With an increased focus on opioid addiction, many states have turned their attention to addressing the problem of doctor shopping as one means of curbing prescription drug abuse and overdoses. Although the term doctor shopping is used to describe various patient behaviors, including seeing multiple physicians in search of more convenient office hours or a different diagnosis, this article concerns doctor shopping as the practice of seeing multiple treatment providers specifically to obtain prescriptions for controlled substances without the prescriber’s knowledge of the other prescriptions. The following is an overview of the doctor shopping phenomenon and a discussion of tactics for managing liability risk when a psychiatrist encounters a patient who may be engaging in this behavior.
Recently, there has been an increasing prevalence of prescription drug abuse often leading to overdose. According to research from the National Institute on Drug Abuse (NIDA), from 2002 to 2015, there was a 2.8-fold increase in the total number of deaths from opioid drugs.1 Research from the Centers for Disease Control and Prevention indicates that in 2015, the amount of opioids prescribed was enough to medicate every person around the clock for three weeks.2 During that same period, there was also a 4.3-fold increase in the total number of deaths from benzodiazepines.3 Research from the Centers for Disease Control and Prevention indicates that opioids killed more than 33,000 people in 2015, and that, of those deaths, nearly half were caused by overdoses involving prescription opioids.4
The supply chain for prescription drugs for those who are abusing controlled medications typically runs from the prescribing physician to the patient to the abuser (who may be the same person as the patient). Many people who abuse prescription drugs obtain medications by diversion through family or friends. A recently published study examined over 146 million prescriptions dispensed in 2008, and concluded that one out of every 143 patients in the United States who received a prescription for an opioid obtained prescriptions from multiple physicians.5 Moreover, while doctor shoppers comprised only 0.7% of patients with opioid prescriptions, they purchased almost 2% of all such prescriptions.6
While the Federal Comprehensive Addiction and Recovery Act of 2016 focuses primarily on drug abuse prevention, education, and treatment, states retain the primary responsibility of regulating prescription drug practice. All fifty states and the District of Columbia have adopted statutes that treat doctor shopping for the procurement of illicit prescription drugs as fraud.7 Most state prescribing laws are based in part upon the model language found in the Uniform Narcotic Drug Act of 1932 and the Uniform Controlled Substances Act of 1970.
These model laws protect physicians who prescribe for legitimate medical purposes. However, if a physician knows that a patient is illicitly procuring prescription drugs and aids in that procurement by prescribing, then liability may follow. If convicted for a violation of any provision of the model acts as enacted by states, a physician may have his or her license suspended or revoked. Additional penalties vary by state but may include a fine or a term of imprisonment. A physician who violates the model laws as passed by states, may also be subject to liability under federal narcotics laws.
Apart from treating doctor shopping as a type of fraud, several states have also enacted laws directly targeting the problem by imposing on patients a duty to disclose to health care professionals that they have received a prescription order for any controlled substance from another practitioner or for the same controlled substance or one of similar therapeutic use. Some of these laws provide specific disclosure timeframes during which the patient is required to disclose previous access to the controlled substance. In a few states, patients are only required to disclose information in instances in which they are seeking a larger quantity of a controlled substance that would indicate substance abuse or diversion.
Although it can be difficult to identify which patients may be engaging in the practice of doctor shopping, there are some common indicators. For example, patients often avoid detection by visiting facilities where medical professionals do not know them. Many patients who are engaging in this behavior will travel long distances to seek care or they may visit emergency rooms and urgent care clinics rather than seeing their primary care physician. Other tactics that patients employ are falsifying identification, being dishonest about the current dosage of their medications, and paying in cash.
Because patients who are doctor shopping may attempt to manipulate a psychiatrist by lying about their symptoms or conditions and because prescription drug abuse can be difficult to detect, it is important to conduct proper screening before prescribing, particularly with new patients. Prescribers should routinely screen all patients at least at intake and annually thereafter. Screening should consist of assessing for current and past substance abuse and drug-seeking behavior. Patients should complete an addiction behavior checklist along with other paperwork for their visit, including answering detailed questions about their current/past use of controlled medications including the amount and frequency and what other substances are being taken or prescribed by other treating physicians.
Physicians and other medical professionals should also learn to identify patients who might be abusing prescription drugs or other controlled substances through observation and physical assessment. Symptoms that may indicate that a patient is under the influence of a controlled substance vary depending on the type of controlled substance a patient is abusing, but side effects commonly include slurred speech, pupil dilation, elevated hair follicles on the skin, and sweating. Because patients who abuse prescription medications may also use intravenous drugs, physicians and other medical professionals should check for needle marks on a patient’s arms, legs, and feet. A patient should also have a urine analysis conducted to detect the presence of any controlled substances in the body. Additionally, physicians’ offices should implement standard policies and procedures to verify patient identification, diagnostic imaging reports, and prior medical records.
Further, all fifty states have implemented Prescription Drug Monitoring Programs (PDMPs).8 PDMPs are electronic databases that collect data from pharmacists on controlled medications dispensed to state residents. Prescribers can register with these programs and log onto the database to see what controlled medications their patients have filled. In the majority of states, physicians are mandated by state law to check the PDMP before prescribing and may be required to recheck the database periodically thereafter. In all other states, prescribers may check the database on a voluntary basis. Many states allow prescribers to dedicate another medical professional to conduct searches for them. A psychiatrist or another medical professional should check the database each time before prescribing a controlled medication. Currently, there is no national database for checking a patient’s procurement of prescription drugs, and patients who are doctor shopping will often cross state lines. However, utilizing state PDMPs may significantly reduce a psychiatrist’s risk of subscribing to a patient who is doctor shopping.
By employing the tactics presented in this article, psychiatrists can reduce the liability risk associated with patients who are doctor shopping. For additional information regarding the liability risks associated with doctor shopping or if you believe that your patient is engaging in this behavior, please consult with a risk management professional or local attorney.
RISK MANAGEMENT TIPS TO PREVENT DOCTOR SHOPPING
- Observe federal and state prescribing regulations;
- Screen patients periodically for substance use disorder;
- Prescribe opioids only when benefits are likely to outweigh risks;
- Prescribe the lowest effective dose of immediate-release opioids. For acute pain, prescribe only the number of days that the pain is expected to be severe enough to require opioids;
- Safeguard prescription pads and log-in credentials;
- Understand and implement Prescription Drug Monitoring Program requirements;
- Thoroughly document all aspects of prescribing for a patient; and
- Consult with attorney/risk management professional when necessary.
1 McDonald, D.C. and Carlson, K.E., Estimating the prevalence of opioid diversion by “doctor shoppers” in the United States, 8 PLoS ONE 7 (2013).
2 CDC, Vital Signs, “Opioid Prescribing,” (July 2017).
4 CDC, Opioid Overdose, (9/5/17), https://www.cdc.gov/drugoverdose/index.html
7 Centers for Disease Control and Prevention, Doctor Shopping Laws, Public Health Law 1-7. https://www.cdc.gov/phlp/docs/menu-shoppinglaws.pdf.