Every day, we go clothes shopping, food shopping, car shopping, visiting establishments (or websites) for widely available products. Most often when you append “shopping” to a concept, you’re talking about the purchase of goods and services.
But not all items are freely sold; the government regulates some products to protect the public’s interest. Prescription drugs, for example. Access to many medications is based on the judgment of a prescriber. When people decide that they want more than the amount they’ve been prescribed, they look for ways to circumvent the system.
Needless to say, “doctor shopping” is quite a bit different than grocery shopping. The term “doctor shopping” refers to obtaining controlled substances from multiple health care practitioners, usually without the prescribers’ knowledge of the other prescriptions. For the patient, this can have both legal and health ramifications. But who are these patients?
Dr. Douglas McDonald and Kenneth Carlson of the research firm Abt Associates, Inc. examined a massive dataset of 146.1 million records of opioid prescriptions to find out what distinguishes doctor shoppers from other patients.
What’s a Doctor Shopper?
Instead of setting an arbitrary border between “normal patients” and “doctor shoppers,” researchers Carlson and McDonald decided to “let the data sort itself out.” Turns out, the data formed three piles.
The largest group of patients received opioids prescriptions from only one prescriber over a relatively short period of time. Presumably, these patients had acute conditions that required a short stint of opioids to treat their pain. On the other hand, it was not unusual for a patient to receive opioids from up to four different prescribers over a longer period of time. Members of this second group, the researchers supposed, may have had chronic conditions being treated by multiple physicians.
The third group looked very different than the first two. Although the smallest in number (only 135,000 people or 0.7 percent of patients with opioid prescriptions), these patients obtained almost two percent of the total opioid prescriptions and four percent of the total amount of opioids measured by weight. Members of the third group averaged 10 different prescribers in a 10-month period. McDonald and Carlson concluded that members of this “extreme” group could be categorized as doctor shoppers.
The data didn’t reveal what each patient chose to do with the opioids. But it does point to a 135,000 Americans that we should be concerned about. Members of the extreme group averaged the equivalent of 109 milligrams of morphine per day for a year. More than 100 milligrams of morphine per day puts a person at high risk for overdose, and this group exceeds those limits by almost 10 percent.
A doctor shopper may also sell the opioids she’s prescribed. Although very few non-medical opioid users buy the drugs from strangers (far more receive drugs for free from family or friends), a person with access to over 100 mg of morphine per day could easily become entrepreneurial.
Traits of a Doctor Shopper
How do these individuals stand out from the crowd? How can you spot a doctor shopper?
Although this analysis did not give detailed demographic information about the “extreme” group, here are some takeaways:
- The threshold for a doctor shopper is probably above three prescribers, the data show. Five or six prescribers in a short period of time may be a red flag.
- Within the “extreme” group, paying in cash was associated with more prescribers. When the researchers looked at only those who had paid for their prescriptions in cash, that average number of prescribers jumped from 10 to 15 per patient.
- Members of the extreme group were more likely to be around 30 years old. While acute and chronic pain patients (members of the first and second groups) were spread relatively evenly across ages 15 to 65, those in the third group clustered around age 30 and tailed off at higher ages.
Clinical Response to Doctor Shopping
Dr. Elinore McCance-Katz, Medical Director at the Substance Abuse and Mental Health Services Administration (SAMHSA), offers the following guidance for a clinician concerned about a patient’s use of opioid medications.
- Take a non-judgmental stance
- Use open-ended questions
- State your concerns about the behavior
- Examine the patient for signs of flexibility, i.e., is the patient more focused on a specific opioid or pain relief?
- Approach as if they have a relative contraindication to controlled drugs (if not absolute contraindication)
- Take pressure off yourself by referring to clinic policies
As health professionals, it is our responsibility to recognize high risk opioid use and engage the patient in a conversation. Keep in mind that this conversation may lead to a referral to treatment. Therefore, clinicians who prescribe opioids need to understand the therapeutic options for opioid use disorders and be familiar with resources in the community that support recovery.
Although Relatively Few, ‘Doctor Shoppers’ Skew Opioid Prescribing (NIDA Notes, 2014)
IRETA and NIDA have joined forces to create a free online course about doctor shopping and other high-risk opioid use: The Prevalence of Prescription Opioid Misuse: Doctor Shopping, Co-Ingestion, and Exposure