Know When to Say “No”
Drug-seeking patients can cause problems
for your practice.
An insurance fraud investigator offers tips on what to do if
you suspect a patient is seeking drugs.
An insurance fraud investigator offers tips on what to do if
you suspect a patient is seeking drugs.
Many Americans benefit from the appropriate
use of prescription painkillers. For individuals who suffer
from severe, chronic pain brought on by diseases like cancer
and arthritis, powerful narcotic painkillers offer them a
chance to manage their pain and return to their normal daily
tasks. However, in the wrong hands, prescription drugs can be
highly addictive, easily abused, and potentially deadly.
Non-medical use of addictive
prescription drugs has been rapidly increasing throughout the
United States. The media regularly reports crimes, overdoses,
and deaths resulting from the abuse of various prescription
painkillers. According to the National Survey on Drug Use and Health, an estimated 6.2 million Americans reported
past use of prescription drugs for non-medical purposes in
2002. In terms of illegal use of drugs, this ranks second only
to marijuana use. As a practicing physician, it is very likely
that you are faced with the occasional drug-seeking patient.
How you respond to them is very important.
Often drug seekers use the
illegal practice of “doctor shopping” in order to
obtain pain medications. This scheme involves patients visiting
multiple doctors and pharmacists to obtain numerous
prescriptions for narcotics. Once the person has the drug, the
pills are either used to satisfy his own dependency or are sold
on the street. For example, the drug OxyContin has been widely
abused and sold on the streets. The strength, duration, and
dosage of OxyContin are the main reasons the drug is attractive
to both abusers and legitimate users. According to a report published
by the Hazelden Foundation in 2004, OxyContin abusers often
chew the tablet or crush it and snort the powder to negate the
controlled release effect and provide rapid release and
absorption of the drug. Some abusers will mix OxyContin with
other drugs or alcohol. The result can be fatal, which is why
OxyContin is one of the most dangerous drugs to abuse.
Other drug-seekers
obtain their medication through altered, forged, or counterfeit
prescriptions, or, more recently, by requesting it over the
Internet.
Spotting a drug seeker
Unfortunately, drug-seeking patients are
not always easy to identify. College students, business
executives, suburban moms, or even physicians themselves can
fall prey to drug addiction. Many addicts will start out taking
narcotics for a legitimate reason—perhaps for an injury
or a major surgery—and end up developing an addiction.
According to addiction
specialist Mike Sucher, MD, use your own sense of the situation
to guide you. “The best way to know if you’ve got a
drug-seeking patient in your office is to pay attention to your
intuition. If you think you are being conned, then you probably
are,” he says in a 2002 article by
Karen Childress published in Physician’s Practice Digest.
“But a lot of the time you don’t have a clue.
Addicts will go to great lengths to obtain their drugs. As they
become more addicted, seeking their next fix becomes a
full-time job for many of them.”
In Childress’
article, L. Todd Stewart, MD, who practices pain management in
Gainesville, Georgia, suggests looking for these red flags to
spot a drug-seeking patient:
• The patient describes vague
symptoms of pain
• The patient professes
conditions that are difficult to prove or disprove, such as low
back pain, neck pain, migraine, renal colic, or toothache
• The pain described
doesn’t make sense—the symptoms don’t add up
• The patient requests
medication by name and dose
• The patient demonstrates
medical knowledge beyond the realm of what you see in the
average patient
• The patient claims to have
allergies to nearly everything—except the drug of choice
• The patient calls ahead to
see who is on duty at the clinic, ER, or urgent care center
• The patient
“bad-mouths” previous physicians
• The patient is hesitant to
follow through with a work-up to get to the bottom of the
problem
• The patient claims to have
lost prescriptions or medications
• You receive an alert from a
pharmacy or insurance company that a patient is getting meds
from several sources
“The bottom line
is, if you suspect a patient is addicted and seeking drugs, use
common sense,” says Stewart. “Listen to your
intuition, document the patient’s actions thoroughly, and
always keep the best interest of the patient at the forefront.
It is your responsibility to prescribe the right drugs for the
right patients at the right time. Be attentive, compassionate,
and prudent with your pen so that both you and your patients
are comfortable.”
Protect your practice
Stewart stresses that documentation is
critical. “Thorough notes regarding your decision-making
is the best defense should any questions arise,” he says.
“If you are prescribing, records should include a history
and physical, evidence of any non-narcotic treatments that have
been tried, what adjunct therapies are being used (such as
physical therapy), periodic re-evaluation of the diagnosis and
pain levels, and how the patient is responding to
treatment.” He also says that if you believe that ongoing
treatment with narcotics is simply beyond the scope of your
practice, then you have the right to refer the patient
elsewhere.
“You have to
care enough to keep a clean practice,” says Stewart.
“In our practice every patient getting narcotics signs a
contract. It says they’ll get their meds only from us and
only from one pharmacy, that they may be required to be
evaluated by a psychologist, that we will drug test them, that
we never prescribe on weekends or after 4:00 pm, and that if
any of theses conditions aren’t met we reserve the right
to dismiss them from the practice and refer them
elsewhere.” He adds that many of the patients he tests
for drugs come back positive for something—marijuana or
other street drugs, or another prescription medication, or the
test shows they are not using the drug which is prescribed for
them. “If a patient refuses a drug screen then they are
dismissed from the practice with arrangements for a weaning
schedule.”
Help from insurers
Private and public insurance companies are
also trying to crack down on drug-seeking patients. They use
sophisticated software to conduct audits on drug claims data.
These audits help identify patients who have an excess number
of prescriptions and quantity of pills dispensed for high-risk
drugs. Claim examiners and fraud prevention staff are trained
to identify the patterns that may indicate illicit drug use.
Insurance companies
should solicit input from doctors to help identify prescription
drug fraud and abuse. For example, Humana Military Healthcare
Services (HMHS) has a Fraud and Abuse hotline for their TRICARE
program. The hotline is completely confidential and is a good
way for a physician to tip off the insurance company when they
suspect a patient is seeking drugs. HMHS has the advantage of
viewing the patient’s entire history of pharmacy and
medical claims. Having access to this data is key in
determining patterns of abuse or doctor shopping. When a case
of prescription drug abuse is identified, the patient is
assigned a case manager to help control the abuse. If this
approach is unsuccessful, then they attempt to limit the
patient to one physician, one ER, and one pharmacy.
In order to successfully
fight prescription drug abuse, it is essential that doctors,
pharmacies, insurers, and law enforcement agencies work
together to monitor and control a patient’s use of
prescription narcotics while also protecting their
privacy and confidentiality.
g
in Louisville, Kentucky.
The comments in Remarks are solely those
of the author and may or may not be shared by UO or its
advertisers.
