Medicine, who treats newborns born with withdrawal symptoms because their mothers abused opioids during pregnancy, told Fox News that prescription monitoring databases alone will not “help us get out of the opioid epidemic.” Such measures will indeed reduce the cost of addictive and diversionary behavior to society, but the larger problems still exist. Past research has found that prescription monitoring databases can prevent 10 deaths related to opioid abuse every day, but public health experts fear that this will simply drive addicted patients to other sources of drugs (or even other drugs like heroin). However, the Addictive Behaviors study did not find evidence that the effectiveness of drug monitoring databases contributed to an increase in heroin use.
Nonetheless, even the lead author of the study expressed caution that “people might begin to substitute,” because of how reducing the rate of doctor shopping would inevitably limit what was once a robust supply of prescription medication. What needs to happen, said Dr. Patrick at Vanderbilt University, is for the opioid epidemic itself to be brought under control. Using a drug database to cut down on doctor shopping, and reduce the cost to society that the practice entails, is the first step in a very long journey.