As physicians, we have all been faced with patients inappropriately looking for prescriptions for controlled substances. Some are looking to abuse them and some to divert them for profit. It is often hard to distinguish when a patient truly needs these medications or when they are just “drug-seeking.” More experienced doctors have a better sense of which patients are which. Drug-seeking patients often play on our emotions because they know we generally care about patients and may have difficulty turning down a request for opioids from someone in supposed pain.
For years, patients have used many ruses to access these medications. Many of them “doctor shop,” use several pharmacies, or frequent various emergency rooms, making it difficult to track their prescriptions. And it’s much harder for a doctor to turn down a request from a new patient in acute pain than from one the doctor knows well and doubts.
Having so many controlled substances available and sold on the streets has led to an increase in prescription drug dependency. These patients have a hard time breaking these addictions and often can only stop with help from special rehab programs. It has led to a further resurgence of IV heroin addiction and opioid deaths in many areas. As the states have tightened controlled substance prescriptions, they have become less available for diversion and are now a gateway drug to heroin—which is cheaper than prescribed medications. I am seeing teens in my practice addicted to IV heroin, a habit that started by raiding parents’ or relatives’ medicine cabinets.
It has never been more imperative for doctors to step up and do their part in stopping the supply of inappropriate substances being available for diversion.
What can doctors do to help stop the controlled substance abuse epidemic?
1. Many states now have a controlled substance monitoring system. Check the system every time you write a prescription for a controlled substance. You may be surprised what you find about some of your trusted patients. If your state doesn’t have one, petition to start one.
2. Never prescribe controlled substances to a new patient without a copy of their previous records. I have had patients lie to me about having herniated discs, kidney stones, and even cancer just to get controlled pain medications.
3. Do not be afraid to say no. Some patients are so sympathy-inspiring that it is hard to do. But keep in mind, it is often the same patients who are the biggest diverters. Some may get aggressive when you deny your request, so never hesitate to call the police if you feel intimidated or threatened. If a patient is asked to leave but refuses, they are now guilty of criminal trespass. This has happened to me on a few occasions in the past, and the police were always very supportive and helpful.
4. Do not prescribe large amounts of medications for your patients that need them. When a large number of pills are lying around, they are more easily taken by family members or others for diversion purposes. Prescribe what you think they exactly need for one month.
5. Never refill a lost controlled substance. This is a very common routine of drug seekers. Make patients take responsibility, and tell them up front you don’t replace lost medications.
6. Have patients sign a controlled substance contract that requires them to only obtain these controlled substances from you, their doctor, and one pharmacy. If they break that contract, immediately discharge them.
7. Don’t routinely refill controlled substances without seeing the patient in the office.
8. Personally establish a set of questions that you can use to find discrepancies in a patient’s history. I often go back and ask the same question but in different ways. A truthful patient should give consistent answers.
While there are many patients that genuinely need controlled substances, doctors must step up and help curb the amount of drugs being diverted. Though we should never deny appropriate medical treatment to a patient, this balancing act can be difficult, and we sometimes fail to differentiate between those in need from those selling a tale. However hard it may be, we should never stop trying because if we do, more people will become addicted, more futures wasted, and more lives will be lost.
What do you do to help identify drug-seekers?
Dr. Linda Girgis MD, FAAFP, is a family physician in South River, New Jersey. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University and she was recognized as intern of the year. Over the course of her practice, Dr. Girgis has continued to earn awards and recognition from her peers and a variety of industry bodies, including: Patients’ Choice Award, 2011-2012, Compassionate Doctor Recognition, 2011-2012. Dr. Girgis’ primary goal as a physician remains ensuring that each of her patients receives the highest available standard of medical care.