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13 Articles in Volume 18, Issue #1
Applying a Collaborative Care Model to the Treatment of Chronic Pain and Depression
Assessing the Pain Triangle
Emerging Technologies in Rehabilitation Medicine
Gaming as a Tool for Pain Relief
Honoring Dr. Forest Tennant’s 50-Plus Years in Pain Management
Is There a Chronic Pain Personality Profile?
Managing Musculoskeletal Pain in Endurance Athletes
Managing Perioperative Pain
Nonparenteral Oxytocin, Erythromelalgia...Letters from the Minds of Peers and Patients
OSKA PEMF Pain Relief Device: A Mini Review Trial
Patient Communication & Opioid Prescribing in the New Year
What Opioid Shopping Means for Pain Practitioners
Would Patients Benefit from a Glucosamine/Chondroitin Supplement to Manage Knee Osteoarthritis Pain?

What Opioid Shopping Means for Pain Practitioners

Identifying those at risk for opioid abuse, misuse, and diversion presents an increasing clinical concern.

Among patients who request prescription pain medication at a frequency above that deemed necessary or appropriate by the primary care practitioner, a common behavior is opioid shopping—defined as obtaining a prescription for opioids from multiple physicians and/or pharmacies.

Opioid Shopping Practices

Researchers have attempted to correlate shopping behavior with identifiable characteristics. In a study by Cepeda et al,1 the researchers introduced a useful definition for opioid shopping that incorporates the number of overlapping prescriptions written by different prescribers and the number of pharmacies that fill those prescriptions.  

An overlap would be indicative of a new prescription that was filled before a prior or older one has expired. By comparing prescription filling habits for opioids versus diuretics, the research team examined patient patterns for obtaining two or more overlapping prescriptions written by different prescribers and filled at three or more pharmacies as indicative of likely shopping behavior.1

Based on this criteria, patients 65 years and older appeared to exhibit shopping behavior less frequently than younger patients.2 Other correlates of possible opioid shopping patterns included concurrent dispensing of benzodiazepines for a diagnoses of mood disorders, back pain, or abuse of non-opioid drugs, where as pain management for patients with a diagnosis of cancer was negatively correlated with shopping behavior.

Likely opioid shoppers were also more likely to pay for prescriptions on their own (ie, in cash), rather than requesting that the prescriptions be processed through their insurance plans. 2

Evident Patterns of Opioid Shopping

Indications of possible opioid shopping activity were assessed using a large database of insurance claims that also included out-of-plan and self-paid prescriptions.3 In this study lead by Alexander M. Walker, MD, and his colleagues, part of a consortium of opioid stakeholders, the goal was to assess opioid shopping behavior and its correlates.3

“Our measure of possible shopping behavior was broader than that of earlier studies,” said Dr. Walker. “We looked at the reliance on many pharmacies to fill scripts from several practitioners over an 18-month block of time. The assessment was based on examining characteristics of dispensing sequences that best distinguished opioids from diuretics, which we took as a control group for which there would be little or no drug-seeking behavior.”

In a population of 264,204 treatment courses in individuals who filled an opioid or a diuretic prescription in 2012 and a second within 18 months, researchers used logistic regression to assess associations between claims characteristics and shopping behavior. 3

The researchers found that “moderate” and “extensive” shopping, defined as obtaining a medication through at least three practices and three pharmacies over 18 months, might be used to sharply differentiate opioid shopping from other reasons for seeking prescription refills. Moreover, this pattern of prescription refilling was associated with 20 significant predictors that may be used to signal opioid shopping based on insurance claims data. 3

In particular, seven factors with the strongest correlations were identified: 3

  • age (extensive use declined with increasing age, particularly > 75 years of age)
  • residence in certain states (ie, top 10 included: New Hampshire, Delaware, New Jersey, Virginia, Arizona, Maryland, New York, Massachusetts, Washington, and Rhode Island)
  • receipt of high doses of opioids (> 5000 morphine milligram equivalents over 18 months)
  • self-payment
  • approaching non-specialist prescribers
  • concurrent high use of anxiolytics, hypnotics, psychostimulants, and antipsychotics
  • use of both immediate release (IR), and extended release (ER) or long-acting (LA) opioids.

Of the individuals deemed the heaviest “shoppers,” 9% exhibited extensive shopping predisposition, having sought both IR and ER/LA opioid prescriptions; this was in comparison to 1% of individuals who obtained only an IR or an ER/LA opioid prescription. 3 There were no significant differences in shopping behavior between the sexes.

Pain diagnoses among the individuals monitored in this study included: arthritis; back pain; late effects of musculoskeletal and connective tissue injuries, including fractures and bone disorders; headaches; cancer; other musculoskeletal disorders (ie, rheumatologic, sprains, dislocations); neuropathies (eg, peripheral neuropathic pain); and other conditions (ie, open wounds, intracranial or spinal injury, pelvic, thoracic, and abdominal injuries, burns).3

These findings corroborated findings from previous investigations.1-3 The authors noted that, although the total percentage of individuals with moderate to extensive levels of opioid shopping behavior—of 5.1%—may not seem high in a cohort of patients with chronic pain, variations in the prevalence of possible shopping between individuals with different characteristics suggested that other nonmedical factors may be at play.3

Identifying “Shoppers” in Clinical Practice

“Doctor shopping doesn’t exist in isolation,” Dr. Walker told Practical Pain Management, “People who go from prescriber to prescriber and from pharmacy to pharmacy have many characteristics that clinicians and health practices may identify.”

His investigative team described doctor shopping as one manifestation of a widespread behavioral pathology that has many observable features.3 The ability to identify correlates of possible opioid shopping by evaluating health insurance claims and not just drug usage patterns may aid practitioners in recognizing individuals who will likely benefit from intervention. These findings may also help to identify prescribers and pharmacies that might gain from focused interventions to assure safer prescribing and dispensing.

“That the data considered in this investigation were collected between 2012 and 2014 limits the generalizability of the results in current clinical realities since the situation has changed with the publication of the draconian opioid prescribing guidelines of 2015 and 2016, and as occurred prior to the onset of the new opioid crises of opiophobia and oligoanalgesia,” said Michael A. Schatman, PhD, CPE, director of research and network development at Boston Pain Care and a pain bioethicist at Tufts University School of Medicine in Medford, Massachusetts.

“Nevertheless, the authors suggest that prescription drug monitoring programs may indeed offer a partial deterrent to doctor shopping, and that they need to become mandatory across the nation,” Dr. Schatman said.

For starters, Michigan has passed legislation set to take effect in June 2018 that requires physicians to check a patient database before prescribing opioids and other Schedule 2-5 medications.4

 

Last updated on: January 31, 2018
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Gaming as a Tool for Pain Relief
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