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The practicing physician is faced with an increasing variety of medicolegal and regulatory risks, not the least of which is the close scrutiny of prescribing practices involving controlled substances. Physicians are more frequently finding themselves under review by the Drug Enforcement Administration (DEA), boards of healing arts and peer review organizations. Of the disciplinary actions taken by state boards of healing arts in 1990, approximately one-third were related to prescription practices, according to the Federation of State Medical Boards of the United States (personal communication, 1991). Disciplinary actions include loss of privileges to prescribe controlled substances, close monitoring of future prescribing and loss of licensure.

Data from the Drug Abuse Warning Network demonstrate that in 1987, 14 of the 20 drugs most commonly reported by emergency department staff as being related to problems with side effects, overdose or dependence were prescription or over-the-counter medications rather than illegal or "street" drugs. [1]

Physicians often do not detect chemical dependency and abuse of prescription drugs in their patients. Medical education is often deficient in preparing physicians for the problems associated with drug abuse and dependence. [2] Improvements are being made in medical education about alcoholism and drug abuse, [3] but curriculum changes also need to emphasize the physician's responsibility when prescribing controlled substances.

The misprescribingly physician has been characterized as "dated, dishonest, disabled or duped." [4] The "dated" physician is unaware of current acceptable prescribing practices, while the "duped" physician is misled by a patient who falsifies symptoms to obtain medication. The "disabled" physician may be too ill to discriminate between appropriate and inappropriate requests for medication. Some physicians may be blinded by their own chemical dependence. The "dishonest" physician seeks financial gain by selling prescriptions. Even the competent, well-trained physician may overlook pharmacokinetics, cross-reactivity and addiction potential when prescribing medications.

Patient Types

Three types of patients may have problems with controlled substances: the patient who overdoses (whether intentionally or not), the chemically dependent patient and the addicted patient. The first type of patient legitimately receives medication for an illness, often depression, and inadvertently takes an overdose. The elderly are particularly susceptible to unintentional overdoses. Analgesics and sedatives present a particular risk, but all medications tend to have heightened effects in the elderly. The physician should prescribe low yet therapeutically effective doses.

Intentional overdose with antidepressants is a particular danger in the depressed patient. Because of the possibility of profound hypotension and dysrhythmias, tricyclic antidepressants must be administered carefully. Antidepressants, either alone or in combination with analgesics or alcohol, can cause respiratory depression, coma and death. Patient at risk for overdose should be strongly discouraged from drinking alcoholic beverages. Alcohol heightens the sedative effects of medications and may have potentially fatal consequences when combined with other sedative-hypnotic drugs.

The second type of patient is at risk of dependence while legitimately taking medication for a specific indication. If medication is abruptly discontinued, the physically dependent patient may have withdrawal symptoms (Table 1). These symptoms may be mild, moderates or severe, depending on the type of amount of medication given and the duration of use.

The physically dependent patient should not be confused with the third type of patient, the addicted patient. This patient's behavior is characterized by loss of control over use of the drug, escalation of the dose used, compulsion to use the drug, development of a drug-oriented lifestyle and continued use, despite the problems caused by drug use. Addicts are often extremely manipulative and tend to lie,

TABLE 1

Signs of Narcotic

and Sedative Withdrawal

TABLE 2

Prescription Drugs of Abuse

falsify their symptoms and use several physicians to obtain prescriptions. These patients may be hostile and demanding.

Commonly Abused Drugs

A wide variety of drugs are abused (Table 2). Drugs may be used alone or in combination (e.g., use of benzodiazepines to modulate the effects of cocaine or to boost the effects of alcohol).

The medications that are most often associated with substance abuse are short-acting or rapidly absorbed agents such as diazepam (Valium) and oxycodone (Percodan). The rapid absorption results in a more rapid feeling of intoxication. Injectable narcotics and stimulants have a particularly high potential for abuse. Oral preparations may be used alone or in combination with other drugs, or may be crushed and injected (e.g., pentazocine [Talwin]).

In addition to pain medication and sedatives, a few other medications warrant brief discussion. Butalbital-containing combinations (e.g., Esgic, Fiorinal) may be additive if taken in large amounts. Other muscle relaxants may be habit-forming to a varying degree, depending on the potency and duration of use. For example, meprobamate (Equanil, Miltown) may cause severe withdrawal, with agitation or seizures.

Physicians are often surprised at the street value of controlled substances. [5] A 5-mg table of Valium may sell for about $2, and a table of the hydromorphone Dilaudid may sell for $50 or more. Brandname products tend to have greater name recognition and,therefore, a somewhat higher street value. Addicts may have two incentives for obtaining drugs; they may abuse the prescribed controlled substances themselves or sell them to other addicts.

Avoiding Problems in Practice

The detection of prescription abuse may require an attitude shift on the part of the physician. Physicians tend to trust their patients and therefore may be at risk for manipulation. When a patient requests a controlled substance, it may be prudent to question the validity of the patient's medical history and to "read between the lines."

Identifying the potential overdose victim can be difficult. Patients who are confused or mildly demented may accidentally take medications incorrectly, thus placing themselves at risk for overdose.

The depressed patient may also be at high risk for an overdose. Although direct questioning about suicidal ideation or death wishes may yield helpful information, further detailed questioning of the patient or family members should also be undertaken. Questions about preoccupation with death, anhedonia, sleep disturbances, loss of perspective or overwhelming hopelessness and incorrect or excessive use of sedatives or antidepressants may be useful. If such behavior is detected, further consultation should be considered. Prescribing only small amounts of medication (such as a one-or-two-week supply) minimizes the risk of overdose. Family members or concerned friends should be alerted to the possibility of medication hoarding and stockpiling.

A number of signs shoud alert the physician to the possibility of prescription drug abuse (Table 3). Patients may exhibit excessive anxiety when providing their history. They may frequently avert their eyes or give confusing or contradictory information. Direct questions about habitual drug use may be avoided or left unanswered. On occasion, needle injection sites ("tracks") may be detected on the extremities. Patients may even be physically menacing or may threaten legal action in an attempt to coerce the physician into prescribing medication.

Physician may be asked to assess a

TABLE 3

Signs of Prescription Drug Abuse

traumatized patient injured as a result of intoxication. Forty percent of patients presenting to an emergency department in one study tested positive for drugs of abuse. [6] Hip fractures in elderly patients in a general medical setting have been correlated with psychotropic drug use. [7] More subtle medical problems, such as sexual dysfunction, may sometimes serve as a clue to drug abuse. [8] Spouses, other family members and, occasionally, employers are useful sources of information about suspected addiction.

Recently, concern about addiction has led to inappropriate withholding of narcotic pain medication from patients with severe pain. When abuse is suspected, it is the physician's right and responsibility to refuse to prescribe habituating medications. [9] However, recent research has shown that giving larger, more frequent doses of narcotics earlier in the course of treatment for severe pain can interrupt the pain cycle and result in lower overall narcotic doses and less pain. Experience has also known that patients with no previous history of drug addiction stop using narcotics with few discontinuation problems when their pain is gone. [10]

When used for severely anxious patients who do not have a history of chemical dependency, benziodiazepines also have a good track record with regard to abuse potential. [11] When the anxiety is reduced, the patient spontaneously stops taking the drug or decreases the amount. Since anxiety disorders may last a lifetime, it is not uncommon for clinically anxious patients to want to use benzodiazepines for long periods of time. [12] In many cases, this is an appropriate treatment for a serious medical illness. [13] However, when possible, nonpharmacologic methods of managing anxiety should be used.

TABLE 4

Five Questions to Determine Whether Drug Use

Is Appropriate or Constitutes Abuse (*)

(*) -- Affirmative responses to all five questions usually indicate appropriate medical use. One to five negative responses usually indicate inappropriate or nonmedical use. All responses should be documented in the patient's chart.

Derived from DuPont and Sayer. [12]

The busy physician must periodically review and document the need for medication, including whether or not it is being used therapeutically. [14] Table 4 lists five questions that may help the clinician distinguish therapeutic drug use from drug abuse. When sedative medications are prescribed, follow-up visits should be scheduled every one to four months. Patients who require narcotic pain medication should probably be followed every one to two weeks. Prescriptions should be limited to small amounts, depending on the drug's potential for abuse.

"Doctor shopping" by drug addicts is a major problem. Addicts may present to several physicians with a convicting complex of symptoms. The level of sophistication of some of these patients is remarkable. Some patients have been known to keep log books so that they could rotate their refill requests without arousing suspicion. Checking with local pharmacies to determine whether a patient is filling the same or similar prescriptions from several physicians can be helpful.

Stealing and altering or forging prescriptions from prescription pads can be prevented by controlling access to pads, writin in ink, confirming the number of pills prescribed in both arabic and roman numerals, and "blacking out" the DEA number listed on the prescriptions pad. [15] Some states have implemented laws regarding prescriptions to aid in monitoring prescribing practices.

Prescribing medications with high abuse potential for the known and/or recovering addict must be undertaken with great care. Litigation is a possibility when prescribing for addicts. The physician may be held at fault for causing addiction or for reactivating an addiction in a recovering addict. Since addiction can be reactivated through the use of medically prescribed controlled substances, their use, especially for long-term therapy in the outpatient setting, shound be held to a minimum.

In addicts, nonsteroidal anti-inflammatory agents should be used for pain control, particularly in the outpatient setting. Pain control is best achieved by scheduled doses rather than doses taken as needed. Once adequate analgesia is obtained, doses may be tapered while maintaining paincontrol. Ketorolac (Toradol), a new parenteral nonopiate analgesic, shows promise as an option for pain control when opiate use is risky. [16] If other nonopiate alternatives have failed, a long-acting opiate such as methadone may be used. The use of opiates should be closely monitored, and only a one to five days' supply given.

Sedatives should also be avoided in the addict. If sedation is necessary, antihistamines such as hydroxyzine (Vistaril) or antidepressants with sedative properties should be used. Addicts with coexistent severe anxiety or panic disorder may benefit from imipramine (Janimine, Tofranil). Buspirone (BuSpar) may also be helpful. Beta blockers may reduce some of the subjective symptoms of anxiety. If a benzodiazepine seems to be the only effective alternative, it is advisable to select an agent with a slow onset of action, such as oxazepam (Serax) or prazepam (Centrax). The patient's use of the drug should be monitored closely, and the amount of medication given at one time should be limited to a one- or two-week supply.

If a patient with known or suspected alcohol or drug dependence is encountered, the most prudent step is to document the problem and consider referral to a chemical dependence treatment program or a physician who specializes in management of addiction. In the office setting, questions such as "When was your last drink?" and "Have you ever had a drinking problem?" can identify alcoholism with a sensitivity greater than 90 percent. [17] Reputable, reliable inpatient and outpatient treatment programs exist in most communities to aid in the assessment and treatment of addicts or depressed patients. Noncompliance or refusal to seek help may be justification to withdraw professional services from the patient as a last resort, but the rationale must be thoroughly documented.

Physicians must be aware that substantial medical and legal consequences may result if prescribing is performed in a cavalier fashion. The best of intentions must be accompanied by appropriate prescribing practices.

REFERENCES

[1] Annual data: 1989. Data from the Drug Abuse Warning Network. Rockville, Md.: National Institute on Drug Abuse, 1989; series 1; no. 9:26.

[2] Kamerow DB, Pincus HA, Macdonald DI. Alcohol abuse, other drug abuse, and mental disorders in medical practice. Prevalence, costs, recognition, and treatment. JAMA 1986;255:2054-7.

[3] Lewis DC, Niven RG, Czechowicz D, Trumble JG. A review of medical education in alcohol and other drug abuse. JAMA 1987;257:2945-8.

[4] Drug abuse related to prescribing practices. JAMA 1982;247:864-6.

[5] Street prices of pharmaceuticals diverted for illicit purposes by dosage unit price: 1990 survey. Topeka, Kan.: Kansas Bureau of Investigation and the Oklahoma State Board of Medical Examiners, 1990.

[6] Rivara FP, Mueller BA, Fligner CL, et al. Drug use in trauma victims. J Trauma 1989;29:462-70.

[7] Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton LJ 3d. Psychotropic drug use and the risk of hip fracture. N Engl J Med 1987;316:363-9.

[8] Miller NS, Gold MS. The human sexual response and alcohol and drugs. J Subst Abuse Treat 1988;5:171-7.

[9] Goldman B. Confronting the prescription drug addict: doctors must learn to say no. Can Med Assoc J 1987;136:871-6.

[10] Melzack R. The tragedy of needless pain. Sci Am 1990;262(2):27-33.

[11] DuPont RL. A practical approach to benzodiazepine discontinuation. J Psychiatr Res 1990;24(Suppl 2):81-90.

[12] DuPont RL, Saylor KE. Sedative hypnotics and benzodiazepines. In: Frances RJ, Miller SI, eds. Clinical textbook of addictive disorders. New York: Guilford Press, 1991.

[13] DuPont RL. Benzodiazepine and chemical dependence: guidelines for clinicians. Presented at the National Conference on Medical Education and Research in Drug and Alcohol Abuse, Association for Medical Education and Research in Substance Abuse. Subst Abuse (In press).

[14] Sellers EM. Defining rational prescribing of psychoative drugs. Br J Addict 1988;83:31-4.

[15] Wilford BB. Abuse of prescription drugs. West J Med 1990;152:609-12.

[16] O'Hara DA, Fragen RJ, Kinzer M, Pemberton D. Ketorolac tromethamine as compared with morphine sulfate for treatment of postoperative pain. Clin Pharmacol Ther 1987;41:556-61.

[17] Cyr MG, Wartman SA. The effectiveness of routine screening questions in the direction of alcoholism. JAMA 1988;259:51-4.

ERICA A. VOTH, M.D. is clinical instructor of medicine at the University of Kansas School of Medicine, Kansas City, and medical director of Chemical Dependency Treatment Services at St. Francis Hospital in Topeka, Kan. Dr. Voth earned his medical degree at the University of Kansas School of Medicine, where he also completed at residency in internal medicine.

ROBERT L. DUPONT, M.D. is clinical professor of psychiatry at Georgetown University School of Medicine, Washington, D.C., and is president of the Institute of Behavior and Health, Inc., Rockville, Md. Dr. DuPont is a graduate of Harvard Medical School, Boston. He completed a residency at Massachusetts Mental Health Center, Boston, and a fellowship at the National Institutes of Health, Bethesda, Md.

HAROLD M. VOTH, M.D. is clinical professor of psychiatry at the University of Kansas School of Medicine and also has a private practice in psychiatry. Dr. Voth received his medical degree from the University of Kansas School of Medicine and completed residencies at the Menninger School of Psychiatry, Topeka, and the Topeka Institute for Psychoanalysis.

COPYRIGHT 1991 American Academy of Family Physicians
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