Tuesday, September 3, 2013

How Common is ‘Doctor Shopping’ for Opioids?

PrescriptionMisuse and abuse of prescription opioid analgesics is a serious threat to public health, resulting in rising numbers of overdoses and deaths. A most troublesome trend is “Doctor Shopping,” whereby persons obtain numerous opioid prescriptions for nonmedical purposes from multiple healthcare providers. However, in the first nationwide study, fewer than 1% of individuals who purchased prescription opioids in the United States were classified as Doctor Shoppers. So, how large a problem is this and what should be done?

While such wrongdoing characterized only a small proportion of the 48 million patients who were prescribed opioid analgesics during the term of the study, the researchers — Douglas McDonald and Kenneth Carlson of Abt Associates Inc., Cambridge, Massachusetts — noted that persons visiting multiple prescribers and pharmacies to obtain opioids may have an outsized impact on the healthcare system [McDonald and Carlson 2013]. Their study, published in the online journal PLOS ONE, analyzed records for more than 146 million prescriptions dispensed in 2008 for opioid analgesics, including buprenorphine, codeine, fentanyl, hydrocodone, methadone, oxycodone, oxymorphone, propoxyphene, and tramadol.

Those opioid analgesics were prescribed by >900,000 healthcare providers, dispensed by about 37,000 pharmacies, representing 76% of all retail outlets), and were purchased by >48 million patients. Prescriptions were linked to unique patients and weighted to estimate all prescriptions and patients in the nation. Statistical modeling was used to estimate different patient populations having varying patterns of how they visited individual prescribers.

On average, patients in the extreme outlying population who were presumed to be Doctor Shoppers — 0.7% of all opioid purchasers — obtained 32 opioid prescriptions from 10 different prescribers. They bought 1.9% of all opioid prescriptions in 2008, totaling an estimated 4.3 million prescriptions, and this constituted 4% of opioids dispensed by weight.

The Doctor Shopping risk was highest for oxycodone (2.8% of all deceitfully obtained prescriptions) and oxymorphone (2.3%). The lowest risk was for codeine (1.2%), fentanyl (1.2%), methadone (1%), and propoxyphene (1%). [For unstated reasons, the analysis did not include morphine or certain other opioids. Hydromorphone was not approved until 2010 and propoxyphene-containing products were withdrawn from the U.S. market in 2010; both, after the period of this study.]

The researchers observe that about 1 in every 143 “patients” appeared to be Doctor Shoppers, often paying in cash and aged in their 20s or 30s. However, the vast majority of opioid prescriptions involved a single prescription from 1 healthcare provider and most patients seemingly did not abuse opioids and/or used them sparingly. For example, among patients prescribed opioids during the first 2 months of 2008, 43% apparently did not use the analgesics for the rest of the year. Of those patients who continued opioid use, 31% received their prescriptions from 1 physician and 14% from 2 physicians. About 3% of patients obtained prescriptions from 5 to 9 prescribers, but among those patients receiving multiple prescriptions from several healthcare providers most of them appeared to be receiving care for chronic conditions.

The researchers concede that their data did not provide information to make clinical diagnoses of individuals purchasing opioid analgesics, or whether opioids were prescribed for acute or chronic conditions. Therefore, very few persons could be classified with certainty as diverting drugs for nonmedical purposes. However, even patients with legitimate medical need for opioids who are using large numbers of prescribers may signal dangerously uncoordinated medical care, and this needs further attention by the healthcare community.


Of necessity, this study — supported by a grant from the U.S. National Institutes of Health, National Institute on Drug Abuse — used a statistical modeling approach, rather than more direct and accurate measures to derive population estimates on a nationwide basis. As such, the estimates are prone to error, which the researchers explain in some detail, noting that their conclusions should be considered as approximate upper bounds of Doctor Shopping during the 2008 timeframe of the study. Whether or not their findings are still relevant today, 5 years later, needs some consideration and, perhaps, more recent data should be collected.

Throughout their report, the researchers questionably and unfortunately refer to Doctor Shoppers as “patients.” This may create some confusion and convey an implication that such scoundrels are legitimate persons with pain when, in fact, their actions are most prominently not motivated by any medical intent or necessity.

Ultimately, Doctor Shopping may threaten public health and safety, and also deter from the adequate treatment of patients with pain if further restrictions are placed on opioid prescribing in response to the problem. While this is a serious challenge facing the healthcare community, regulatory agencies, and legislators, there might be some question as to how many resources — time, money, manpower — or regulatory/legislative effort should be prudently devoted to addressing the issue; for example, Doctor Shoppers represented roughly 0.7% (1/143) of all persons receiving opioid analgesic prescriptions according to data in this study

Furthermore, McDonald and Carlson suggest a number of open questions about Doctor Shopping that merit greater research attention in helping to guide any remedial actions, such as:

  • “What proportion of the illicit market for opioids is supplied by Doctor Shopping as opposed to unethical prescribers or pharmacies, other forms of prescription fraud, smuggling, theft, pilfering, or unused pills left over from prescriptions written for legitimate medical reasons?”

  • “Is Doctor Shopping more prevalent in some places than others, and if so, what accounts for these differences?”

  • “To what extent do Doctor Shoppers seek drugs for their own misuse as opposed to reselling them to others?”

  • “Some Doctor Shoppers operate in rings that are organized and financed by leaders; how much of the illicit market is supplied by these organized rings as opposed to solo shoppers?”

The researchers also question how effective Prescription Drug Monitoring Programs (PDMPs) are in preventing Doctor Shopping, and how much of this occurs across state borders that would be less visible to a PDMP in any one state. While they believe that PDMPs can be helpful, they also lament that these programs need to be improved, and PDMPs do not take the place of prescribers adopting procedures to carefully screen new patients for risk of opioid abuse or misuse and to adequately monitor current patients' adherence to prescribed analgesic therapies.

REFERENCE: McDonald DC, Carlson KE (2013) Estimating the Prevalence of Opioid Diversion by “Doctor Shoppers” in the United States. PLoS ONE. 2013;8(7):e69241 [access here].

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