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.

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 In an unpublished study of general practitioners, we found that they tended to identify 4 groups that comprise the vast majority of their drug-seeking patients.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?

Pattern: Is the pattern of use one of appropriate medicinal doses or is it one of intoxicating doses?

* 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
  • 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

Table 2

State/Territory and HIC drugs of dependence resources: information on drug-seeking patients

State/Territory Phone/Fax Postal address
New South Wales ph: 02 9887 5996
fax: 02 9805 0392
Chief PharmacistPharmaceutical Services BranchNSW Health DepartmentPO Box 380NORTH RYDE NSW 2113
Victoria ph: 03 9412 7354
03 9412 7928
03 9412 7958
fax: 03 9412 7385
Drugs and Poisons UnitPO Box 4057MELBOURNE VIC 3001
Queensland ph: 07 3224 5587
fax: 07 3224 5591
Drugs of Dependence Unit7th FloorHealth and Welfare Building63 George StreetBRISBANE QLD 4000
South Australia 1300 652 584 (office hours)
fax: 08 8226 7102
Drugs of Dependence UnitDrugs and Poisons SectionSA Health CommissionPO Box 6Rundle MallADELAIDE SA 5000
Western Australia ph: 08 9388 4980
fax: 08 9388 4988
Drugs of Dependence UnitPharmaceutical ServicesHealth Department of WAPO Box 8172Stirling StreetPERTH WA 6849
Tasmania ph: 03 6233 3906
fax: 03 6233 3904
Drugs of Dependence UnitPharmaceutical Services BranchDepartment of Community and Health ServicesGPO Box 125BHOBART TAS 7001
Australian Capital Territory ph: 06 205 0961
fax: 06 205 0997
Pharmaceutical ServicesACT Department of Health and Community CareGPO Box 825CANBERRA ACT 2601
Northern Territory ph: 08 8922 7340
fax: 08 8922 7200
Poisons BranchTerritory Health ServicesPO Box 40596CASUARINA NT 0811

Health Insurance Commission (HIC) (Medicare, Pharmaceutical Benefit Scheme)

Doctor shopperhotline 1800 631 181 General ManagerProfessional Review DivisionHealth Insurance CommissionPO Box 1001TUGGERANONGACT 2901

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.

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.

References

  1. Hume F, Croker B. The management of the violent and aggressive patient. Aust Prescr 1993;16:90-2.