Prescription drug abuse is on the rise. Taking advantage of their legitimate need for pain medication, some postoperative patients will visit multiple doctors, a practice known as "doctor shopping," in order to acquire more than one narcotic prescription. Now, a new study presented at the 2014 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) estimates that 20 percent — one in five — of all post-op orthopedic trauma patients are doctor shopping, which has led to a general increase in drug use.

For the new study, a team of researchers reviewed prescription records for 151 adult patients admitted to an orthopedic unit at a level one trauma center during 2011. Using the Tennessee Controlled Substance Monitoring Database (CSMD), the team compiled data on narcotic prescriptions obtained three months before and within six months after each patient's orthopedic procedure. The results of the study, titled "Narcotic Use and Postoperative Doctor Shopping in the Orthopaedic Trauma Population," found one out of every five patients were "doctor shopping." These same patients used postoperative narcotics four times longer than single provider patients (112 days versus 28 days) and they also had an average of seven prescriptions for opioid drugs compared to just two prescriptions for single provider patients. Plus, they had a higher morphine equivalent dose (MED) each day (43 milligrams versus 26 milligrams).

All told, the researchers found that patients were 4.5 times more likely to seek out an additional provider if they had a history of preoperative narcotic use. In order to end this practice, the study team recommends close monitoring of opioid prescriptions following orthopedic surgeries.

How to Prevent Prescription Drug Abuse

The National Institutes of Health estimates that about one in every five Americans have used prescription drugs for non-medical reasons, a practice considered to be prescription drug abuse. Of all drugs, pharmaceuticals are second to marijuana as most commonly abused. In a post on the AAOS website, Drs. Michael R. Marks, Donna Phillips, David Halsey, and Andrew Wong address the general subject of dealing with a patient who complains of severe pain and requests an opioid prescription. “As the misuse of prescription medications has increased dramatically in the past few years, particularly for opiates, it has become increasingly important to identify drug-seeking behavior,” the team wrote.

According to this team of doctors, one of the first steps in dealing with a drug-seeking patient is to try to understand the underlying motivation. Physicians often assume the desire is based primarily on addictive tendencies or lack of coping mechanisms to deal with pain. Yet the situation may be much more complex. For example, a patient might not understand the normal course of recovery. Or a patient might be unaware of treatment alternatives or has failed to adhere to the treatment program in place, which might include physical therapy, oral NSAIDs, or modified physical activity. Other patients may want the extra narcotics in order to sell them for the extra money.

No matter the reason, this situation amounts to a difficult conversation between doctor and patient.

How many doctors are simply embarrassed to question their patients about potential drug abuse? Probably most. Some physicians naturally prefer to give patients the benefit of the doubt. At other times any number of practical factors, such as a lack of time or a lack of training in this area, prevent a doctor from speaking to their patients. For this reason, Marks and his colleagues have outlined a set of prevention strategies:

  1. Create a policy that covers prescription medication use, including the timing and frequency of refills, and make patients aware of this policy at the first visit.
  2. Avoid prescribing controlled substances at the first visit.
  3. Partner with other doctors and providers to limit the patient’s sources of pain medications.
  4. Document the frequency and timing of drug refills in a pain management contract that gives patients a clear understanding of recovery times for injury or surgery.

Currently, 37 states have prescription drug monitoring programs to help law enforcement identify doctor shoppers. What many physicians don’t know is the same data is also accessible to them. Whenever possible, surgeons should review medical records and speak with a patient’s primary physician about past medication problems. With the advent of electronic medical records, this step will be even easier. Finally, doctors might even insist on urine or other tests to identify prescription drug abuse, if necessary.

Source: Marks MR, Phillips D, Halsey D, Wong A. Tips for Dealing with the Drug-seeking Patient. AAOS website. 2014.