Thursday, April 08, 2010

Shopping Spree

CNN recently had a story entitled How physicians try to prevent 'doctor shopping', about states' efforts to control and prevent prescription drug abuse. While it's a good story, it's unfortunate that we only tend to talk about this issue after the overdose death of a celebrity. Here at Shrink Rap we've talked before about our concerns and challenges related to this issue in a series of blog posts and one podcast which we've collectively referred to as "the Benzo Wars".

The Shrink Rappers have seen both sides of the prescription drug abuse issue and so we have different opinions about it. Neither opinion is all right or all wrong, we just differ on the degree of the problem and to some degree how it should be handled. Our opinions are shaped by the patients we treat: Dinah has a private practice and (I'm guessing here) probably doesn't have many patients with active addictions or legal problems related to this. I work in prison, and nearly 80% of my patients are locked up for crimes related to substance abuse.

First, the things we agree about (and that the CNN story also addresses): we agree that doctors can't be detectives and that we aren't lie detectors. We have no special ability to figure out who is or isn't lying to us about their pain and anxiety or exaggerating problems to obtain medication. We agree that most doctors have certain 'red flags' that raise a concern about abuse. We agree (although Dinah thinks I don't believe this) that patients with real pain and panic disorder deserve care that is delivered in an empathic, sensitive fashion and that questioning or doubting these patients can cause serious problems with the doctor-patient relationship.

That was the easy part.

What the CNN article doesn't address is this: what do you do when you find out that your patient is, in fact, receiving multiple controlled substances from more than one doctor? The CNN article implies that whenever this happens it means the patient must be "doctor-shopping" and that there's a problem.

This situation is going to be more of a challenge for Dinah than it is for me, because in correctional facilities controlled substances are rarely prescribed. When they are ordered, they are dispensed in a tightly supervised manner and generally for a limited time. If an inmate is caught with pills in his cell---whether or not they were prescribed for him---you know the medication is not being used as prescribed. Easy enough.

But what about free society? What if the patient tells you, "I have chronic pain and I get medication from Dr. So-and-So." Truthfulness is a good indicator that the patient probably isn't out to snooker you. True drug addicts rarely give you an avenue to check up on them easily. Nevertheless, physiologic dependence can happen even in the absence of abuse. If the patient is coming to see you for anxiety, I probably still wouldn't choose a benzodiazepine as a first-choice medication because I wouldn't want to cause yet one more dependency issue. There are non-habit-forming alternatives and SSRI's have been shown to have anxiolytic effects.

But what if the patient comes to you already on a benzodiazepine? This is where the benzo war started on the podcast, and where Dinah and I may differ. In this case I think you have to consider what the goal of treatment is going to be and physicians are going to differ with regard to their comfort levels in this situation. Presumably the patient has been referred to you because the previous prescriber either was unable or unwilling to continue the prescription. Unless the prescriber was dead or retiring, to me this could indicate a clinician's concern about the patient's pattern of use and I'd be reluctant to merely continue the status quo. A reasonable treatment goal would be to build coping skills to the extent that either the patient would no longer need medication, or could function with a non-controlled alternative. As strange as it may sound coming from a psychiatrist who mainly does medication-management, I do believe that psychotherapy can help with this.

What if you find out that the patient actually is selling, trading or giving away your controlled substances?

Most free society docs don't find out about this until the patient gets arrested. But say the patient is released on bail---do you accept them back in treatment? Do you continue to prescribe for them? Or what if the other doctor is prescribing unusual combinations of meds, or meds in doses that would raise the eyebrows of even the most liberal psychiatrist? Do you assume the doctor is over-prescribing or do you assume the patient must really 'need' the medication?

It's a complicated situation, made more complicated by the fact that even non-controlled psychiatric medications have street value. And don't even get me started on legalized marijuana.

I'm not trying to start Benzo War Part II, but it's an issue that doctors struggle with. I await your thoughts.


moviedoc said...

Most of my patients are recovering alcoholics or addicts, and I believe that many if not most of them are honest. As far as benzo's are concerned I almost always feel like a pusher when prescribing them. I never know whether the patient really benefits from them as a treatment. So I try very hard to screen out patients on benzo's before the initial evaluation, ie suggest they seek help elsewhere. And if I discover that a patient I am treating has been obtaining them from another source, I often discharge them. It's not a moral thing; it's just that I can't do my job well if I don't know what's going on. And if the patient can't trust me enough to accept my advice, they we be better off finding another physician.

Opiates like oxycodone are bigger problem. I treat opiate addicts with buprenorphine which has been the most successful single treatment of my career. Unfortunately the Feds send a mixed message, now harassing us with disruptive unannounced inspections which will discourage physicians from prescribing the drug, attempting to force us into an enforcement role which we really cannot fill. As you suggest physicians should focus on diagnosis and treatment. The notion that we can prevent diversion is make believe. And if buprenorphine were routinely prescribed for post-surgical pain, many lives would be saved.

Dinah said...

Dinah rarely prescribes benzodiezepines.

Anonymous said...

I'm a little confused about the definition of doctor shopping. Does the definition only apply when patients are seeing different docts to obtain addictive drugs? Does it only apply if patients are doubling up (or more) on scripts? Does it only apply if there's deceit involved?

I don't take any medication on a regular basis, but when I do see a physician I rarely see the same one. I opt for convenience. Since I'm not sick very often I look for who is open and available at the time I need to be seen. To wait a week or two to see a PCP for something that doesn't need to wait a week or two, well then I'm not going to wait. I did that before and ended up in the hospital with a kidney infection. That's when I decided I would go with who is available instead of trying to wait on my PCP. I no longer have a PCP. I go to the doctor only when I'm sick which is about twice a year if that. I see who ever is open, available and near where I live. Is that doctor shopping if I see a different doctor every time I'm sick? Is it doctor shopping if I am only prescribed an antibiotic? If so, then I guess I don't really care much because I think it's the patient's business unless of course they're lying to obtain narcotics or something.

moviedoc said...

Question well put, Anon. The term "doctor shopping" is definitely pejorative. I have never heard it applied to the idea of something noble like looking for the best or most skilled physician. Usually it is used in connection with drugs, more specifically drugs of abuse, and implies the "patient" wants a particular class of drug to get high, that most doctors using their best judgment refuse to prescribe those drugs, but the patient hopes to find an unprincipled physician will do almost anything to keep a patient coming back.

Anonymous said...

Folks with chronic pain and failed back surgeries almost uniformly never get better and find themselves being prescribed opiates basically for life. I admire the rare doctors who force their patients into work-hardening programs and alternative therapies. I work in a law firm and, unfortunately, I see this all the time. The patients taking opiates then get depressed about the pain and their restricted lifestyle; they get prescribed SSRIs by non-psychiatrists, such as PCPs; they suddenly can't sleep and get prescribed Seroquel. It's complete mismanagement.

Sometimes, folks who aren't properly screened do show up on a psychiatrist's doorstep "shopping" for benzos. But I believe most pdocs are smart enough to know who they're dealing with. Oh, I just had a thought: Is there a black market (street drug market) for Seroquel? Because they prescribe it for everyone and I know it's not that great unless you're trying to combat mania or voices or delusions/paranoia.

Anonymous said...

@ Anon #1 I shared the confusion about the term "doctor shopping." When I read the title, I was all set to emphatically argue that people certainly SHOULD meet multiple doctors and choose the most competent one who is most suited to treat their particular issues, yadda yadda, before realizing that you weren't referring to "doctor shopping" in the logical sense of shopping around for the best doctor before deciding on who to see.
@ Anon #2, I remember reading an article at some point about there being a black market for Seroquel-- I can't remember where it was that I read it, though. Speaking from my own experience, Seroquel is the only drug I've ever taken that perpetuated itself in the sense that it did horrible things to me, I hated it, and felt the need to keep taking it just so I wouldn't care so much about the side effects. I wanted to get off of it, and I couldn't, because without the numbing effects of the Seroquel, I'd be too devastated to be able to handle what my life had become while taking it. If that's not addiction, I don't know what is. Those scales measuring addictiveness as "enjoyability" are vastly misleading.

Anonymous said...

Anon #3, in a perfect world people would have time to interview and find the best physician. That's not reality for a lot of people. I grew up in a rural area where people could just walk in to the local doc's office and be seen that day. I saw the same physician growing up, and yes that's ideal.

Now, I live in a large city where it's a hassle to get anywhere. I'm opting for convenience. I don't see anything wrong with that. I don't have a chronic condition that necessitates continuity of care. I'm rarely sick, but when I am sick I'm not waiting on a PCP to get me in days later. It's not necessary that the physician trained at Harvard, was in the top 10% of his/her graduating class, and has excellent bedside manner to treat a UTI. In fact, it was the doc-in-a-box who sent me straight to the hospital when I had tried to wait on my PCP to get me in for what originally started as a routine UTI.

If by talking about doctor shopping this means only those going from doctor to doctor to obtain narcotics, then yes I agree that's wrong. My understanding is that that's illegal. I have no problem with anyone obtaining a narcotic being put into a database for physicians to check & making this database accessible to doctors in other states. If physicians are going to be held accountable when a patient lies to obtain script after script and then od's, then the physicians need to be able to protect themselves. I still see this as the patient's fault, though, not the physician's responsibility.

I don't support one database for all scripts, however. I think if the scripts are not addictive a patient should be able to see whoever they want whenever they want without it being anyone else's business.

Anon # 1

Dinah said...

Anon #1:
If you're on medicines (even if they aren't addictive) then you're doctor needs to know: medicines have side effects that mimic illness and if it's a likely side effect of a medicine, then you may end up with a whole work up you didn't need, and medicines interact with each other in dangerous ways. Also, people often don't know what medicines they are taking, and a data base allows a doc to check these things.

Doctor shopping? I think if someone doesn't think their doctor is helping them, they are entitled to see another doc. Dr. Shopping is fine. Clink's issue, however, is one of deception...not so cool

Sarebear said...

What about being prescribed clonazepam (generic for Klonopin, for those who don't know) for sleep punching, among other things.

Will it get to the point at some point where I'd have to go in with the bruises on my thighs that I assume are from sleep-punching myself? Because I haven't had them since being on the Clonazepam.

Actually, I tried to lower the dose of this med recently, to see if 3/4 of a mg would be effective, although since I didn't know if I was sleeping deeply enough given the knee/leg pain interfering with my sleep, for me to get into a state where the medication might be needed, I wasn't sure. But it turned out that 3/4 mg wasn't sufficient to stop nightmares with me shouting and yelling in my sleep, with me being aware of yelling "Help!" so loudly that as I awoke, yelling that, I could hear the people in the apartment above creak in their bead, and then go deathly still, pondering whether or not someone was being attacked below them; listening to hear if further noises of such kind would ensue. Since they didn't, as I carefully listed, it's almost like I heard them relax and then turn over, and sort of "stand down" from an alertness . . . at least, so I imagined. Cause I'd yelled "Help!" like bloody murder, like I was being assaulted. Because when I yelled it, I thought I was, for real. Of course, I was asleep at the time, but . . . at least this time I didn't sleep-run out of the room and try to open the front door and attempt to run out into the night.

That's only happened once, about a month in to our marriage.

So you can see, that I need SOMETHING to stop the . . . unconscious body movements and yelling, I suppose. Not that I want to be on such a medication forever, because I don't know what the long term consequences are. Thus my recent experiment with lowering the dose, but upon having several incidents in a week's period of time, I put it back to 1 mg.

Sleep punching the legs after a total knee replacement surgery wouldn't be so good, either. Doing the right one on Tuesday, took me two hours just now to finish the online registration forms, nothing like the last minute is there . . . .

But I DON'T want to be on meds like this forever. I'm extremely cautious with the Xanax, although I can say, since I had forgotten to get a prescription for a, what's that tranq that begins with a V, one each, for each of my MRI's last fall, that I was left with only the Xanax last fall to fall back on to control the panic, and boy, having never had an MRI before, and I'm not small, it took that and every erg of willpower I had to not bloody scream get me out of this thing.

But, I REALLY REALLY don't want to be on clonazepam long term, because I don'tknow what it'll do to me, long term. It's better than the close calls with a mean right hook my husband's had to his face, a couple of times, though, and a left hook that I've almost smashed into a nasty corner of a desk near the bed, at a speed that likely would have broken something (in me, not the furniture.)

Why do I have to have such wierd night habits? Some medical personnel have almost chortled disbelievingly when I've mentioned it.

Anonymous said...

Dinah, while I understand the rationale for a database allowing physicians to see what meds a patient is taking, I still want to be the one who determines what information about myself is available to the treating physician (with the exception I mentioned before being addictive drugs). I'm a grown up, and I'm capable of telling the physician what meds I take and at what dosages. If I choose not to disclose what I take and there is a drug interaction, then that would be my own fault.

I know that doctor shopping is a problem and people go from doctor to doctor to obtain addictive meds, however I have concerns that attempts to address the problem may go too far. Fine to keep track of controlled substances, not fine to go beyond that. Why do I care about physicians having access to info about other medications without my permission? I would never be free from my psych history, and I kind of like not being viewed as a psych patient by my subsequent treating physician(s).

Anon # 1

Anonymous said...

""If the patient is coming to see you for anxiety, I probably still wouldn't choose a benzodiazepine as a first-choice medication because I wouldn't want to cause yet one more dependency issue. There are non-habit-forming alternatives and SSRI's have been shown to have anxiolytic effects.""

Hmm, have you ever tried to get off an SSRI? And please, no arguments that it is discontinuation syndrome and not an addiction.

Anyway, that is why sites like Paxil Progress are so popular. It is run by an RN whose son had severe problems due to a Paxil tapering schedule that was way too fast. Now that he is off Paxil, he is fine.

Many people on other SSRIs come to this site for support because psychiatrists like Clink act like they are not addictive.

Please don't misunderstand me, I am not extolling the virtues of benzos. I don't disagree that they can be addictive.

But to act like they are the only psych meds that cause addiction is simply inaccurate.

To the last anonymous - I agree about physicians having complete access to my drug history without authorization. Once I am completely off the psych meds which I suspect will be sometime next year, this is something I want to leave behind.

And even now, I am careful about sharing this because I have had the experience of being discounted by doctors once I said I was taking a psych med.


Anonymous said...


You make a good point, and while I'm not going to keep my disanosis secret from other providers, I sort of agree with you. Now you have got me thinking. I saw a neurologist for migraines and he always had his receptionist sit in the office with us--to take notes. Even if it was a 10-min follow-up appt., there she was. If the phone rang, she would go into a corner of the room and whisper into it. I don't know if this was because she wanted to study nursing (at age 48??), or if the physician made note of my psych history and wanted an observer in the room.

Is there even any doctor-patient privilege when the receptionist is part of the clinical exam? More than likely, he found out I was an attorney, and he needed a witness for fear of being sued. What a jack@ss! I don't know, though, if I filled out a demographic questionnaire and he saw my profession on there, or if he got into the electronic med record system and read it in some other provider's note; or if he found out I was an attorney after the receptionist had already joined us. Still, I wish I knew if this was his standard operating procedure for all patients. . . .

moviedoc said...

Anon the attorney: Not sure about privilege, but you certainly had a right to ask that the receptionist not be present. On the other hand the receptionist would likely have access to records anyway, and even HIPAA, I believe, does not require patient authorization for other office staff to see your records.

As for patients who want to conceal their history of psych meds, you certainly have a right to do that, and it's laudable to take responsibility for the consequences for yourself, but this also serves as a reminder to all docs that we cannot trust our patients to tell the whole truth.

BTW: The Web based "eprescribing" service I have been using shows me a list of meds prescribed by all prescribers. I like it. Patients should know about it.

Anonymous said...

Depending on how a script database is setup or works it may or may not be helpful.

With chronic illness I'm seeing multiple docs, some within the same university medical center with a centralized electronic medical record system. I have one doc outside this system

I am dutiful about correcting/updating my medications list at each appointment to note any changes by my outside doc. Frequently I find on my next appointment that the med list was not updated or updated incorrectly - including listing the wrong meds, old meds or incorrect dosages. Not a very accurate system from my perspective.

On another note - I would not have thought it necessary to hide my psych dx until the past year when I started developing pain issues. I'm really tired of being told by docs that "fixing the depression will fix the pain." Having a mental illness doesnt mean its all in my head and its frustrating to go untreated. Seems to me if someone would treat my pain I would be less angry and depressed.

Anonymous said...

Moviedoc writes, "BTW: The Web based "eprescribing" service I have been using shows me a list of meds prescribed by all prescribers. I like it. Patients should know about it."

You're right patients should know about it. I'm glad I've known about it for quite some time and it makes me even more glad I stopped seeing that psychiatrist when I did.

When stigma disappears then maybe I'll consider sharing previous psych history with health care professionals. My psych disorder was largely iatrogenic, and once I was off all the meds it cleared right up. So, I don't feel a misdiagnosis is pertinent info to share when giving my medical history.

When I see how those with a psych history are treated by other health care professionals then I know I'm making the correct decision. Stigma around mental illness is alive and well. Just ask the patients with a psych history who visited Beth Israel's ER. Do I feel badly about not sharing my psych history with the physicians I see today? Heck no. I'm pleased with the care I've received in the years since then.

Anon # 1

moviedoc said...

Anon #1: I wish it were just stigma: People with history of psychiatric treatment or addiction are also denied life insurance and otherwise discriminated against. The type of prescription database I said patients should be aware of will also make docs think they know everything when they really don't, so they will neglect to ask, and patients will get hurt. It's a catch 22, maybe one reason we don't have support for a single payer system.

Jules said...

It disturbs me immensely that any doctor would allow a new patient to go through benzo withdrawal (when you know full well it can precipitate a seizure and possibly death), just to CYA. Unreal. I thought I'd heard it all.

Anonymous said...

Moviedoc, I agree that it's not just stigma that's a problem. If I were self employed I would be completely screwed. I would have to disclose the psych history on an application for health insurance/life insurance, and I'm sure I wouldn't qualify because of it. I guess I'll always have to work for a large company.

Anon # 1

Roy said...

So many good issues here.
To the Anon Esquire: another explanation for the receptionist sitting in taking notes may be that the doc was using a "scribe." Scribes are seen with increasing frequency in the ER, freeing the doctor to focus on tha patient's problems, not the patient's documentation. I've not heard of private practice docs doing this, though I wouldn't be surprised to see more of it in the future, especially with the push for docs to adopt computerized EHRs. I can imagine a receptionist in the corner with the iPad, dutifully recording what is being said and done.

On the issue of doctor shopping for narcs, I see this in my hospital setting, but it plays out differently. Patient comes in for an overdose after being found unresponsive, waking up angrily when the paramedic pushes a shot of Narcan (a narcotic blocker that lasts an hour or so). There are current symptoms of depression with occasional suicidal ideation due to the pain, and patient says he has chronic back pain for which he is prescribed Percocet 10mg 4 times per day as needed, sometimes more than prescribed. It is always needed. Asking to speak with his PCP, he says he stopped going to Dr Jones who had insisted he go to a pain specialist, but the patient hadn't set that up, for any number of reasons. The patient is admitted to psychiatry for a suspected suicide attempt and depression.

Now, what do you do? Hospital pain consults for chronic pain (as opposed to acute pain) are rarely very helpful, in my experience. So, do you put the patient on pain medication in the hospital? If not, do you need to detox? Who do you call to confirm the dosage, or do you just take their word for it? Do you discharge them with a narcotic prescription? How much? 3 days? A week? Who prescribes it after that is gone? What happens often is that they show up in the ER a week later with pain and asking for pain medication. They show the empty 3-day bottle of narcotics with my name on it as proof that they are really prescribed this medication. And so the circle continues.

This is the type of patient for which a registry of controlled prescriptions might make sense. If an ER doctor could pull up their history and see that 15 different doctors from three different counties have provided short-term prescriptions over the past 6 weeks, it is likely that the ED physician would not provide yet another prescription. You don't know if the patient truly needs them, is abusing them, or is selling them (at $5 per pill, a 30 day supply of 120 Percocets is $600, which is quite an income supplement to someone getting $706 per month for disability). These registries could help to stop this part of the cycle.

On the other hand, I also believe that all patient health information should be available to the patient, who should be able to control which information is available to whom and to see who has accessed which information and for what purpose. This level of transparency is increasingly becoming advocated for by groups like and, and even Microsoft and Google, who both have PHR products.

If this were to happen, some method would need to be considered to indicate to a prescribing physician that *relevant* information is available but that the patient chooses to keep it confidential.

Dinah said...


moviedoc said...

Roy: I propose you give this type of patient buprenorphine/naloxone SL as soon as they are alert enough to manage it. You can prescribe it legally off label for pain without having the special DEA number you need for detox/maintenance use. It has a longer elimination half life than methadone, so even if you only provide a small amount there should be minimal w/d syndrome, and it's a much safer drug in OD, and produces little high. Maybe the pt. will like it and get on maintenance.

Who do you call? Dr. Jones! If the pta. doesn't let you, don't give them anything. Drives me nuts when my patients go to the ER and the ER docs don't have the courtesy to call me. I consider that negligence.zeduce

Dinah said...

Please don't egg on Roy until he finishes his chapter on Hospital-based psychiatry. He missed his deadline last week, and if he doesn't get this chapter in on monday, it will not be a very happy blog we have here.

moviedoc said...

Roy: If Dinah gives you too much trouble here you should feel free to comment on one of my blogs. Besides, you can't force creativity.

Anonymous said...

Roy writes, "If this were to happen, some method would need to be considered to indicate to a prescribing physician that *relevant* information is available but that the patient chooses to keep it confidential."

Who gets to define relevant? If a patient doesn't want a physician to see what another physician has written about them, then why should there be notification the patient is hiding something? Not everything a physician writes is relevant. Some physicians are impaired and quite screwed up. I had one of those. He also had a criminal record that he hid. Will the patient also get to include notification when the physician is hiding *relevant* information, so the treating physician will have the complete picture?

I hate the big brother stuff. A patient is not doing anything illegal if he/she chooses not to disclose his/her psych history. I've always had great care in all the years since without my treating physician knowing I was treated by a drunk shrink many moons ago.

Anonymous said...

To Roy: While the doc could have been using the receptionist as a scribe, I'm sticking with the "cover-your-ass-in-front-of-lawyers" theory. I say this because this provider has made more than one nasty comment about lawyers in my presence. And, honestly, the receptionist wasn't that good. The doc said, "Come back and see me in 4 weeks" and she offered something that was 8 weeks away. I reminded her, "I think he wants it to be in 4 weeks" and she said, "Oh. Duh. And you're the one with the headache . . . ."

I doubt this doctor's ever been sued, but perhaps someone attempted to take him or a mentor to the cleaners. It's a shame he didn't realize that when I'm in a doctor's office for treatment or consultation, I'm wearing only my "Patient" Hat.

-Anon Esquire