Doctor Shopping and
Rx Drug Abuse
Bonnie Mixon McCrickard, Community Anti-Drug Coalitions Across Tennessee
Kristine Harper Bowers, Coalition on Appalachian Substance Abuse Policy
Rural Health Association of Tennessee 2010 Annual Conference
November 17-19, 2010
Pigeon Forge TN
Doctor Shopping is
• A strategy used by patients (dealers and
addicts) to procure and/or divert prescription
drugs from multiple physicians for nonmedical use/abuse or illegal resale.
Methods of Dr. Shopping
• Going to multiple doctors with a wide-array of
complaints in search of many prescriptions
• Alternatively, using legitimately sick patients, i.e.
cancer patients, to seek prescriptions in different
cities
• Physicians who readily dispense prescriptions
without appropriate examination or screening are
often targeted
• Drugs are used and/or ‘diverted’ (sold) for other
uses than prescribed
Four Ds of Doctor Shopping
•
•
•
•
Deficient (Dated Practitioner)
Duplicity (Deception)
Deliberate (Dealing)
Drug Dependent (Addict)
Outline
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Defining the problem
Issues that impact the problem
Impacts
What’s being done
Resources
Objectives
• Recognize Rx drug abuse issues in Tennessee
• Identify current strategies to stem the flow of
illegal medicines and reduce overall abuse
• Take away: basic information to engage local
communities
Indicators
•
•
•
•
#s of Rxs
Crime
Deaths
Reports and statistics
– Insurance payments
– Crime reports
Sky Rocketing Opioid Use
•
•
•
•
Pharmaceutical marketing
Guidelines and standards
Patients’ Bill of Rights
Increase in internet
availability
• “Pill Mills”
• Street value of drugs
*Manchikanti, L. “Prescription Drug Abuse: What is being done to address this new drug epidemic?
TN Drug Snapshot: BCBST Commercial
* Courtesy
of Dr. Bruce Taffel, Shared Health
Retail Sales of Selected Opioid
Medications (grams of medication) for
*http://www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html
QuickStats: Age-Adjusted Death Rates Per 100,000
Population* for the Three Leading Causes of Injury†
Death --- United States, 1979--2006
National Vital Statistics System, mortality data, http://www.cdc.gov/nchs/deaths.htm (for 2006 rates); and CDC
WONDER, compressed mortality file, underlying cause-of-death, available at http://wonder.cdc.gov/mortsql.html
(for 1979--2005 rates).
CDC/NCHS, National Vital Statistics System:
From 1999 through 2006, the number of poisoning deaths nearly doubled
from almost 20,000 to more than 37,000. In 2006, over 90% of poisoning
deaths involved drugs.
Unintentional Drug Poisoning Mortality Rates by Drug
Category in the United States from 1979-1998
*Paulozzi et al. Increasing death from opioid analgesics in the United States
Nonmedical Use of Pain Relievers in Past Year among Persons Aged 12
or Older, by Substate Region: Percentages, Annual Averages Based on 2006,
2007, and 2008 NSDUHs
Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2010). Substate estimates from the 2006-2008
National Surveys on Drug Use and Health. Rockville, MD. Web only report is available at: http://oas.samhsa.gov/substate2k10/toc.cfm
What is the difference?
Nonmedical Use of Pain Relievers in
Substate Regions: 2004 to 2006
Nonmedical Use of Pain Relievers in
Substate Regions: 2006 to 2008
Death rates for poisoning involving opioid analgesics varied
more than eightfold among the states in 2006.
Illicit Drug Dependence or Abuse in Past Year among Persons Aged
12 or Older, by State: Percentages, Annual Averages Based on 2004
and 2005 National Survey on Drug Use and Health, SAMHSA
Source Where Pain Relievers Were Obtained for Most
Recent Nonmedical Use among Past Year Users Aged 12
or Older: 2006
Source Where Respondent Obtained
Bought on
Drug Dealer/ Internet
0.1%
Stranger
More than 3.9%
One Doctor
1.6%
One Doctor
19.1%
Bought/Took
from Friend/Relative
14.8%
Other 1
4.9%
Free from
Friend/Relative
55.7%
Source Where Friend/Relative Obtained
More than One Doctor
3.3%
Free from
Friend/Relative
7.3%
Bought/Took from
Friend/Relative
4.9%
One
Doctor
80.7%
Drug Dealer/
Stranger
1.6%
Other 1
2.2%
Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown.
1
The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s
Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”
Tennessee Prescription Facts 2007*
• Tennessee retail prescriptions per capita annually were
1.41% higher than the national average (TN = 16.2 vs. US =
11.5). West Virginia was highest at 17.7 annual
prescriptions per person followed by Alabama (16.7) and
South Carolina (16.4). Tennessee was fourth.
• 19-64 year olds filled prescriptions at 1.42% higher rate
than US average (TN = 15.9 prescriptions per person vs.
11.2 US) - the fifth highest in the nation. Prescriptions per
person for ages 65+ were 1.56% higher than US average
(44.5 for TN vs. 28.6 for US) - the highest in the nation.
Men and women filled prescriptions at a rate 1.43% higher
than the rest of the US.
*The Henry J. Kaiser Family Foundation State Health Facts
www.statehealthfact.org
Reasons for Abuse
•
•
•
•
•
•
Increasing Supply and Demand
Advertising and Advocacy
Availability, Internet, and Street Value
Perceived Safety and Perception of Risk
Lack of Education
Ineffective Prescription Monitoring
Improper Prescribing
• Some physicians lack knowledge about:
–
–
–
–
Pain management guidelines
Addiction potential
Identifying signs of addiction
Database for patients’ narcotic prescription history
• Although rare, some physicians may write illicit
prescriptions for profit or to feed their own
addiction.
Accidental Drug Overdose Deaths in Tennessee, Largest
Increase by County
30
Other Select Counties
Major
Metropolitan
Counties
25
Rate Per 100,000
20
2001
2005
15
10
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Selected Tennessee Counties
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Data provided by TN DOH Health Care Statistics
From Controlled Substance Monitoring Database by Keith Eidson, Pharm.D. April 6, 2009
Top 10 Prescription Drugs Listed on Death Certificates in Tennessee
2001
1
2
3
4
5
6
7
8
9
10
Morphine*
Diazepam**
Carisoprodol***
Hydrocodone*
Methadone*
Oxycodone*
Codeine*
Amitriptyline
Promethazine
Coumadin
2005
21
15
14
14
14
13
8
8
6
6
1
2
3
4
5
6
7
8
9
10
Methadone
Morphine
Fentanyl
Oxycodone
Diazepam
Alprazolam
Hydrocodone
Carisoprodol
Citalopram
Propoxyphene
112
74
46
46
44
39
36
25
16
14
*11 not included classified only as 'opiates'
**10 not included classified only 'Benzodiazepines'
***6 included due to Meprobamate
Data provided by the Department of Health, Health Care Statistics
From Controlled Substance Monitoring Database by Keith Eidson, Pharm.D. April 6, 2009
Tennessee Controlled Substance
Monitoring Database Statistics
Pharmacist:
Practitioner:
Total # of 17,738,054
Rx’s
Total # of
135,940
Request
2007
1,678
1,888
2008
2,290
5,310
14,602,916
2.54 million
From Controlled Substance Monitoring Database by Keith Eidson, Pharm.D. April 6, 2009
Top 5 Drugs Dispensed in Tennessee
Hydrocodone
Zolpidem-Ambien®
Propoxyphene
Oxycodone
Benzodiazepines Alprazolam/Lorazepam…
From Controlled Substance Monitoring Database by Keith Eidson, Pharm.D. April 6, 2009
Street Resale Values
Drugs and Alcohol found in Autopsy Cases
Upper East Tennessee Forensic Center
*Harrell C, Ferslew K, et al. IMPACT OF DRUGS AND ALCOHOL ON MANNER OF
DEATH BY SEX AND AGE AMONG AUTOPSY CASES PERFORMED AT THE UPPER
EAST TENNESSEE FORENSIC CENTER IN 2007.
Individual Drugs from East Tennessee Autopsy
Results
*Harrell C, Ferslew K, et al. IMPACT OF DRUGS AND ALCOHOL ON MANNER OF DEATH BY
SEX AND AGE AMONG AUTOPSY CASES PERFORMED AT THE UPPER EAST TENNESSEE
FORENSIC CENTER IN 2007.
Narcotic Violations in 2007 County by County for East Tennessee
A Case Study: Dr. John T. Hancock
 FORMER HAWKINS COUNTY DOCTOR ARRESTED FOR
PRESCRIPTION DRUG CHARGE -September 17, 2008
 Charged patients $80 to $100 in cash per visit netting
him over a million $
 Wrote narcotic prescriptions without performing
physical examinations and without determining
sufficient medical necessity for the prescriptions
 Narcotic prescriptions were for patients’ use and to
share with him
 Prescribed inappropriate drug quantities/combinations
- including: Oxycodone, Hydrocodone, Methadone,
Morphine, Fentanyl, Lortab, and Benzodiazepines.
• Result: 112-count indictment issued in Greeneville,
Tennessee. The indictment identifies five patients who
are alleged to have died as a result of Hancock's
prescribing practices.
Who is Affected?
•
•
•
•
•
Physicians
Pharmacists
Patients
Law Enforcement
Community
Problems Facing Physicians
• Top 3 mechanisms of diversion PERCEIVED by physicians
– Doctor shopping (96%)
– Patient deception (88%)
– Prescription forgery (69%)
• 47% feel pressured by patients
• Only 19% reported medical school training in identifying
prescription drug diversion
• 43% do not inquire about prescription drug abuse history
• In the last 12 months, 74% have refrained from prescribing
controlled medication for fear of patients becoming addicted
Problems Facing Physicians
• Costs of pain management systems
• And they must always consider:
– Litigation for failure to treat pain or for
undertreatment
– Criminal charges for abuse, addiction, or death
– Numerous Federal regulations
– Investigation / Action by State Board of Medical
Examiners, Drug Enforcement Agency, and State
Bureau of Narcotics
– Complaints by State Board of Pharmacy
Problems Facing Pharmacists
• When a patient asks for a controlled drug by brand name,
78% become “somewhat or very” worried about diversion
or abuse
• Only 50% receive training in identifying prescription drug
diversion, abuse, or addiction
• 61% do not regularly inquire if patient is taking any other
controlled medications when dispensing a controlled
medication; 26% rarely or never do so
• 29% have experienced a theft of controlled drugs at their
pharmacy within the last 5 years; 21% do not store certain
controlled drugs in order to prevent diversion
• 25% do not regularly validate the DEA # of the prescribing
physician when dispensing controlled drugs
• 83% have refused to dispense a controlled medication on
grounds of suspicion of diversion or abuse
Problems Facing Pharmacists
• Costs
– Time to validate DEA license
– Time to check Controlled Substance Database
• Institutional restrictions
• Privacy regulations
Problems Facing Patients
•
•
•
•
•
•
•
•
Under-treatment of pain
All patients are under suspicion
Influence of pharmaceutical advertising
Influence of advocacy groups to increase to
patient demand of more opioids
Easy access to drugs through the Internet
Patient beliefs that they have the right to total
pain relief
Increased healthcare costs
Aggravation
Law Enforcement Issues
• Crime
– Diversion
– Theft
– Prosecution
• Enforcement
• Public trust
• Costs
– Personnel
– Coverage
Impacts on the Community
•
•
•
•
Quality of life
Crime
Social fabric
Increased costs
Other Issues Impacting Prescribing
• Insurance availability
– Tenncare/Medicaid
• Healthcare shortages
• Health disparities
• Demographics
• Borders with other states & regional
impacts
• Ethics
National Strategies
• SAMHSA Initiatives
– Data
– Treat & Prevention Block Grants
– Grants and other resources
• Office of Drug Control Policy
• NASPER
• Drug Enforcement Administration
– Safe and Secure Drug Disposal Act 2010
• Drug Free Communities
(Wall Street Journal map) October 29, 2009
State Strategies
• Controlled Substance Data Base
• Anti-fraud prosecution
– Tenncare
– BCBST
• Drug Task Force
• Provider Incentive Program to encourage EMR
• TN Dept of Mental Health & Developmental
Disabilities Initiatives
• TN AMA Rx Safety Course for Physicians
Community Strategies
• Community Education
• Encourage use of Controlled Substance
Database
• Relationship with law enforcement
• Drug Take Back/Disposal events
• Community Coalition
– Assessment
– Planning
– Environmental strategies
Other Proven Strategies
• Academic detailing
• Broad physician use of accepted pain
management techniques
• SBIRT
• E-prescribing acceptance
• Medication Safety classes for Seniors
If you try to obtain a prescription for a
controlled
substance that you have had filled in the last
30 days, and
do not tell your prescriber about it, you are
breaking the
law and we must report you to local law
enforcement.
If you are unsure if your medications apply,
please talk to
your prescriber.
This office will not aid criminals in obtaining
controlled substances and we reserve
the right to refuse a prescription
to anyone at any time.
More to be done
• Communication
– Education required for Providers, Patients, Law Enforcement
– Community awareness
• Coordination
– Among all sectors involved
– Horizontal and vertical
– Across state boundaries
• Cooperation
– Among agencies
– Between providers
• Specifics
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–
–
–
–
Use of Rx monitoring database
Prescribing & pain mgt. guidelines
Abuse resistant prescriptions
Improved labeling
Monitor Methadone clinics
QUESTIONS and DISCUSSION
Contact Us
Bonnie Mixon McCrickard, LAPSW
Program Director
Community Anti-Drug Coalitions Across
Tennessee (CADCAT)
1120 Dickerson Pike
Nashville, Tennessee 37207
Office: 615-227-5250
Fax: 615-227-5249
Mobile: 615-587-4788
Toll-Free: 877-727-1772
BMcCrickard@cadcat.org
Kristine Harper Bowers
Coalition on Appalachian Substance Abuse
Policy (CASAP)
ETSU Office of Rural and Community Health
and Community Partnerships
PO Box 70412
Johnson City, TN 37614
Office: 423-439-7156
Fax: 4423-439-7156
Bowersk@etsu.edu
Coalition on Appalachian Substance Abuse Policy
www.cadcat.org
www.appalachiancoalition.com