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Identifying drug seekers and doctor shopping behaviours

Identifying drug seekers and doctor shopping behaviours

Drug-seeking behaviour is often sophisticated, manipulative, and demanding. Are you aware of the behaviours that should raise your suspicion?

29 / 06 / 2021

Quick guide

  • Drug-seeking behaviour is varied and patients who become dependent on drugs can be from all walks of life.
  • Many doctors have access to real-time prescription monitoring services in their state or territory, which should be used to assist in quality and safe prescribing practices.
  • The Prescription Shopping Programme is available to all doctors in Australia to check a patient’s prescribing history.

People from all walks of life can develop a problematic use of drugs of dependence. These drugs have properties which make them addictive, with a high potential for misuse. Recognising behaviours which suggest misuse of drugs is crucial to ensure patients are kept safe. This can be difficult because drug-seeking behaviour is often sophisticated, manipulative and demanding.

There are unique clinical considerations and legal obligations for doctors when prescribing drugs of dependence. A failure to comply with these could lead to disciplinary action.

What is drug-seeking behaviour?

The term ‘drug-seeking behaviour’ describes a range of actions a patient may use to obtain a particular drug. It is important to consider these actions with the other circumstances surrounding the patient and the consultation. These considerations should help you determine whether or not a patient has a legitimate need for the drug.

Some patient behaviours which may raise your suspicion are:

Requests and complaints

  • requests a drug by name and sometimes by dose
  • claims that pain-specific medicines are ineffective despite maximum dosages
  • asks for something to help cope with opiate or benzodiazepine withdrawal
  • presents with a range of problems for which many interventions have apparently been ineffective
  • claims they have an allergy to non-addictive drugs or complains that they “don’t work”
  • presents with inconsistent examination findings
  • claims to be in pain that appears disproportionate to medical presentation.

Common behaviours

  • frequently presents or calls after hours, or late in the day for a consult
  • travels far from home/work to visit the practice, or claims to be from out of town
  • frequently calls the practice or arrives unannounced for refills
  • consults with multiple doctors
  • claims to lose prescriptions or run out early; this would require further questioning from you
  • becomes distressed or angry when told “no”
  • doesn’t adhere to drugs of dependence agreements
  • offers bribes or makes threats.

A drug-seeking patient is less likely to be a long-term patient of your practice. However, long-term patients may also present to you with similar reasons or excuses. You may see such a patient when their usual doctor is not available, or they may present to emergency departments. They may have also refused or failed to attend appropriate specialists for review and advice on managing their pain or addiction.

How can I identify a doctor shopper?

‘Prescription-shopping’ or ‘doctor-shopping’ is when patients deliberately obtain more medicines than are clinically needed. This is often done by visiting many doctors, without telling them about their other consultations.

It is not only patients who are drug-dependent who are at risk of becoming doctor-shoppers. Patients in financial need may attempt to sell their medicines.

Some states and territories have real-time prescription monitoring services to help doctors understand their patients’ prescribing history outside of their practice. Doctors should access this information where available to help identify circumstances where a patient may be at risk of harm from the use of a medicine. Increasingly, software and computer programs limit multiple scripts being prescribed. In some jurisdictions, it is mandatory for doctors to check a patient’s prescription history in the jurisdiction's prescription monitoring service before prescribing a ‘monitored medicine’. Make sure you are aware of the legislative requirements in your state or territory. A patient’s My Health Record may also have information about past prescriptions.

Doctors in all states and territories can use the Australian Government’s Prescription Shopping Programme. It allows doctors to check a patient’s prescription history to help make more informed prescribing decisions for their patients. The program includes an information service and an alert service. You can call the information service 24 hours a day, seven days a week on 1800 631 181. It is important to note that patients will only be flagged in this system if they have visited six or more doctors and received 25 prescriptions in total from these doctors. Therefore, only frequent drug-seeking behaviour is identified. The service does not monitor private scripts or those from the Department of Veterans’ Affairs.

Practice management and clinical strategies

Patient safety and high-quality care and empathy should be the underlying principles when discussing clinical strategies. Although sudden withdrawal from a drug of dependence may expose the dependent patient to risk, continuing to prescribe can perpetuate problem behaviours and jeopardise the patient’s safety. It also exposes you to professional and legal consequences if you fail to comply with your jurisdiction’s prescribing guidelines and legislation. To help manage these requests, it is important to develop a consistent approach within your practice. You could place a sign in your waiting room or on the front door. Suggested wording includes:

Strong painkillers and sleeping pills policy

Except for terminal cancer, our policy is that we will not prescribe these types of medicines (e.g. oxycontin or temazepam):

  • at your first appointment
  • on a phone request
  • without a proper assessment
  • over the long term (we prefer safer and better options).

This does not mean you cannot prescribe a drug of dependence on the first appointment if the situation requires, but it might limit drug-seeking behaviour. If you refuse a patient's request, the presence of the sign or practice policy indicates that it is a policy decision, not a personal one.

Ideally, a patient should be seen by the same doctor in the practice to manage their requests, provide consistent care and help monitor and adhere to any plans in place. Try also to encourage patients to go to a local pharmacy, again for consistency.

Before prescribing, you should complete a detailed clinical assessment and fact-checking exercise such as:

  • Confirm the patient’s identity and history: attempt to call the previous doctor/s or services involved in care and consult databases (e.g. pharmacists, Services Australia’s Prescription Shopping Information Service). Check for injection sites and consider a urine drug screen.
  • Check real-time monitoring services, if available in your state or territory.
  • Consider time-limited trials, supervised dosing and staged supply and/or prescribing small amounts and implement a follow-up regime. Ask for advice or second opinion if unsure.
  • Write tamper-resistant prescriptions that comply with the legislative requirements for prescribing drugs of dependence and prescribe the exact amount to carry through to the next appointment.
  • Phone a professional telephone advice service in your state or territory and discuss your concerns with an addiction medicine specialist.

All doctors and practice staff should be made aware of practice policies to ensure consistent adherence to them. Doctors should also make detailed notes in a patient’s medical record about requests, management plans and adherence. This will help with continuity of care within the practice in the long term.

How do I say "no”?"

You need to say “no” in a respectful and clear way so there is no room for misinterpretation and ambiguity. Give a reason for not prescribing, such as: “It’s my choice not to prescribe this to you today” or “It’s clinic policy we don’t prescribe to patients I haven’t seen before”. Ideally, do this early in the consultation.

Consider non-pharmacological alternatives or offering to refer the patient to a colleague with an interest or expertise in this area.

Sometimes, declining to provide a prescription can trigger an aggressive or threatening response from a patient. It is paramount that you have personal safety measures in place in your practice should a situation such as this arise. These measures should already be in place (e.g. positioning the office furniture so a patient cannot block your exit, placement of readily accessible duress alarms, use of the internal phone or messaging systems). In addition, trust your judgement and take additional measures such as leaving the consulting room door open, or finding a reason to leave the room if you feel uncomfortable.

Other services

Each state and territory has alcohol and drug advisory services which you can contact. This will give you the opportunity to discuss the situation with a specialist and receive advice on the management of drug-dependent patients.

Additional resources

IMPORTANT: Avant routinely codes information collected in the course of assisting member doctors in medico-legal matters into a standardised, deidentified dataset. This retrospective analysis was conducted using this dataset. The findings represent the experience of these doctors in the period of time specified, which may not reflect the experience of all doctors in Australia. This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision-making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published (June 2021). © Avant Mutual Group Limited 2021.

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