The problem of prescription drug abuse in this country is significant. According to the Drug Enforcement Administration (DEA, n.d.), in 2009, 7 million Americans 12 and older used prescription drugs nonmedically within the past month, representing a 13% increase from the previous year. There has also been an increase in prescribing rates of controlled drugs. The DEA indicated retail drug sales of opioid agents increased by 127% between 1997 and 2006 (Manchikanti & Singh, 2008). The DEA also estimated the financial cost of prescription drug diversion, which occurs when medications are obtained or used for purposes other than what they are intended, to be approximately $72 billion per year (National Drug Intelligence Center, 2009). Aside from the huge financial cost, the human cost is also significant. A recent Centers for Disease Control and Prevention (2010) report showed that deaths from opioid poisoning tripled from 1997 to 2007.
To obtain these controlled drugs illicitly, patients visit numerous prescribers, a practice called doctor shopping and considered a major source of diversion of controlled drugs. Doctor shopping is significant to nursing because advanced practice nurses (APNs), including nurse practitioners, make up a significant portion of health care providers who prescribe medications in the United States.
Two drug classes in psychiatric care are most often abused and sought after by doctor shoppers. Benzodiazapines (e.g., alprazolam [Xanax®])—schedule III controlled drugs used to treat anxiety—are frequently abused and are often listed as the second-highest abused drug class after opioid pain medication. Another drug class often abused in psychiatric care is stimulant agents (e.g., dextroamphetamine and amphetamine [Adderall®])—schedule II controlled drugs used to treat attention-deficit/hyperactivity disorder. Doctor shoppers are able to fabricate many symptoms when requesting these medications. Prescribers are not necessarily able to determine which patients are seeking these medications for illicit use. Who are doctor shoppers? One study found that male youths from cities were not significantly associated with doctor shopping (Wilsey et al., 2010). In some cases, vulnerable individuals such as women, older adults, and those with developmental disabilities may be seeking the medications on behalf of others. No amount of intuition or clinical expertise will enable a prescriber to determine which patients are legitimate and which patients are doctor shopping.
Prescription drug monitoring programs (PDMPs) are state-run electronic databases that collect data on controlled drug prescriptions so that prescribers can access the data to determine whether the patient is doctor shopping. Currently, 48 states have laws providing for PDMPs. Most states have reactive programs, which require prescribers to access the data, unlike proactive programs, which notify prescribers when doctor shopping is detected. PDMPs have been proven to reduce the incidence of doctor shopping (National Alliance for Model State Drug Laws, 2011). Checking PDMPs is optional in most states, and only seven states have laws that require prescribers to check them. To check the PDMP, prescribers must register with the state by providing license and DEA information. Each state’s PDMP is different, but accessing the database is generally fast and simple, requiring a prescriber to log on and enter basic patient information, such as name and date of birth. They are then able to view a list of all the prescriptions for controlled drugs the patient has received, including the name of the prescriber and the pharmacy. Since doctor shopping is so prevalent, it appears that prescribers are not routinely checking the PDMPs; this has been my experience as a nurse practitioner, prescribing medication for the past 18 years, who regularly checks the database and discovers rampant doctor shopping.
Reasons why prescribers may not be using the PDMP have not been fully researched, but possible reasons include time constraints and lack of knowledge, training, and Internet access. Another factor could be that providers are not comfortable confronting patients with PDMP findings. Nevertheless, prescribers, including APNs, have a moral obligation to use this database to detect doctor shopping and prevent prescription drug abuse. Nurses who do not prescribe medication can still play a pivotal role in detecting doctor shopping. In many states, only the prescriber is legally able to access the data, so delegating to a nurse is not possible. Nurses can still help the prescriber, physician, or APN by developing a protocol or plan for providing a list of patients to check prior to their visit. Nurses can also make recommendations to the prescriber to check the PDMP for patients.
Nursing organizations need to develop position statements encouraging APNs to use PDMPs. It is essential to educate nurses on using the database and how to handle the situation when doctor shopping is detected. Referring these patients for treatment is also important. In addition, nurses can lobby for improved legislation regarding PDMPs. A nationwide proactive PDMP that allows state-to-state communication is needed, as well as laws mandating that all prescribers check the PDMP prior to prescribing a controlled drug. Point-of-service regulation is also likely necessary, such as preventing pharmacists from filling prescriptions for more than one controlled drug from more than one provider in a 30-day period or when patients get controlled drugs from numerous providers within a certain time frame. Insurance companies should be able to deny payment for medications and provider visits when doctor shopping is involved. This would help reduce the incidence of unscrupulous prescribing for profit, which occurs when prescribers knowingly prescribe controlled drugs to patients who are doctor shopping.
Doctor shopping and prescription drug abuse affects psychiatric nurses directly, as several psychiatric medications are often the target. Both issues are huge societal problems, and psychiatric nurses and nurse researchers are in a unique position to research, document, detect, and deter.
Julie Worley, MS, RN, FNP-BC, PMHNP-BC
Psychiatric-Mental Health Nurse
- Centers for Disease Control and Prevention. (2010). Quickstats: Number of poisoning deaths involving opioid analgesics and other drugs or substances—United States, 1999–2007. Morbidity and Mortality Weekly Report, 59. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a6.htm
- Drug Enforcement Administration. (n.d.). Fact sheet: Prescription Drug Abuse—A DEA focus. Retrieved from http://www.justice.gov/dea/concern/prescription_drug_fact_sheet.html
- Manchikanti, L. & Singh, A. (2008). Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician, 11(2 Suppl.), S63–S88.
- National Alliance for Model State Drug Laws. (2011). Practitioner education in the utilization prescription monitoring program (PMP) data. Retrieved from http://www.namsdl.org/documents/PractitionerLiability-NatPMPMtg-6-8-11.pdf
- National Drug Intelligence Center. (2009). National drug threat assessment 2009. Retrieved from http://www.justice.gov/ndic/pubs31/31379/pharm.htm#Top
- Wilsey, B.L., Fishman, S.M., Gilson, A.M., Casamalhuapa, C., Baxi, H., Zhang, H. & Li, C.S. (2010). Profiling multiple provider prescribing of opioids, benzodiazepines, stimulants, and anorectics. Drug and Alcohol Dependence, 112(1–2), 99–106. doi:10.1016/j.drugalcdep.2010.05.007 [CrossRef]