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How to detect and prevent prescription abuse

Vol. 1, No. 10 / October 2002

Addiction and prescription abuse are potential dangers with some medications that psychiatrists prescribe for long-term use. Benzodiazepines for chronic anxiety and stimulants prescribed for narcolepsy and attention-deficit/hyperactivity disorder are among the agents most commonly abused by psychiatric patients. Here are some telltale signs that point to prescription abuse:

• The patient frequently loses the prescription or medication. Accidents will happen, and any patient can misplace a prescription medication or experience a mishap (e.g., “I knocked my pills in the toilet”). Give the patient the benefit of the doubt if it happens once, but a second report of lost or accidentally discarded medication should raise a red flag.

• The patient’s dosage of a potentially addictive medication has steadily increased in recent months. This is especially telling if the dosage had been static for years.

• The patient often exhausts the medication early.

• The patient asks you to send the prescription to a different pharmacy with each renewal. A patient with accounts at several pharmacies might try to forge copies of a legitimate prescription and get it filled simultaneously at multiple pharmacies.

• The police call your office to check on a prescription you wrote. This is an obvious red flag: The patient may be trying to forge a bogus prescription in your name.

Tips on preventing prescription fraud

The following steps can reduce the potential for prescription fraud:

• Keep copious patient records. I can’t stress enough the importance of documenting every visit, every interaction, every prescription, every refill. When several doctors cover the same office, detailed documentation ensures that the covering physician can make informed decisions about refills

• Make sure stable patients are seen at least once a year. This helps you stay on top of any medical status changes and ascertain whether a change in medication or dosage is needed.

• Mail prescriptions directly to the pharmacy. This is especially useful if the patient is stable and is on a long-term prescription.

Forwarding prescriptions for some agents via fax may be an option, depending on the laws in your state. For example, some states allow faxed prescriptions for benzodiazepines, but federal law requires original written prescriptions for most stimulants.

• Require 2 weeks’ notice before refilling a prescription. This allows you to keep tighter controls on the prescription and will ensure that the medication will be mailed before it runs out. This is prudent when prescribing Schedule II agents (legal but highly addictive prescription medications).

• Stipulate that the patient must have prescriptions and refills authorized by a single provider, be it you or the primary care physician. Be explicit and unyielding in this demand. If you find that the patient is getting the medication you’ve prescribed from at least one other physician, discontinue the prescription.

If you suspect the patient is abusing a prescribed medication, you must confront that patient. Be scrupulously honest; tell the patient, “I’m concerned about your steadily increasing use of this medication. It is important that you trust me and follow my directions, or else I cannot help you.”

Consider referring the patient to a substance abuse specialist if prescription abuse is suspected. I’ve also known some clinicians to administer urine tests to check for medication abuse.

Dr. Altchuler is director of addiction services, department of psychiatry and psychology, Mayo Clinic, Rochester, MN.

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