Dangerous diversions: Specter of prescription drug abuse creates tough balancing act for doctors

Questioning patients about past addictive disorders can alert physicians to the need for care when prescribing medication with the potential for misuse.

By — Posted March 17, 2008

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Walking the line between appropriately prescribing controlled substances and unwittingly contributing to the increase in prescription drug abuse becomes less precarious when certain precautions are taken, say those familiar with the balancing act.

Prescription drug abuse is widespread and on the rise. Nearly 7 million Americans abused prescription drugs in 2005, compared with 3.8 million in 2000 -- an 80% jump, says the Justice Dept.

While research has shown that most medications are prescribed responsibly and that the Internet and street sales feed the illegal drug trade, physicians could play a larger role in fighting this problem, several experts said.

Prescribing of controlled substances has increased dramatically, said Robert DuPont, MD, president of the Institute for Behavior and Health, a nonprofit drug abuse policy organization in Rockville, Md., a block from the National Institute on Drug Abuse, where he served as the first director.

"Before the last decade, doctors were very reluctant to prescribe these medications to outpatients. But because of concern about the undertreatment of pain, their prescription has become ubiquitous," Dr. DuPont said.

If physicians think their practices are immune from prescription abuse, they should think again, said Mark Gold, MD, distinguished professor and chief of addiction medicine at the University of Florida's McKnight Brain Institute in Gainesville.

Properly prescribed medications can be diverted by teens pilfering drugs from their parents' medicine cabinet before heading out to a party. Or patients may sell their medications to supplement their incomes. And then there are the "doctor shoppers" who hit a different physician's office every day, seeking controlled substances.

Regardless of how it happens, the outcome of this abuse can be deadly. Actor Heath Ledger, who died Jan. 22 after taking a variety of prescribed medications, can be counted among its victims, as can musicians Elvis Presley, Judy Garland, Dinah Washington and Jimi Hendrix.

For as long as there have been medicines, the danger of overuse, experimentation and abuse has existed. The rise of patent medicines -- based largely on morphine and cocaine -- in the middle and late 1800s resulted in one in 200 Americans becoming addicted. These widely used substances were embraced by doctors and patients alike before harm was detected and the first drug control laws were passed.

That was then. The drugs of choice now, according to the National Institute on Drug Abuse, are opioids commonly prescribed to treat pain; central nervous system depressants used to treat anxiety and sleep disorders; and stimulants used to treat narcolepsy and attention-deficit hyperactivity disorder.

Pain reliever or drug of abuse?

But there is a flip side. The same medications subject to abuse provide much-needed relief to patients. A larger problem comes when pain is not treated adequately or when patients are afraid to ask for pain relief because they fear they might become addicted, said A. Thomas McLellan, PhD, CEO and founder of the Treatment Research Institute, a nonprofit group in Philadelphia that studies addiction.

American Medical Association policy also cautions that undertreating pain is a concern that must be balanced against the risk of abuse.

Undertreatment of chronic pain is an important public health concern, said B. Todd Sitzman, MD, MPH, president of the American Academy of Pain Medicine. An aging population means that arthritis, cancer, degenerative disc disease and other disorders will become more common, leading to an increase rather than a decrease in pain scripts, he said.

The need for both pain treatment and addiction treatment is clear. "We know there are 70 million Americans who experience pain every day. Along with that, we know 10% of the adult population will have some kind of addictive disorder in their lifetime, although most will be addicted to some legal substance, like alcohol."

Primary care physicians can address these problems before even picking up a pen and prescription pad, several physicians said. "Because so many patient problems have fallen at the feet of primary care, we need to look at ways primary care can be part of the solution and not part of the problem," said Michael M. Miller, MD, president of the American Society of Addiction Medicine.

A report about prescription drug abuse will be presented at the AMA Annual Meeting in June. Current AMA policy supports physician education, research activities and the development of state-based programs.

As a first step, physicians need to ask questions about a patient's history of addiction or previous difficulties in controlling their prescription drug use, Dr. Miller said. While addiction to opioids and psychostimulants is relatively rare when the medications are properly prescribed, these screening questions can alert physicians to the need to exercise particular caution, he said.

Doctors can incorporate such queries into a busy practice, Dr. Gold said. Questions about tobacco use, once a rarity, are commonplace today.

Doctors may think that national statistics don't apply to their practices, he said, but that's not the case. "Tobacco, alcohol and drug problems are so important in our society and health system, it is imperative for physicians to acquire the skill to ask and intervene."

Physicians also should consider what might happen to the medication that isn't used right away, said Kyle Kampman, MD, medical director of the Charles O'Brien Center for Addiction Treatment at the University of Pennsylvania. Physicians often provide too many pills, he said. "We hate to see somebody in pain run out of medicine, so sometimes we may be a little too generous."

Pharmaceutical leftovers are kept in case patients need them again. And where are they stored? In medicine cabinets and kitchens, where they can be found by children and others, Dr. Kampman said.

Physicians need to warn patients to lock up unused medications, he added. "Patients tell me they worked as a maid at the height of their addiction and they would go through people's medicine cabinets. I had a patient who was a roofer tell me, 'If you ever let a roofer in your house and in the bathroom, chances are they are looking through your medicine cabinet.' "

Physicians also need to look for signs of abuse, such as patients who return early for a refill. "It's a joke among addiction providers that sinks and toilets seem to be magnets for people's medications. That's an excuse you often hear: 'I dumped my medicine down the sink or down the toilet.' So that should ring alarm bells," Dr. Kampman said.

If this occurs, it's best to confront a patient directly, he said. Sometimes patients will acknowledge a problem, and the physician needs to stop prescribing and insist the patient be evaluated for substance abuse, Dr. Kampman said.

Other times, patients' pain is undertreated, leading them to take increasing amounts of a medicine. In these cases, referral to a pain specialist is necessary, he added.

Every physician prescribing controlled substances has clear responsibilities set forth by the Federation of State Medical Boards, Dr. Sitzman said. These duties -- which include obtaining a physical exam before prescribing, having a written treatment plan and stressing the responsibilities of both patient and physician -- aren't always followed closely, he said.

Physicians should tell patients that it is illegal to share medications with other people, and that unused or expired drugs should be destroyed, Dr. DuPont said. Destroying them means rendering them unusable by mixing them with cat litter or coffee grounds. Flushing them down the toilet is permissible only if the label says so, according to the Office of National Drug Control Policy.

Detecting doctor shoppers

Turning to a prescription drug monitoring program, a searchable database for tracking users of controlled substances, is another option for physicians on the trail of doctor shoppers. For instance, the Indiana Scheduled Prescription Electronic Collection & Tracking program is gaining popularity in that state.

"It takes about 30 seconds to check to see if patients are filling other prescriptions," said family physician Terry Haffner, MD, of Kokomo. Previously available only to law enforcement agencies, the INSPECT program opened to doctors last July.

Congress enacted the National All Schedules Prescription Electronic Reporting Act in 2005 with strong doctor support. But the law, which authorizes a system of federally supported, state-based drug monitoring programs, has yet to be funded.

NASPER investment is critical, said Andrea Trescot, MD, president of the American Society of Interventional Pain Physicians. If it were funded, the law would provide an important preventive tool, she said.

Talk-show host Rush Limbaugh might not have gotten into trouble with prescription abuse if NASPER had been operational, she noted. He was charged in 2006 with doctor shopping to get extra pain killers. "When he saw a second doctor, [that] doctor would have said, wait a second, maybe there is a problem here. Let's see if we can intervene before you crash, burn and die."

Back to top


Getting pain pills

Friends and relatives were the primary source of prescription pain relievers abused by those 12 and older, a new survey finds. But physicians were also sources.

56% of respondents said they had received pain relievers free from a friend or relative.

19% received them from a doctor.

9% bought them from a friend or relative.

7% identified another source.

5% took them from a friend or relative.

4% bought them from a drug dealer.

Source: "2006 National Survey on Drug Use and Health: national findings," Substance Abuse and Mental Health Services Administration, September 2007

Back to top

Controlling controlled substances

Specialists in pain medicine and addiction medicine suggest ways to prevent drug diversion:

  • Ask patients about a history of addiction or any previous difficulties in controlling prescription drug use.
  • Don't prescribe too many pills. Those that aren't used are often kept where they can be found by teens and visitors.
  • Warn patients to lock up their medications.
  • Encourage patients to dispose of unused medicine by mixing it with coffee grounds or cat litter, wrapping it in a plastic bag, and then a paper bag, before throwing it in the trash.
  • Be aware of signs of misuse or of inadequate pain relief, such as "losing" prescriptions and medications or running out early.

Back to top

Abusing Rx drugs, and more

More than 2.1 million teens reported abusing prescribed substances in 2006, according to a national survey on drug use and health released last September. People 12 and older who reported using an illicit drug for the first time in the past year (numbers are in thousands):

2,150,000 used pain relievers

2,063,000 used marijuana

1,112,000 used tranquilizers

997,000 used cocaine

860,000 used ecstasy

783,000 used inhalants

267,000 used sedatives

264,000 used LSD

258,000 used meth

91,000 used heroin

69,000 used PCP

Source: "2006 National Survey on Drug Use and Health: National Findings," Substance Abuse and Mental Health Services Administration, September 2007

Back to top

External links

American Society of Addiction Medicine (link)

American Academy of Pain Medicine (link)

American Society of Interventional Pain Physicians (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn