Deception for Drugs: 'Doctor Shopping' Among Young Adults
Deception for Drugs: 'Doctor Shopping' Among Young Adults
Background: Pharmaceutical abuse is a burgeoning problem, and various forms of drug diversion are becoming more common. At present, little is known about those who attempt to deceive physicians to receive medications, and even less is known about those who successfully avoid detection and abuse-related repercussions. The goal of this study is to assess the prevalence of attempted physician deception in a general population, explore common motives, and evaluate risk factors associated with the behavior.
Methods: A stratified random sampling technique was used to obtain a locally representative sample of 2349 young adults. The sample was 48.4% male, 68.9% white, 24.4% black, and 2.8% Hispanic. Selected individuals were surveyed using a self-report instrument (80.4% response rate).
Results: Of the respondents, 93 (4.0%) self-reported having attempted to deceive a physician to obtain a pharmaceutical. Most of these indicated that they were at least partially motivated by their own abuse. Approximately half reported that selling a portion of the prescription was a motivating factor. Alcohol use, marijuana use, and pharmaceutical misuse each were risk factors associated with attempted deception. Although no traits were definitively linked to the behavior, attempted deception was more commonly reported by men, Hispanics, self-identified lesbian/gay/bisexual/transgender individuals, and those at the lowest and highest extremes of the income spectrum. Logistic regression models of rare events indicated that past substance use along with sexual orientation and family income were related to attempted deception when controlling for other factors.
Conclusion: Results suggest that attempted physician deception may be more common than previously believed. Practicing physicians should attempt to use risk factor information presented within this study, albeit very cautiously. This study identifies general characteristics of young people who might divert medications but notes that only a small minority of any patient group will do so. Awareness should not equal bias in the treatment of these patients; instead, it should reinforce the need for careful clinical interviewing and the utilization of prescription drug monitoring programs and local law enforcement databases.
Despite intensified regulations and enhanced efforts to securely store, distribute, and closely monitor pharmaceutical products, prescription medication misuse has grown significantly in recent years. Among adolescents and young adults, pharmaceuticals now trail only marijuana and alcohol in terms of substance use. Findings from Monitoring the Future indicate that 7.9% of US high school seniors have misused prescription pain medications in the past year, and according to the National Survey on Drug Use and Health, use among young adults is even higher (9.8%). These actions are not without consequences; pharmaceutical misuse and abuse contributes to an estimated 1.3 million emergency department visits each year. While there is clear evidence that large quantities of pharmaceuticals are reaching unintended users, adequate detail about the routes of drug diversion is lacking.
Pharmaceutical diversion takes many forms. Patients may retain a portion of a needed prescription to sell, give away, or use themselves for recreational purposes. Theft from the supply chain or patients, fraudulently altered prescriptions, stolen prescription pads, international travelers, and "rogue on-line pharmacies" all likely partially contribute to the problem. Unethical or irresponsible prescribing practices remain a leading contributor; "pill mills," pain clinics, and unethical employees of pharmacies are of particular concern. However, most ethical physicians focused on their own practice are likely more concerned with the final form of drug diversion—physician deception. Physicians must be concerned that some patients are "doctor shopping" to obtain prescriptions from multiple physicians for a single malady or that they are feigning or exaggerating symptoms to obtain a prescription for which they have no legitimate need. Unfortunately, this concern can negatively influence the regular practice of medicine because suspicions may lead to the undertreatment of pain in patients who are not feigning or exaggerating symptoms.
This study focused on physician deception, broadly defined as any dishonesty on the part of the patient directed at gaining access to pharmaceuticals (including complete fabrication of pain and symptoms, exaggeration of actual pain or symptoms, or attempts to obtain medications for an already treated illness). Physician deception includes patients attempting to gain access to an unneeded category of drugs, stronger doses, more dosages, or a stronger than needed pharmaceutical. Virtually all studies focusing on patient-based drug diversion fail to directly assess physician deception. They either quantify the proportion of patients that misuse or divert their own medication or focus on abusers or traffickers who were identified by law enforcement or health care providers. Extant analyses also are largely limited to case or cohort studies, self-reports of identified heavy users, and analysis of records. As a result, our knowledge of pharmaceutical diversion may be overly reliant on the experiences of heavy users, and little is known about those involved in physician deception who avoid medical or legal repercussions.
A better picture of physician deception may originate from large random samples of the population that include successful "patients." As such, we collected survey data from 2349 randomly selected individuals from a group with high rates of alcohol, marijuana, and prescription abuse to determine the prevalence of, and motives for, physician deception. Detailing factors linked to attempted deception will likely assist physicians who have traditionally received little direct training in assessing the truthfulness of patients. This may be particularly important because many of those inappropriately seeking medications may have honed their deceptive skills after attempting to deceive multiple physicians. Our study offers insights and suggests situations in which physicians may need to heighten their suspicions, but we stress that no traits are absolutely linked to deceptive behavior, nor should physicians underprescribe medications with abuse potential simply because a patient matches a profile associated with physician deception.
Abstract and Introduction
Abstract
Background: Pharmaceutical abuse is a burgeoning problem, and various forms of drug diversion are becoming more common. At present, little is known about those who attempt to deceive physicians to receive medications, and even less is known about those who successfully avoid detection and abuse-related repercussions. The goal of this study is to assess the prevalence of attempted physician deception in a general population, explore common motives, and evaluate risk factors associated with the behavior.
Methods: A stratified random sampling technique was used to obtain a locally representative sample of 2349 young adults. The sample was 48.4% male, 68.9% white, 24.4% black, and 2.8% Hispanic. Selected individuals were surveyed using a self-report instrument (80.4% response rate).
Results: Of the respondents, 93 (4.0%) self-reported having attempted to deceive a physician to obtain a pharmaceutical. Most of these indicated that they were at least partially motivated by their own abuse. Approximately half reported that selling a portion of the prescription was a motivating factor. Alcohol use, marijuana use, and pharmaceutical misuse each were risk factors associated with attempted deception. Although no traits were definitively linked to the behavior, attempted deception was more commonly reported by men, Hispanics, self-identified lesbian/gay/bisexual/transgender individuals, and those at the lowest and highest extremes of the income spectrum. Logistic regression models of rare events indicated that past substance use along with sexual orientation and family income were related to attempted deception when controlling for other factors.
Conclusion: Results suggest that attempted physician deception may be more common than previously believed. Practicing physicians should attempt to use risk factor information presented within this study, albeit very cautiously. This study identifies general characteristics of young people who might divert medications but notes that only a small minority of any patient group will do so. Awareness should not equal bias in the treatment of these patients; instead, it should reinforce the need for careful clinical interviewing and the utilization of prescription drug monitoring programs and local law enforcement databases.
Introduction
Despite intensified regulations and enhanced efforts to securely store, distribute, and closely monitor pharmaceutical products, prescription medication misuse has grown significantly in recent years. Among adolescents and young adults, pharmaceuticals now trail only marijuana and alcohol in terms of substance use. Findings from Monitoring the Future indicate that 7.9% of US high school seniors have misused prescription pain medications in the past year, and according to the National Survey on Drug Use and Health, use among young adults is even higher (9.8%). These actions are not without consequences; pharmaceutical misuse and abuse contributes to an estimated 1.3 million emergency department visits each year. While there is clear evidence that large quantities of pharmaceuticals are reaching unintended users, adequate detail about the routes of drug diversion is lacking.
Pharmaceutical diversion takes many forms. Patients may retain a portion of a needed prescription to sell, give away, or use themselves for recreational purposes. Theft from the supply chain or patients, fraudulently altered prescriptions, stolen prescription pads, international travelers, and "rogue on-line pharmacies" all likely partially contribute to the problem. Unethical or irresponsible prescribing practices remain a leading contributor; "pill mills," pain clinics, and unethical employees of pharmacies are of particular concern. However, most ethical physicians focused on their own practice are likely more concerned with the final form of drug diversion—physician deception. Physicians must be concerned that some patients are "doctor shopping" to obtain prescriptions from multiple physicians for a single malady or that they are feigning or exaggerating symptoms to obtain a prescription for which they have no legitimate need. Unfortunately, this concern can negatively influence the regular practice of medicine because suspicions may lead to the undertreatment of pain in patients who are not feigning or exaggerating symptoms.
This study focused on physician deception, broadly defined as any dishonesty on the part of the patient directed at gaining access to pharmaceuticals (including complete fabrication of pain and symptoms, exaggeration of actual pain or symptoms, or attempts to obtain medications for an already treated illness). Physician deception includes patients attempting to gain access to an unneeded category of drugs, stronger doses, more dosages, or a stronger than needed pharmaceutical. Virtually all studies focusing on patient-based drug diversion fail to directly assess physician deception. They either quantify the proportion of patients that misuse or divert their own medication or focus on abusers or traffickers who were identified by law enforcement or health care providers. Extant analyses also are largely limited to case or cohort studies, self-reports of identified heavy users, and analysis of records. As a result, our knowledge of pharmaceutical diversion may be overly reliant on the experiences of heavy users, and little is known about those involved in physician deception who avoid medical or legal repercussions.
A better picture of physician deception may originate from large random samples of the population that include successful "patients." As such, we collected survey data from 2349 randomly selected individuals from a group with high rates of alcohol, marijuana, and prescription abuse to determine the prevalence of, and motives for, physician deception. Detailing factors linked to attempted deception will likely assist physicians who have traditionally received little direct training in assessing the truthfulness of patients. This may be particularly important because many of those inappropriately seeking medications may have honed their deceptive skills after attempting to deceive multiple physicians. Our study offers insights and suggests situations in which physicians may need to heighten their suspicions, but we stress that no traits are absolutely linked to deceptive behavior, nor should physicians underprescribe medications with abuse potential simply because a patient matches a profile associated with physician deception.
