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Drug-seeking behaviour |
Summary
Prescribers should be alert to drug-seeking behaviour. Appropriate responses require careful recognition of the signs of drug-seeking, intoxication and withdrawal, and consideration of the treatment options. Management may include denial of a prescription or referral to an appropriate drug treatment facility. At the same time, it is important not to deny appropriate treatment to those in the community who are dependent on drugs.
Key words: opioids, benzodiazepines, drug dependence, drug abuse.
(Aust Prescr 1997;20:68-70)
Nature of the problem
Drug-seeking behaviour describes the presentation of people falsely reporting symptoms in order to obtain a prescription or requesting a drug in order to maintain dependence.
Which drugs are used?
The two prescription drug classes most closely associated with drug-seeking behaviour are the benzodiazepines and the opioids. Prolonged use of drugs from both of these classes can result in pronounced physical dependence. Nevertheless, it should not be assumed that only those with significant dependence will engage in drug-seeking behaviour. There are large numbers of occasional users of these drugs who may attempt to obtain prescription supplies, especially of benzodiazepines. In most instances, the drug will be consumed by the person requesting a prescription. However, health professionals should also realise that there is an illicit market in benzodiazepines, with the most favoured drug being flunitrazepam. There is also `trafficking' in prescribed opioids such as morphine and oxycodone.
As well as the benzodiazepines and the opioids, other drugs may be sought. These include stimulants such as ephedrine, amphetamine, and appetite suppressants such as phentermine. Some users of these drugs may take them to prevent fatigue (e.g. shift workers), while others may be seeking euphoria and other subjective effects. Anticholinergics have hallucinogenic effects when high doses are consumed. Prescription drugs such as benztropine have been abused for this purpose and a small illicit trade is carried on. Tricyclic antidepressants may also be abused for their anticholinergic effects. Recently, attention has focused on anabolic steroids. Although users of these drugs are typically different from opioid, benzodiazepine, stimulant and hallucinogen users, they may engage in similar drug-seeking behaviour to obtain their supply.
Indicators of drug-seeking behaviour (Table 1)
There are no fixed characteristics of drug-seeking patients. In an unpublished study of general practitioners, we found that they tended to identify 4 groups that comprise the vast majority of their drug-seeking patients. These were:
1. patients known to the practice who were dependent on benzodiazepines and wanted to maintain a continuous supply
2. patients known to the practice seeking an opioid (dependence may have arisen following treatment for chronic pain, but later, dependence rather than pain relief had become the major reason for using opioids)
3. patients unknown to the practice seeking a benzodiazepine (these patients are typically younger than those in groups 1 and 2 and many are not drug dependent)
4. patients unknown to the practice seeking an opioid (these patients also tend to be younger than those in the first two groups and most will be dependent on opioids)
Patients in the first two groups may be readily identified given their familiarity to the practice. More problematic is how to identify those seeking drugs who are not known to the practice. A number of indicators may be useful. These include patients:
• presenting near closing time without an appointment
• requesting a specific drug and refusing all other suggestions (may display considerable knowledge of drugs)
• presenting with inconsistent symptoms being reported (e.g. does not appear to suffer significant pain)
• reporting a recent move into the area from somewhere
beyond the vicinity of the practice, making direct validation of prescribed drug supply with the previous practitioner difficult.
| Table 1 Five questions to determine whether drug use is appropriate or constitutes abuse* Intent: Is the drug used for a legitimate medical purpose? Effect: Does the drug improve the quality of the patient's life? Control: Is the physician helping the patient maintain control over use of the drug? Legality: Is use of the drug legal and uncomplicated by illegal drug use? * Affirmative responses to all 5 questions usually indicate appropriate medical use. 1-5 negative responses usually indicate inappropriate or non-medical use. All responses should be documented in the patient's chart. (Derived from DuPont and Saylor) |
Those patients reporting a recent move may have a supporting letter apparently from their local practitioner. This should be checked if at all possible - it may have been used numerous times and may have been written on stolen letterhead.
Careful observation of patients may be useful in identifying them as drug users. Look for signs of drug use, intoxication and withdrawal. Benzodiazepine intoxication is characterised by sedation, poor co-ordination and balance, impaired memory and general impairment of cognitive function. In contrast, benzodiazepine withdrawal is characterised by anxiety, irritability, palpitations and tremor. Opioid-intoxicated patients may present with pupillary constriction, itching nose and skin, difficulty concentrating and dry mouth. Injection site marks may be evident. Patients experiencing opioid withdrawal may present with dilated pupils, increased heart rate and blood pressure, diarrhoea, muscle cramps, aches and pains, frequent yawning, rhinorrhoea and lacrimation. It is important to note that opioid-dependent patients may seek benzodiazepines, particularly if they are experiencing withdrawal and want these drugs to alleviate some of the symptoms.
Strategies for responding to drug-seeking behaviour
Once drug-seeking behaviour has been identified or there is reasonable suspicion, the possible response is determined in part by the laws applying in the State or Territory. While these vary, in general it is illegal to prescribe solely to maintain someone's dependence. The only exception is those with special permission such as methadone prescribers.
A second response is to contact State or Territory health authorities (Table 2). Most will keep records of known drug-seekers and may assist in identifying if a patient has a history of this behaviour, unless a false ID has been used. Other responses will depend on the particular case, but, in addition to refusal to prescribe, may include a prescription for a limited term (e.g. a supply for 2-3 days with frequent review), and prescribing a drug appropriate for the reported symptoms but different from the one requested by the patient (e.g. a benzodiazepine less favoured by drug users
than flunitrazepam). Supervised daily dosing may be an option for those patients known to be dependent and where there is a risk of diversion.
The potential dangers of prescribing to a drug-seeking patient include:
• enhancing the development of drug dependence
• interfering with the treatment of the patient's drug problem (e.g. if the patient is in a methadone maintenance program)
• increasing supplies of drugs in illicit markets
• increasing the risk of overdose, in both the patient and others who may eventually use the drug prescribed
• missing an opportunity to refer a patient with a problem of drug dependence to an appropriate service or to treat them within the practice
| Table 2 State/Territory and HIC drugs of dependence resources: information on drug-seeking patients
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| State/Territory | Phone/Fax | Postal address |
| New South Wales | ph: 02 9887 5996 fx: 02 9805 0392 |
Chief Pharmacist Pharmaceutical Services Branch NSW Health Department PO Box 380 NORTH RYDE NSW 2113 |
| Victoria | ph: 03 9412 7354 03 9412 7928 03 9412 7958 fx: 03 9412 7385 |
Drugs and Poisons Unit PO Box 4057 MELBOURNE VIC 3001 |
| Queensland | ph: 07 3224 5587 fx: 07 3224 5591 |
Drugs of Dependence Unit 7th Floor Health and Welfare Building 63 George Street BRISBANE QLD 4000 |
| South Australia | ph: 08 8226 7166 fx: 08 8226 7102 |
Drugs of Dependence Unit Drugs and Poisons Section SA Health Commission PO Box 6 Rundle Mall ADELAIDE SA 5000 |
| Western Australia | ph: 08 9388 4980 fx: 08 9388 4988 |
Drugs of Dependence Unit Pharmaceutical Services Health Department of WA PO Box 8172 Stirling Street PERTH WA 6849 |
| Tasmania | ph: 03 6233 3906 fx: 03 6233 3904 |
Drugs of Dependence Unit Pharmaceutical Services Branch Department of Community and Health Services GPO Box 125B HOBART TAS 7001 |
| Australian Capital Territory | ph: 06 205 0961 fx: 06 205 0997 |
Pharmaceutical Services ACT Department of Health and Community Care GPO Box 825 CANBERRA ACT 2601 |
| Northern Territory | ph: 08 8922 7340 fx: 08 8922 7200 |
Poisons Branch Territory Health Services PO Box 40596 CASUARINA NT 0811 |
| Health Insurance Commission (HIC) (Medicare, Pharmaceutical Benefit Scheme) |
Doctor shopper hotline 1800 631 181 |
General Manager Professional Review Division Health Insurance Commission PO Box 1001 TUGGERANONG ACT 2901 |
• increasing the likelihood of other drug-seeking patients presenting to the practice; those prescribers who are 'easy targets' become well known within subgroups of drug users
• the potential for violence1
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Table 3 The drug user in genuine need Before prescribing for medical purposes a drug with abuse potential, it is important to document the following: 1. Is there a clear clinical indication for the use of this drug to be preferred above a drug without abuse potential? 2. Are the therapeutic aims and endpoints for treatment, including duration of therapy, clearly established? 3. Is there a plan for regular re-assessment of drug use (this is usually combined with a limited prescribing policy)? 4. Is the patient adequately informed and in agreement with the therapeutic contract? |
The drug user in genuine need (Table 3)
People who are dependent on a drug may have a genuine need for medication of various kinds. This may include drugs from the class on which they are dependent. For example, an opioid user experiencing pain as a result of injury or some other acute cause will still require appropriate pain relief. Indeed, if an opioid is indicated for their treatment, then they may have a requirement for a larger than normal dose because of their tolerance to these drugs. If the need is genuine, drugs should only be prescribed for the time required to alleviate the patient's pain effectively.
(See also Dental implications)
Reference
1. Hume F, Croker B. The management of the violent and aggressive patient. Aust Prescr 1993;16:90-2.
Further reading
Finch J. Prescription drug abuse. Prim Care 1993;20:231-9.
Roche AM, Guray C, Saunders JB. General practitioners' experiences of patients with drug and alcohol problems. Br J Addict 1991;86:263-75.
Voth EA, DuPont RL, Voth HM. Responsible prescribing of controlled substances. Am Fam Physician 1991;44:1673-8.
DuPont RL, Saylor KE. Sedatives/hypnotics and benzodiazepines. In: Frances RJ, Miller SI, editors. Clinical textbook of addictive disorders. New York: Guilford Press, 1991:69-102.st questions
| Doctor shopper program Patient details Using this criterion, there are more than 20 000 doctor shoppers. There are more than 850 people who see in excess of 50 separate doctors. Examples of doctor shopper prescribing patterns: |
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| Doctors seen |
PBS items dispensed | Drugs | |
| Case 1 | 580 | 900 | codeine phos/paracetamol |
| Case 2 | 125 | 470 | codeine phos/paracetamol, pethidine injections |
| Case 3 | 112 | 375 | oxazepam, oxycodone, codeine phos/paracetamol |
| Case 4 | 101 | 860 | codeine linctus, diazepam, codeine phos/paracetamol |
| Doctors who have many doctor shopper patients • general practitioners who have 35 or more doctor shopper patients, and • prescribe more than 50 PBS scripts per year for a doctor shopper, and • more than 50% of the PBS items prescribed for a doctor shopper are for the target drugs There are: |
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| 130 doctors in New South Wales | 20 doctors in Western Australia | ||
| 97 doctors in Victoria | 54 doctors in South Australia/Northern Territory | ||
| 53 doctors in Queensland | 1 doctor in Tasmania | ||
| These 355 doctors provide the majority of prescriptions used by 8281 doctor shoppers. Most of the drugs are benzodiazepines or compound analgesics. Many doctor shoppers have travelled some distance to visit these doctors. |
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| New NHMRC publications |
| The National Health and Medical Research Council (NHMRC) has released a series of publications on the identification, assessment, diagnosis, prevention and management of depression in young people. Three of the publications are available from the Australian Government Publishing Service (AGPS) and from Government Info Shops throughout Australia. The main clinical practice guideline `Depression in young people: clinical practice guidelines' (Cat. No. 9609296, $16.95) covers issues from the detection of depression to treatment methods. From this guideline, `Guide for mental health professionals' (Cat. No. 9609342, $10.50) and `Guide for general practitioners' (Cat. No. 960927X, $11.95) were developed. |
Self-test questions
The following statements are either true or false (click here for the answers) |
