Identifying drug seekers and doctor-shopping behaviours

• Drug-seeking behaviour is varied and there is no single profile of a patient who may become dependent on drugs.
• All states and territories have real time prescription monitoring services that doctors are encouraged, and in some states required, to use to assist with safe prescribing practices.
• The Prescription Shopping Program is also available to all doctors in Australia to check a patient’s prescription history.

People from all walks of life can develop problematic use of drugs of dependence. These drugs have properties which make them addictive, with a high potential for misuse. To keep patients safe, it is important for doctors to learn to recognise behaviours that suggest misuse of drugs. However, this can be difficult because drug-seeking behaviour can be sophisticated, manipulative and demanding.

Doctors have specific clinical considerations and legal obligations when prescribing drugs of dependence. Failing to comply with these could lead to patient harm, as well as regulatory action.

The term ‘drug-seeking behaviour’ describes a range of actions a patient may use to obtain a particular drug. When identifying ‘drug- seeking behaviour’ it is important to consider the behaviours as a whole and in the context of the patient’s presentation, past history and clinical findings. Based on your clinical judgement, consider whether the patient has a legitimate need for the drug.

Requests and complaints that may raise your suspicion include:

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

Common behaviours that may raise your suspicion include:

• frequent presentations or calls after hours or late in the day
• travels far from home/work to visit the practice, or claims to be from out of town
• frequent calls to the practice or unannounced attendances for repeats
• consultations with multiple doctors, including within the one practice
• losing prescriptions or running out early
• distress or anger when told ‘no’
• non-adherence to drugs of dependence agreements
• threats or offers of bribes
• presentation with a letter purporting to be from another doctor recommending specific drugs of dependence to be prescribed.

A drug-seeking patient is less likely to be a long-term patient of your practice. However, long-term patients may present to you with similar behaviours. You may see a drug-seeking 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’ occurs when a patient deliberately visits several doctors to obtain more medicine than is clinically indicated.

It is not only patients who are drug-dependent who can be doctor shoppers. Patients in financial need may attempt to sell excess medicines.

All states and territories have real time prescription monitoring to help doctors understand their patients’ prescription history outside of their practice.

In Victoria, Queensland, South Australia and the Northern Territory, it is mandatory for doctors to check a patient’s prescription history in the real time prescription monitoring system before prescribing a ‘monitored medicine’. Make sure you are aware of the legislative requirements in your state or territory. For more information, see Avant’s factsheet on prescribing drugs of dependence.

Even if it is not mandatory, doctors are strongly encouraged to access this information to help identify circumstances where a patient may be at risk of harm from the use of a medicine.

While real time prescription monitoring systems are state based, a national view is available from the Australian Government’s Prescription Shopping Program (PSP) which identifies patients who, over a three-month period, received:

• any PBS items prescribed by six or more different doctors
• 25 or more PBS target items
• 50 or more target or non-target PBS items.

The PSP 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. The service does not monitor private scripts or those from the Department of Veterans’ Affairs.

The underlying principles of any clinical strategy should be patient safety, high-quality care, and empathy. Managing patients with drug dependence requires a careful balance. Sudden withdrawal from a drug of dependence may expose a dependent patient to risk but continuing to prescribe can perpetuate problem behaviours and also jeopardise the patient’s safety. You could be exposed to professional and legal consequences if you fail to comply with your jurisdiction’s prescribing guidelines and legislation.

Ensure a consistent approach 

Develop a consistent approach within your practice to help manage patient expectations and reduce the pressure to prescribe.

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.

To set expectations, you could place a sign in your waiting room or on the front door such as:

Strong painkillers and sleeping pills policy 

Except for palliative care needs, our policy is that we will not prescribe these types of medicines (e.g. OxyContin and morphine and Valium):

• 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 one pharmacy, again for consistency.

Carefully assess requests 

Before prescribing:

• confirm the patient’s identity
• conduct a comprehensive medical assessment:
  • take a detailed medical history including past conditions and their management
  • call the patient’s previous doctor/s or services involved in their care
  • check your state/territory real time prescription monitoring system and the PSP
  • assess for physical signs of recent or past drug abuse, such as injection sites
• formulate a diagnosis or working diagnosis of the presenting problem and consider if it can be appropriately managed by other means
• if you need further advice phone a professional telephone advice service in your state or territory and discuss your concerns with an addiction medicine specialist.

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, ‘Based on my assessment today, there is no clinical need to prescribe that today. I can provide the following alternatives.’ Try to keep your message simple and consistent.

Some doctors find it useful to use the information and alerts in the real time prescription monitoring system or the PSP to explain their concerns to a patient.

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

Sometimes, declining to provide a prescription can trigger an aggressive or threatening response from a patient. For more information on safety in your practice and dealing with aggressive behaviours, listen to Avant’s Advice for managing angry or aggressive patients podcasts.

Avant factsheet: Prescribing drugs of dependence

Avant podcast series: Advice for managing angry or aggressive patients

RACGP: Drugs of dependence: responding to requests

Services Australia: Prescription Shopping Program

Drug and Alcohol Clinical Advisory Service (DACAS)

The Avant Learning Centre has articles, eLearning courses, videos and webinars under the topic ‘Prescribing’.

For more information or immediate medico-legal advice, call us on 1800 128 268, 24/7 in emergencies.