Estimating the Prevalence of Opioid Diversion by “Doctor Shoppers” in the United States

Abstract

BackgroundAbuse of prescription opioid analgesics is a serious threat to public health, resulting in rising numbers of overdose deaths and admissions to emergency departments and treatment facilities. Absent adequate patient information systems, “doctor shopping” patients can obtain multiple opioid prescriptions for nonmedical use from different unknowing physicians. Our study estimates the prevalence of doctor shopping in the US and the amounts and types of opioids involved.Methods and FindingsThe sample included records for 146.1 million opioid prescriptions dispensed during 2008 by 76% of US retail pharmacies. Prescriptions were linked to unique patients and weighted to estimate all prescriptions and patients in the nation. Finite mixture models were used to estimate different latent patient populations having different patterns of using prescribers. On average, patients in the extreme outlying population (0.7% of purchasers), presumed to be doctor shoppers, obtained 32 opioid prescriptions from 10 different prescribers. They bought 1.9% of all opioid prescriptions, constituting 4% of weighed amounts dispensed.ConclusionsOur data did not provide information to make a clinical diagnosis of individuals. Very few of these patients can be classified with certainty as diverting drugs for nonmedical purposes. However, even patients with legitimate medical need for opioids who use large numbers of prescribers may signal dangerously uncoordinated care. To close the information gap that makes doctor shopping and uncoordinated care possible, states have created prescription drug monitoring programs to collect records of scheduled drugs dispensed, but the majority of physicians do not access this information. To facilitate use by busy practitioners, most monitoring programs should improve access and response time, scan prescription data to flag suspicious purchasing patterns and alert physicians and pharmacists. Physicians could also prevent doctor shopping by adopting procedures to screen new patients for their risk of abuse and to monitor patients' adherence to prescribed treatments.

Harmonizing Post-Market Surveillance of Prescription Drug Misuse: A Systematic Review of Observational Studies Using Routinely Collected Data (2000–2013)

“…Observational Studies in Epidemiology (STROBE) Statement Checklist for Observational, Population-Based Cohort Studies [26,27].…”

“…Many studies did not report basic cohort details including sex (20), age (18) and/or cohort size (8). Studies did not identify how they managed any bias (26), loss to follow up (39), missing data (39) or sensitivity analyses (38). Furthermore, 21 studies did not report the funding source.…”

“…Our recommendations center around three key areas: methodology (promotion of consistent metrics to determine appropriate measures of misuse); reporting (listing all drugs by generic name included in each study and the specifics of the misuse measures), and study nomenclature (where possible, consistency in the use of key words including 'prescription drug misuse' that facilitate direct mapping to searchable subject headings). Future studies should combine these recommendations with the current standard reporting requirements for observational studies [26,27], which will support the current FDA initiative and add value across other jurisdictions.…”

A description of Medical Examiner prescription-related deaths and prescription drug monitoring program data

“…Kenan and colleagues [7] found that the number of opioid prescriptions per 100 persons increased by 35.2% between 2000 and 2009, and the average size of an oxycodone and hydrocodone prescription increased by 69.7% and 69.4%, respectively, during the same period. For 146 million opioids dispensed, 0.7% of purchasers accounted for 1.9% of all opioid prescriptions, and higher opioid dosage correlated with a higher risk of overdose [8].…”

“…Doctor shoppers were found to have an increased number of prescriptions, higher number of pills, and higher number of morphine equivalents [4]. The work of McDonald and Carlson [8] in 2008 found that patients who were diverting opioids had an average of 32 prescriptions from 10 providers.…”