Aberrant Prescription Medication Seeking Behavior Used by Prescription Drug Users to Obtain Prescription Medications from Physicians: A Qualitative Review of Webpages, Blogs and Forums

Prescription medications, after cannabis, are the second most commonly used drugs in all age groups in the United States. Evidence indicates prescription medication abuse has been associated with significant morbidity and mortality and imposes a serious burden to the health care system [1].

It is estimated that about half of all emergency department visits for drug misuse were attributed to prescription medication abuse [2]. From 1999 to 2016, more than 200,000 people died in the United States from overdoses related to prescription opioids. This number was five times higher in 2016 than in 1999 [3].

According to the Drug Abuse Warning Network of the United States, [4] over 1.2 million emergency department (ED) visits involved nonmedical use of prescription medicines, over-thecounter drugs, or other types of pharmaceuticals in 2011. Pain relievers were the most common type of drugs involved in medical emergencies and narcotic pain relievers were involved in 29 percent. According to this study, the overall medical emergencies related to nonmedical use of pharmaceuticals increased 132 percent in the period from 2004 to 2011, with opiate/opioid involvement rising 183 percent. Central nervous system (CNS) stimulants (e.g., ADHD drugs) have experienced an 85% increase in the short-term, a similar short-term rise observed for involvement of illicit stimulants (amphetamines/methamphetamine) (71%).

In the US, according to the 2014 National Survey on Drug Use and Health, past year nonmedical use of prescription drugs (opioids Citation: Siavash Jafari, Ashkan Nasr, Nazila Hassanabadi. Aberrant Prescription Medication Seeking Behavior Used by Prescription Drug Users to Obtain Prescription Medications from Physicians: A Qualitative Review of Webpages, Blogs and Forums. Open Access J Addict & Psychol. 3(1): 2019. OAJAP.MS.ID.000555. DOI: 10.33552/OAJAP.2019.03.000555. Page 2 of 6 stimulants, tranquilizers and sedatives) was reported by 6.2% of 12-17 year-olds and 11.8% of 18-25 year-olds, mainly driven by nonmedical use of prescription opioids, which has remained stable in the past decade despite rising trend since the late 1990’s [5].

Americans constitute less than 5% of the world’s population; however, they consume 80% of the global opioid supply and 99% of the global hydrocodone supply [6]. From 1997 to 2007, retail sales of commonly used opioid medications (including methadone, oxycodone, fentanyl base, hydromorphone, hydrocodone, morphine, meperidine, and codeine) have increased from a total of 50.7 million grams in 1997 to 126.5 million grams in 2007 [7]. This is an overall increase of 149% with increases ranging from 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl base, 866% for oxycodone, to 1293% for methadone.

The Canadian Alcohol and Drug Use Monitoring Survey 2013 found that opioid pain relievers were used by 4.3 million (15% of Canadians aged 15 years and older) [8]. Of these users, 99,000 (2%) of all self-reported abusing their opioid painkillers. This number was 6% among youth aged 15 to 19. United States, in 2002, abuse of prescription drugs cost nearly $181 billion [9].

One US study found that depressive symptoms and suicidality were significantly associated with greater odds of any non-medical prescription drug use (NMPDU), with painkiller use representing the greatest correlate among college students [10]. Other studies indicate that early onset of NMPDU was a significant predictor of prescription drug dependence. These findings reinforce the importance of developing prevention efforts to reduce NMPDU and diversion of prescription drugs among children and adolescents [11].

Several studies have found that patients who obtain prescribed medications could share them with friends and family [11-14]. Mc Cabe, et al. in 2006 investigated the prevalence and factors associated with the illicit use of prescription stimulants and assessed the relationship between the medical and illicit use of prescription stimulants among undergraduate college students [15]. A total of 9,161 undergraduate students, attending a large, public, midwestern research university in the United States completed a self-administered web-based survey. Of them, 8.1% reported lifetime illicit use of prescription stimulants and 5.4% reported past year illicit use. The number of undergraduate students who reported illicit use of prescription stimulants exceeded the number of students who reported medical use of prescription stimulants for attention deficit hyperactivity disorder (ADHD). The leading sources of prescription stimulants for illicit use were friends and peers [15]. Students may take stimulants to improve their concentration, stay awake on exam nights, or improve their academic performance [16,17].

Prescription drugs can be retrieved through doctors, theft, or forgery. Doctor shopping is one of the most common methods of obtaining prescription medications among those who abuse them [18]. Doctor shopping is the act of “filling overlapping prescriptions from more than one prescriber at more than two pharmacies.” Prescription medication users use a variety of approaches to obtain medications of their choice from prescribers.

Blogs, websites, online forums and social media are common and easy ways of sharing information. Ease of access, confidentiality and ability to hide one’s own identity makes online platforms lucrative for exchange of ideas and sharing personal experiences on obtaining the drugs of choice. In this study we try to explore the methods that prescription medication users share in online platforms to guide other users how to obtain their drugs of choice from prescribers.

Search strategy

We used a combination of keywords to search five main search engines: Google, Yahoo, Bing, MSN and AOL. Our search strategy focused on highly abused medication categories: opioids (painkillers) and stimulants. The following keywords were used for the purpose of this search: Tylenol 3, Tylenol #3, Morphine, Hydromorphone, Dilaudid, Dexedrine, Ritalin/Adderall, and Pain Medications. Also, our search included a combination of questions inquiring about how to obtain specific medications from prescribers, such as:

1. how to get narcotics from doctors?

2. How to obtain morphine, Oxy, Percocet, Tylenol #3 from doctors?

3. How to get ADHD medications from doctors?

4. How to obtain stimulants (Adderall, Ritalin, Dexedrine, amphetamines, dextroamphetamines) from doctors?

For each search engine we looked at all first 50 pages which provided 500 URLs. We included any website, blog, documents, online chat, forum, or any other communication records that provided information about obtaining prescription medication from doctors.

Data collection

We created an excel spreadsheet with columns for each of the categories of medications. The text of webpages and the relevant URLs of the webpages were copied and pasted into the table. Extracted content was reviewed in detail by two reviewers. All relevant text was collected and placed into the table under the related category.

Data analysis

We used summative content analysis to explore the approaches shared online to obtain prescription medications from prescribers. Summative content analysis involves counting and comparisons of keywords followed by the interpretation of the underlying context [19]. Two authors (SJ and PG) reviewed the content independently. Duplicate text was removed from the table. Text was coded based on relevance to the keywords. Themes and subthemes were identified for each category of medications in this study. Aberrant behaviors were identified through this process and were grouped in five main categories based on the themes that were created in the first step.

Qualitative analysis of the verbatim revealed 5 themes and 34 sub-themes that are presented in Table 1.

Table 1: The themes and subthemes that emerged from our qualitative assessment.

The following verbatim presents some examples of online advice and discussions among prescription medication users.

False reporting of symptoms

False reporting of the symptoms consists of over-reporting the severity of illness and symptoms. This approach was the most common approach suggested by users.

“What usually works for me, is complaining of some mysterious pain that prevents you from participating in normal activities. If that doesn’t work, there’s always threatening to sue them for malpractice, or then again, there is always flat out bribery. Hope this helps.”

“I would start by telling the doctor that what he is giving me isn’t working and you are taking more than the prescribed dose to try and rid yourself of the pain.”

“NEVER say you tried amphetamines and they helped – that’s seeking. if asked about drug use, say you smoked pot a few times and “didn’t like the feeling of being altered. Aside from that, go in and complain of not being able to concentrate - if this is a new doctor, tell him you were on Adderall (maybe 10mg twice a day) back when you were and it helped. but if he doesn’t want to prescribe an amphetamine right away, do NOT FIGHT IT! Take what he gives you then tell him it doesn’t work. Will someone post the Guide to Faking ADHD?”

In this study we investigated the approaches that nonmedical users of prescription medications share online to access prescription opioids and stimulants. Findings of this study revealed that individuals who seek prescription medications use a variety of aberrant drug seeking behaviors to obtain their medications of choice. Most of these approaches have good face validity such as: knowing the symptoms of illness, having a family member along with you during the visit, finding a clinic in a low socioeconomic status (SES) area, avoiding asking directly for the medication of choice, going to the emergency room (ER), crying in pain, finding an easy-going physician and paying cash.

Others utilize unacceptable and abusive approaches such as: reporting a false past medical history, bribing the provider or the pharmacy, threatening a lawsuit, finding an online pharmacy, reporting fake symptoms, exaggerating pain severity, reporting symptoms that are difficult to diagnose (fibromyalgia), and finding a pharmacy that asks for no prescription.

Reducing non-medical use of prescription medications requires engagement of all stakeholders, including the prescribers, patients, health service organizations, and pharmacies. Provider factors can focus on educating the physicians to perform indepth assessment of patients prior to initiation of any treatment plan. Physicians should be aware of the potential risk of abuse of prescription medications. Developing clinical practice guidelines would help providers keep updated about available treatment options and benefits and risks related to each treatment [20,21]. Also, prescribers should be aware of the individual risk factors of non-medical use of prescription medications and the warning signs such as multiple doctoring, lost scripts, and lost medications [22,23]. Clinicians can use a combination of approaches to identify drug seeking behaviors. A detailed history and physical examination followed up by a thorough documentation of findings would be the first and the most important component of such an assessment [24]. A comprehensive and detailed assessment of symptoms and signs and consultation with the previous physician about the potential diagnosis, treatment history, medication dose, and aberrant behavior could be helpful. Validating the past medical history and the past treatments is very important and could be achieved by contacting previous providers, although this could be impossible for some patients [24-27].

Patient factors should take into account patient knowledge of drug-related harm, educating patients about benefits and risks of their medications and about avoiding medication sharing, development of patient handouts, safe storage of medications, avoidance from stockpiling and increasing access to drug addiction services, assignment of high-risk patients to a single-prescriber and single-pharmacy, and automated cancellation of multiple same-time prescriptions [28,29]. Also, lifestyle modification, alternative approaches such as physical therapy and rehabilitation, natural products, acupuncture and stress management could be other alternatives or adjuncts to prescription painkillers in the management of patients’ pain, rather than constantly increasing their painkiller dose. Regular monitoring programs such as pill counts, urine drug screens, limiting the dose per prescription and reducing the frequency of dispensing have been suggested by some researchers.

The greater “social acceptance” for using these medications (versus illegal substances) and the misconception that they are “safe” may be contributing factors to their misuse. Hence, a major target for intervention is the general public, including parents and youth, who must be better informed about the negative consequences of sharing medications with others that were prescribed for their own ailments. Equally important is the improved training of medical practitioners and their staff to better recognize patients who are at potential risk of developing nonmedical use. Such practitioners should consider potential alternative treatments as well as closely monitor the medications they dispense to these patients [5].

Health services factors should consider inter-provincial data sharing, prescription drug monitoring programs. Prevention of pill mills, pharmacist involvement and education about prevention of multiple prescription dispensing, and state law enforcement around prescription requirements [20,21,30-37]. Also considered should be the prevention of illegitimate online pharmacies, improving access to counselling and psychology services [38], increasing casemanagement services, and increasing treatment opportunities and services for prescription medication dependence [38-40].

Pharmacies are one of the main pillars of patient care and can take an active role in preventing and reducing prescription medication abuse. Reporting aberrant behaviors such as any modified prescription to the prescriber, establishing a lock-in program, [36] validating any out of range doses of prescriptions, reminding and validating early refills, securing the storage of sensitive medications, establishing a multidisciplinary controlledsubstance inventory system, and working with local, state, and federal authorities in controlling substance abuse, including participation in state prescription drug monitoring programs. Other approaches include encouraging participation in appropriate prescription disposal programs and complying with controlledsubstance reporting regulations [41,42].

In conclusion, non-medical use of prescription medications in Canada and the United States is a public health problem and requires multidisciplinary approach. Non-medical use of prescription medications poses significant risks to individuals and families and significant costs to the health care system. Individuals who use not-medically-indicated prescription medications share aberrant drug seeking behavior in social media and educate others on the approaches to obtaining prescription medications from physicians. To deal with this matter, engagement of all stakeholders, including the prescribers, patients, health service organizations, and pharmacies is required.

None.

No conflict of interest.

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