MULTIPLE PROVIDER EPISODES/

The CDC has recommended that prescription drug abuse prevention efforts focus resources on patients at highest risk in terms of prescription opioid painkiller dosage, numbers of controlled substance prescriptions, and numbers of prescribers (Centers for Disease Control and Prevention, 2013b). This includes individuals who obtain

prescriptions for the same drugs and/or controlled substances from multiple healthcare practitioners without the prescribers’ knowledge of the other prescriptions (Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Unintentional Injury Prevention, 2012; McDonald & Carlson, 2013; Sansone & Sansone, 2012). Patients in this category of prescription drug abuse are often

classified as “doctor shoppers” or “pharmacy shoppers” and represent a significant contribution to diversion rates. The author of this dissertation prefers the term ‘multiple provider episodes’ (MPE), given that shopping behavior occurs across healthcare

providers (i.e., physicians and pharmacists). However, the current literature utilizes both terms, therefore both terms will be used interchangeably throughout. Additionally, the terms ‘doctor shopping’ and ‘pharmacy shopping’ have been found to be correlated and often interchangeable, given that the as the number of providers that a patient uses

increases the number of pharmacies has been found to increase as well. The term “doctor shopping” varies based on different definitions and indicators of questionable activity, such as: the numbers of pharmacies visited; numbers of prescribers used; prescriptions that are overlapping; using more than one class of controlled substance prescription from different providers; early refills of prescriptions; and excess of ‘standard’ doses over different periods of time. These individuals often receive additional prescriptions for

medication than intended by their provider(s). Some doctor shoppers may be obtaining multiple prescriptions to divert the medications to other individuals. As documented from SAMHSA’s 2010 survey, over 75% of individuals who abuse prescription medications obtained them from someone else’s prescription (Substance Abuse and Mental Health Services Administration, 2011a).

As shown in Table 1.5, several studies have been conducted characterizing

patients doctor and pharmacy shopping for controlled substances. A variety of thresholds and different criteria were used to identify aberrant utilization in these studies. Hall et al. characterized doctor shopping as obtaining prescriptions for controlled substances from five or more clinicians during the preceding year (Hall et al., 2008). Whereas other studies used less specific standards and define doctor shopping as ‘patient consultation with multiple physicians in a short time frame with the explicit intent to deceive them in order to obtain controlled substances’ (Shaffer & Moss, 2010). Therefore there is currently no “gold standard” definition for identifying aberrant behavior.

Table 1.5. Definitions and Operationalization of Doctor and Pharmacy Shopping in the Literature

Study Operational Definition Findings

Prevalence and determinants of pharmacy shopping behavior (Buurma et al., 2008)

Non-shopper: 1 pharmacy Light: >1 pharmacy

Moderate: 3-4 pharmacies and proportion of prescriptions elsewhere >10% and number of prescriptions elsewhere >10 Heavy: >5 pharmacies, proportion of prescriptions elsewhere >10% and number of prescriptions elsewhere >10

Even light shopping behavior may put the patient at risk for unintentional drug-related problems

Usefulness of prescription monitoring programs for surveillance--analysis of Schedule II opioid prescription data in Massachusetts, 1996-2006 (Katz et al., 2010)

>4 pharmacies and >4 prescribers for any Schedule II drug

or >2 pharmacies and >2 prescribers for the opioid product in question

The greater number of providers used, the greater the number of pharmacies used

Time Series Analysis of California’s Prescription Monitoring Program: Impact on Prescribing and Multiple Provider Episodes (Gilson et al., 2012)

Receiving prescriptions for the same medication from 2 or more practitioners within a 30-day period

Multiple provider episodes represented almost 10% of all Schedule II opioid prescriptions issued during the 7-year study period Doctor and Pharmacyf Shopping for Controlled

Substances. (Peirce et al., 2012)

≥4 doctors in 6 months-doctor shopping ≥4 pharmacies in 6 months-pharmacy shopping

25.21% of individuals who had died from a drug-related death were identified as doctor shoppers; 20.23% of doctor shoppers were also pharmacy shoppers, and 55.60% of pharmacy shoppers were doctor shoppers

Patterns of abuse among unintentional pharmaceutical

overdose fatalities (Hall et al., 2008) >5 clinicians in year before death

Most overdose deaths involved opioid analgesics; 21.4% deaths involved doctor shopping

Distance Traveled and Frequency of Interstate Opioid Dispensing in Opioid Shoppers and Nonshoppers (Cepeda et al., 2013)

Shopper: filled overlapping opioid prescriptions written by >1 prescriber at ≥3 pharmacies.

Heavy shopper: ≥5 shopping episodes

Opioid shoppers travel greater distances and more often cross state borders to fill opioid prescriptions than nonshoppers, and their dispensings accounted for a disproportionate number of opioid dispensings

Profiling multiple provider prescribing of opioids, benzodiazepines, stimulants, and anorectics (Wilsey et al., 2010)

Receiving a prescription for the same medication from ≥2 practitioners filled by ≥2 pharmacies within a 30-day period.

Opioid prescriptions (12.8%) were most frequently involved in multiple provider episodes and patients with simultaneous categories of controlled substances

Shopping Behavior for ADHD Drugs: Results of a Cohort Study in a Pharmacy Database (Cepeda et al., 2014)

≥1 overlapping prescription written by ≥2 prescribers filled by ≥3 pharmacies

Shopping episodes occurred 4 times more frequently in the ADHD cohort than those in comparison asthma cohort

Consequently, the lack of a standard definition for doctor shopping, and the wide variation across studies, may result in the unintended consequence of a high risk for both false positives and negatives. Using criteria that is not stringent enough in its criteria (e.g., ≥ 3 doctors and/or ≥ 3 pharmacies) may lead to the misclassification of patients who may actually be using opioids appropriately, resulting in false positives for doctor shopping. However, increasing this criteria to be too lenient (e.g., ≥ 5 doctors and/or ≥ 5 pharmacies) may result in excess false negatives and missed opportunities to identify individuals with apparent behavior (Katz et al., 2010). The uncertainty with identifying doctor shopping individuals may also be elevated due to the fact that most PDMPs are not linked with patient medical records, which may verify that a patient has a diagnosis warranting excessive controlled substance use. Consequently, in settings such as community pharmacies where pharmacists may not have access to patient records, identifying doctor shoppers may be challenging and problematic. Therefore, clinical expertise should be consulted before setting specific doctor shopping thresholds, as well as conducting sensitivity analysis based on the specific objectives of the study. Katz et al. (2010) also recommends the use of both multiple providers and multiple pharmacies for defining ‘doctor shopping’ (Katz et al., 2010), hence the term ‘multiple provider episodes’.

While defining doctor shopping is problematic, healthcare providers are also faced with the issue of what to do if a patient is suspected of doctor shopping. In West Virginia, where prescription drug overdose rates are the highest in the nation, a physician survey reported that while 40% of responding physicians suspected a patient of doctor

shopping at least once a week, only 22% were presently reporting doctor shopping. However, 85% of physicians responded that they would be likely to report doctor shopping if there was a law granting immunity to physicians for reporting doctor shoppers in good faith to law (Shaffer & Moss, 2010).