Download Indicators of `Doctor Shopping`

B3: 6 Challenging
Behaviours HO1
Indicators of ‘Doctor Shopping’
It is impossible for patients who consume large quantities of benzodiazepines
or pain relieving medication to acquire them from a single prescriber or
pharmacy. This necessitates either purchase on the street or practising
‘doctor shopping’ or ‘prescription shopping’. A person considered a ‘doctor
shopper’ is someone who in one year visits more doctors than is clinically
necessary, to gain more medication than is therapeutically required.
The dependent patient will often visit a variety of doctors, often in the same
day, to obtain the required number of scripts. This process can consume a
great deal of time, especially when combined with visiting a range of different
pharmacies to collect the prescriptions. Australian HIC data indicate that many
of the ‘doctor shoppers’ are female (58%) and aged between 15 and 29 years
(20%) and 30 and 49 years (58%). (HIC, 2000). Of the total PBS medicines
obtained by doctor shoppers, 35.5% are benzodiazepines, 14.6% are codeine
compounds and 8.4% are narcotic analgesics (HIC, 2001).
CHOICE OF DOCTORS
The choice of doctor is often determined by word of mouth. Some dependent
users compile a list of “easy prescribers”, or will experiment until they find a
range of doctors who will meet their needs. While the majority tend to include
their regular doctor in their routine, some choose to exclude their regular GP.
METHODS OF OBTAINING PRESCRIPTIONS
Patients generally have a routine story they use in order to gain prescriptions.
Common stories include stress, sleeping difficulties and alcohol-related
problems. Often the preferred drug is requested by name, sometimes stating
that this drug is what their usual doctor prescribes. It is likely that patients will
try to persuade doctors to provide the maximum allowable tablets, giving
reasons such as going away on a trip or saving on dispensing costs.
INDICATORS OF DOCTOR SHOPPING
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patient has a well rehearsed story, possibly with themes of insomnia,
stress or dealing with alcohol withdrawal
patient is familiar with drug names
requests a specific drug to be prescribed
pressure to prescribe the maximum amount
expresses reservations about other treatment options
punishes or rewards the doctor according to response
other significant drug–related problems.
Resource Kit for GP Trainers on Illicit Drug Issues
Part B Clinical Complexity: Challenging Behaviours
MANAGING THE INTOXICATED OR WITHDRAWING PATIENT
Mind altering (psychoactive) drugs affect the functioning of the CNS and
hence a person's actions and reactions. Intoxication may involve anger or
aggression, which can cause angst and disruption for staff, the practitioner
and other patients. Appropriate management can reduce the likelihood of the
situation escalating out of control.
Behavioural changes associated with intoxication include:
poor memory
poor judgement
slurred speech
confusion
decreased attention span
gaps in understanding
disinhibition
frustration
mood swings, sudden,
lack of ability to respond
unprovoked and unpredictable appropriately
lack of retention of
information.
However, since symptoms such as slurred speech, weakness or ataxic gait
are associated with conditions other than intoxication, if symptoms persist
beyond the expected length of time, further investigations are required to
determine underlying pathology.
Intoxicated persons are ready to take umbrage and to see insult where none
was intended, but they are not totally out of control. The behaviour and
expectations of the practitioner will shape the patient’s responses. Therefore it
is important to speak politely, address the patient formally and do not laugh at
the behaviours associated with the intoxication.
When addressing the intoxicated person, always:
 state and repeat if necessary where they are,
 who you are,
 what you are asking them to do,
 or what procedure you are about undertake.
Maintain a quiet, calm tone of voice. Use short sentences and clear, simple
language. Make one request or give one instruction at a time and allow the
patient time to absorb the request.
Resource Kit for GP Trainers on Illicit Drug Issues
Part B Clinical Complexity: Challenging Behaviours
Remember that the effect of the drug on the CNS increases reaction time. If
the patient is being aggressive and angry in a waiting room, or where other
people are located, move the person to another area where there are no
onlookers. Without an audience, the patient may quieten because they feel
there is less of a need to defend themselves from what they perceive as an
attack on their self esteem.
Asking the patient to move around may cause problems as they are often
ataxic, clumsy, slow to move and slow to follow directions. A careful and clear
request by the practitioner will assist and the use of a polite gesture, such as a
waiter may use when showing patrons to their dining table, is the best
approach. Challenging the patient gives the person the sense that their pride
and self-esteem are being questioned. This will lead to anger and outbursts
and is best avoided.
Adapted from: Alcohol and Drug Training and Research Unit (ADTRU), Queensland Divisions
of General Practice and Department of Psychiatry, University of Queensland, 2002, Training
package for medical practitioners in the effective identification and treatment of
pharmaceutical and illicit drug problems. ADTRU: Brisbane. p.8
Resource Kit for GP Trainers on Illicit Drug Issues
Part B Clinical Complexity: Challenging Behaviours