Where patients obtain pain medications.

1. ORIGINAL RESEARCH
Prescription Medication Obtainment Methods and Misuse
Daniel Tyler Bouland, MD, Eric Fine, MD, David Withers, MD, and Margaret Jarvis, MD
Background: Abuse of prescription medications is an ever-
expanding epidemic in the United States.
Objective: This study intends to help provide physicians with more
knowledge about the behaviors that patients with a substance use
disorder may exhibit in an effort to obtain medications.
Design: Patients who were willing to participate in the survey were
interviewed by a physician.
Setting: Patients were screened, selected, and interviewed while par-
ticipating in an inpatient rehabilitation program.
Results: Thirty-six patients completed the survey. There was a mean
of 50.2 prescriptions per person. An average of 1.2 states was utilized
by the surveyed patient population. There was an average of 2.11
providers seen per patient. Data show that 78% of patients surveyed
utilized more than one pharmacy. The type of medications obtained by
respondents were as follows: opioids, 35 (97.2%); sedative-hypnotics,
17 (47.4%); and amphetamines, 2 (5.5%). Seventy-five percent of pa-
tients (27 of the 36) stated that they feigned symptoms in attempts
to obtain prescriptions. Two patients used a falsified (via mislabel-
ing) magnetic resonance image of injury. Two patients paid a physi-
cian outright for the prescription. Three patients (8.3%) stated they
would physically harm themselves in an attempt to obtain prescription
medications.
Conclusions: It may be noted that patients seeking prescription med-
ications tend to utilize more than one physician and more than one
pharmacy. On the basis of survey results, it seems that primary care
and pain management physicians are considered the easiest venues
to obtain prescription medications. It suggests that patients will go to
great lengths to obtain prescription medications.
Key Words: addictive behavior, doctor shopping, medication obtain-
ment
(J Addict Med 2015;9: 281–285)
Abuse of controlled prescription medications is an ever-
expanding epidemic in the United States. Between 1999
and 2010, the rate of death from prescription opioids quadru-
pled, which far exceeded the combined death toll from cocaine
overdose and heroin overdose (Volkow et al., 2014). The num-
From the Marworth Treatment Facility, Waverly, PA.
Received for publication June 5, 2014; accepted March 3, 2015.
The authors declare no conflicts of interest.
Send correspondence and reprint requests to Daniel Tyler Bouland,
MD, 17273 Ohio 104, Building 24, Chillicothe, OH 45601. E-mail:
Daniel.Bouland@va.gov.
Copyright C 2015 American Society of Addiction Medicine
ISSN: 1932-0620/15/0904-0281
DOI: 10.1097/ADM.0000000000000130
ber of emergency department visits and treatment admissions
for substance use disorders related to prescription opioids has
increased significantly as well (Volkow et al., 2014). The sig-
nificant increase in prescription medication abuse prompted
the Department of Health and Human Services (HHS) to label
prescription opioid overdose deaths an epidemic. The HHS has
4 main objectives, one of which is to improve the provider’s
knowledge of the issue and increase the provider’s ability to
identify patients with substance use disorders. Much time and
research has been placed on finding alternatives for poten-
tially addictive medications, specifically benzodiazepines, opi-
ates/opioids, and amphetamine-based medications. However,
the treatment of choice for many diseases still remains de-
pendent on these restricted medications, which usually cause
physical dependence and may cause the disease of addiction.
One component of addiction medicine training is to
understand the behaviors of an addicted individual, and the
lengths patients may go to obtain their desired substance. As
part of this education, certain clinical vignettes were shared,
during personal interviews with the Addiction Medicine Pro-
gram Director and the Facility Medical Director, which had oc-
curred with previous patients. One individual had their home
licensed as a pharmacy so that narcotics would be delivered
without question to the front door. In an attempt to try and
appear like a normal pharmacy, this person would also or-
der other medications such as antibiotics and antihyperten-
sives. Another vignette involved stealing a truck and trailer
along with an elephant from the visiting circus. The indi-
viduals then took the elephant to veterinary clinics claiming
that the elephant had renal colic. This was in an attempt to
obtain opioid medications. It should be noted that a male
African elephant weighs anywhere from 8818 to 13,889 lb
(Chadwick et al., 2008). The patients believed they would
(and did) receive a significant amount of opioids for the ele-
phant on the basis of the elephant’s body weight. Another
vignette involved stealing mobile homes to support the sig-
nificant others opioid addiction. The truck was appropriately
configured for towing large, fully furnished mobile homes.
The individual would cut the power and water lines to the mo-
bile home while its occupants were away, hook up the truck,
and tow the mobile home away to be sold at a later time. The
person would then provide the significant other with the pro-
ceeds to support their habit. These aforementioned vignettes
prompted the need for further inquiry, and a certain level of
respect, for the lengths patients would go to obtain prescription
medications.
A review of articles and studies revealed a limited
amount of data and published material in regard to the
methods used by patients to obtain restricted prescription
Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
J Addict Med r Volume 9, Number 4, July/August 2015 281

2. Bouland et al. J Addict Med r Volume 9, Number 4, July/August 2015
drugs, including benzodiazepines, opiates/opioids, and
stimulants.
This study, by obtaining insight from patients, was de-
signed to identify methods used by patients to obtain pre-
scriptions for diversion or improper consumption. With the
compilation of information, we may improve the quality of
treatment by tailoring patient care to address any inappropri-
ate prescriptions and behavior before discharge. In addition,
this study was undertaken to provide physicians with more
knowledge to assist sifting through their patient population,
identify symptoms of addiction, and be able to make appro-
priate referrals for treatment. The study design, survey, and
consent forms were presented and approved by the relevant
institutional oversight committee.
METHODS
The study occurred from September 2013 through
March 2014 and was conducted at a residential addiction treat-
ment program. The residential facility maintains a total of 91
beds and has an average of 1200 annual admissions. Patients
admitted to the facility range from 18 to 80 years of age.
The catchment area consists of a diverse combination of ru-
ral, suburban, and urban populations. Approximately half of
the patients admitted to the facility reported alcohol as their
primary substance of use. About one third of the patients re-
ported opioids as their primary substance of choice, and the
remaining one-sixth primary substances of choice are cocaine,
inhalants, benzodiazepines, or other.
During the routine admission process, patients were
asked about their substance use by medical staff. Patients who
endorsed abuse of prescription medications were then asked
whether they obtained these medications from the street or
from a physician. For the purposes of this study, the phrase
“from the street” may refer to obtaining it from a dealer, friend,
or family member (whether by request or stolen). Patients who
endorsed obtaining prescription medication from a physician,
with the intent to divert or abuse, were noted and queried re-
garding their willingness to discuss the matter in further detail.
Patients were also informed that their drug obtainment patterns
would not be reported to law enforcement.
Patients who were willing to be interviewed were given
a consent form. Participants were notified that the study was
being conducted by the Addiction Medicine Fellow and the
Family Medicine Resident and that if they agreed to partic-
ipate, a 13-question survey would be performed by 1 of the
2 physicians.
After consent was signed, the 13-question survey was
initiated. The interviews were performed in a private exami-
nation room to protect patient confidentiality. The 23-survey
questions are as follows:
1. How many times have you attempted to obtain controlled
substances from a physician?
2. What do you feel prompted you to obtain prescriptions
from a physician as opposed to buying off the street?
3. How many physicians would you obtain prescriptions from
simultaneously?
4. How many states have you attempted to obtain prescrip-
tions in?
5. How many different pharmacies have you used?
6. What medications would you attempt to obtain from physi-
cians?
7. What methods would you use to obtain prescriptions? (ie,
falsify laboratory reports, imaging, prior physician visits,
and prescriptions)
8. Would you “fake” symptoms to obtain prescriptions? If
so, where was the symptomatology information obtained
from? What percentage of the symptoms you knew of
would you exhibit when seeing the physician?
9. What may a physician do or say that would help you stop
seeking drugs and/or consider seeking help for an addic-
tion?
10. Would you physically harm yourself to obtain prescrip-
tions? If so, explain.
11. What do you look for in a physician to determine whether
they are likely to provide prescriptions?
12. What is the best setting to obtain prescriptions? (ie, emer-
gency room, primary care physician, urgent care, and or-
thopedic office)
13. Is there a particular day of the week, or time of day, that
you target?
At the completion of the survey, patients were given
the opportunity to discuss any concerns with the interviewing
physician. Patients were also encouraged and given the oppor-
tunity to discuss any concerns with their individual counselor
outside the survey interview.
RESULTS
While planning the study, it was intended to survey 100
patients. This number was based on the available time and pre-
vious patient information from the treatment facility. It should
be noted that patient demographics were not compiled for this
study. For each patient who participated in the study, there
were many more who were screened. The majority of opioid
patients screened were solely using heroin and pills obtained
from the street. Of all the patients who were using or obtaining
pills, 50% of them would solely obtain their medications from
the street. One patient initially stated they would complete
the survey but did not, leaving 36 completed surveys. Thus,
all data incorporate 36 patients who elected to complete the
survey of questions.
Data were separated into 7 categories: frequency and
duration of obtainment, factors for utilizing physicians over
purchasing from the street, number of resources used (physi-
cians/pharmacies/states), types of medications obtained, meth-
ods utilized to obtain prescriptions, optimal venue of obtain-
ment, and what intervention might a doctor do to help stop or
change the addictive behavior.
Frequency and Duration of Obtaining Drugs
The surveyed patients utilized an estimated total of
1806 drug prescriptions over 136.5 years of combined du-
ration of prescription obtainment time. There was a mean of
50.2 prescriptions per person and median of 20.5 prescriptions
per person (Table 1). A right skew distribution revealed few
long-term utilizers of controlled substances.
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282 C 2015 American Society of Addiction Medicine

3. J Addict Med r Volume 9, Number 4, July/August 2015 Prescription Medication Obtainment Methods and Misuse
TABLE 1. Descriptive Statistics of Surveyed Patients
Prescriptions, n Duration, yrs
Prescriptions
per Month, n Providers, n States, n Pharmacies, n
Mean 50.17 3.79 10.03 2.11 1.19 5.36
Minimum 1.00 0.33 2.00 1 1 1
Maximum 400.00 13.00 30.77 7 2 50
There was a broad range of responses to the question
of how many times a patient attempted to obtain a controlled
substance from a physician (Fig. 1). One patient stated they
had only made one attempt to obtain a controlled substance
from a physician. Another patient stated they attempted to
obtain controlled substances from physicians about 400 times.
Two patients stated they had attempted to obtain controlled
substances from a physician “more times than I can count.”
The results revealed a diverse array of responses to
the question of over how long a time period the patient had
attempted to obtain controlled substances from a physician
(Fig. 2). One patient stated they had only seen a physician one
time in an attempt to obtain a controlled substance and thus
their response to this question was “one day.” On the other
hand, 2 patients stated they had been attempting to obtain con-
trolled substances from physicians for about 13 years.
Factors for Utilizing Physicians Over Purchasing
From the Street
Of the patients interviewed in this study, the most com-
mon reason cited for utilizing physicians instead of purchasing
from the street was related to legal concerns. Fourteen of the
36 patients felt that it was “more legal” to obtain their drugs
from a physician with a prescription as opposed to buying
them from the street. Both cost and comfort/safer were the
second most cited reason, with 11 of the 36 respondents not-
ing both. Ease of obtainment and medical necessity were the
lowest cited reasons for obtainment of prescriptions, with 5 of
the 26 respondents noting both.
Number of States, Physicians, and Pharmacies
Used
In an attempt to quantify the severity of addiction and
use, patients were asked the number of providers, number of
states, and number of pharmacies used in their obtainment
methods. There was an average of 2.11 providers per patient,
and a median of 2.0 providers per patient. The maximum num-
ber of prescribers utilized was 7 (Table 1).
An average of 1.2 states was utilized by the patient pop-
ulation (Table 1). The majority of patients who used more than
one pharmacy stated they would pay cash and use small “mom
and pop” pharmacies. Their given reason for this behavior
was so that insurance would not be tracking their prescrip-
tions. Also, patients noted that by using these smaller phar-
macies there would be less chance of communication between
pharmacists.
Initially, it was suspected that the increased number of
pharmacies utilized would be a good indicator of addictive
behavior. The data show that 78% of patients surveyed utilized
FIGURE 1. How many times have you attempted to obtain
controlled substances from a physician?
FIGURE 2. Over how long of a time have you attempted to
obtain controlled substances?
more than one pharmacy, which may be consistent with this,
as an average of 5.36 pharmacies were used (Table 1).
Types of Medications Obtained
The types of medications obtained by respondents
were as follows: opioids, 35 (97.2%), sedative-hypnotics, 17
(47.4%); and amphetamines, 2 (5.5%).
Methods Utilized to Obtain Prescriptions
Seventy-five percent of patients (27 of the 36) stated they
contrived symptoms in attempts to obtain prescriptions. Sev-
enteen patients stated that they had been treated for medical
conditions in the past, which required the desired prescrip-
tion, and thus feigned these same symptoms to obtain further
prescriptions.
Of the 9 patients that did not fake symptoms previously
experienced, 3 used old prescriptions or forged fake prescrip-
tions. Two patients used a falsified (via mislabeling) magnetic
resonance imaging (MRI) of injury. Two patients paid a physi-
cian outright for the prescription. Finally, 2 patients stated they
had legitimate pain, which was uncontrolled.
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C 2015 American Society of Addiction Medicine 283

4. Bouland et al. J Addict Med r Volume 9, Number 4, July/August 2015
Of interest, 3 patients (8.3%) stated they would phys-
ically harm themselves in an attempt to obtain prescription
medications. One patient would complain of urinary tract in-
fection and/or renal stone symptoms and then proceed to cut
fingers to obtain blood to place in the urine sample. This same
patient would also induce vomiting to worsen a gastrointesti-
nal diagnosis. A second patient had unnecessary surgery on
a clinically stable, but pathological on imaging, body part to
obtain medications. The third patient, while in jail, would bang
their head into a wall until unconscious or dazed. The patient
stated that this was done to obtain more opioids as they were
going through opioid withdrawal after being jailed. (It should
be noted that this may have been prevented by an appropri-
ate detoxification regimen, although the exact scenario of this
patient was not known.)
Optimal Venue of Obtainment
The purpose of this inquiry was to elicit how patients
were determining which physician to see and in what setting.
Sixteen patients stated that their physician of choice was a
referral from a fellow addict, friend, or family member. Twelve
patients (33.3%) stated that they did not use any profiling
of physicians. Three respondents (8.6%) sought “waffling or
leniency” during the encounter with the physician and/or staff.
Three patients stated they would seek a physician that did
not know the patient. Patients would do this by assuring the
physicians were in different health networks and/or completely
different geographic locations.
Of the different venues to access health care, 22 (61.1%)
patients stated that a primary care physician was the easiest per-
son from whom to obtain medications. Eight patients (22%)
cited pain management as the optimal venue. Four patients
(11.1%) stated that urgent care was the optimal venue because
of higher volume of patients, physicians have less time, and
physicians “do not know you.” Only one patient cited psychi-
atry as the optimal venue and this patient was attempting to
obtain benzodiazepines.
What Intervention Might a Doctor Do to Help
Stop or Change the Addictive Behavior?
The majority of patients (24 or 66.7%) cited that inter-
vention may have changed their behaviors. Of these 24 pa-
tients, one cited that patients undergoing urine drug screen-
ing would have prompted behavior change. Thirteen patients
(36.1%) cited nothing could be said or done to stop their ef-
forts to obtain prescription medications. Twenty-two patients
(61.1%) stated they would have welcomed an intervention by
their physician. These patients were then asked to further ex-
plain what an intervention meant to them. Most patients stated
that being confronted by a physician in an empathetic man-
ner would have changed their behavior. On further discussion,
5.6% of patients actually stated that this exact intervention had
occurred in the past and only prompted the patient to seek an-
other physician. Two respondents stated that they sought help
for their addiction after an intervention by a physician.
DISCUSSION/CONCLUSIONS
The majority of patients screened were obtaining opioids
from the street. This is important as it excluded many patients
from participating in the survey and was a major obstacle in
obtaining the initial goal of 100 patients. Another considera-
tion in our failure to obtain our goal of patients surveyed may
be related to an inherent behavior of the addictive disease. It
is possible that patients who wanted to “protect” their source
(ie, a physician) of medications/drugs would simply state they
were obtaining their drugs from the street. This also may have
been a contributing factor in patients who did not want to speak
about their behaviors with a physician and thus opted out of
participating. It should also be considered that patients may
have been concerned that their doctor shopping would be re-
ported in some way and thus they reverted to endorsing street
use. In addition, when interpreting the study results, it should
be taken into consideration that there is an inherent selection
bias and recall bias.
The result that 97% of participants were obtaining opi-
oid prescriptions is likely due to selection bias. It is possi-
ble that this statistic represents the addicted population, but
a large-scale study would need to be performed to elicit this
information. For patients who obtained medications from a
physician, it may be stated that most patients utilized more
than one provider. Thus, seeing more than one provider may
be considered a risk factor when screening for drug-seeking
behavior.
The result of 61% of participants stating that primary
care was the easiest venue to obtain abused prescriptions from
is important for a few reasons. First, primary care may be
the easiest venue due to the higher quantity of primary care
providers versus pain management, orthopedics, or other sub-
specialties. Another reason may be due to high patient vol-
ume and limited physician time in primary care. In addition,
primary care offices may take a broader range of insurance
coverage than other specialties, and thus see a broader range
of patients. It should also be taken into consideration that few
physicians have training in addiction.
It is important to note that 61% of patients stated that
an intervention by a physician would have been welcomed.
The meta-analysis for the United States Preventive Services
Task Force concluded that behavioral interventions improve
behavioral outcomes for adults with risky drinking (Jonas et al.,
2012). This may also be the case for patients with behavioral
issues related to prescription medications, although further
studies would need to be performed.
As part of the study, the question of “What methods
would you use to obtain prescriptions?” prompted a diverse
array of answers. The intent of the question was to help provide
doctors examples of the lengths that patients will go to obtain
prescriptions. Two answers involved providing the physician
with both a DVD and paper copy of a fake MRI with appropri-
ately contrived pain. In a similar answer, a patient stated that
they would bring in feigned prescription bottles with appropri-
ate dosages of the medications they wished to be prescribed.
With practice time constraints, most physicians would likely
assume legitimacy of the MRI and/or prescription bottles and
provide appropriate prescriptions and referrals without much
hesitation. This study intends to alert physicians about these
types of addictive behaviors.
It is important for physicians in all specialties to be
able to recognize patients with addictive disease. This may
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284 C 2015 American Society of Addiction Medicine

5. J Addict Med r Volume 9, Number 4, July/August 2015 Prescription Medication Obtainment Methods and Misuse
be by performing patient screening for drug and alcohol use
or by recognizing drug-seeking behavior. When discussing
drug and alcohol screening, it is important to touch on the
topic of urine drug screening. The initial screening is usually
a urine immunoassay, which is inexpensive and yields rapid
results. It is important that prescribers have real-time urine
drug screening results before prescribing. The major downfall
of the urine immunoassay is cross-reactivity and thus many
false positives. A urine drug screen is a medical screening test
like all other screening tests. It is not medicolegal. Because
there may be major consequences for an individual on the
basis of positive drug test results, it is important to obtain a
confirmatory test. The major consequences of a positive urine
drug screen being the detection, diagnosis, and treatment of
serious medical behaviors (substance use) and/or disease (ad-
diction). In many cases, the second (confirmatory) test may be
chromatography. Many times gas chromatography with mass
spectroscopy may be used, which will be able to precisely
identify the compound (Ries et al., 2009). Gas chromatogra-
phy with mass spectroscopy typically is a “send out” test and
therefore not immediately available to help guide a clinical
decision.
There are other tools that may be used in conjunction
with a urine drug screen in assisting a health care professional
with their prescribing practices. One tool is a prescription mon-
itoring program (PMP). A PMP may be either a computerized
or noncomputerized system that monitors prescribing practices
of controlled substances in an attempt to decrease prescription
medication diversion (Ries et al., 2009). Each state is different
in their availability of a PMP and the rules and regulations sur-
rounding its use. Another useful tool is the risk evaluation and
mitigation strategy (REMS). The Food and Drug Administra-
tion Amendment Act of 2007 gave the FDA the authority to
require pharmaceutical manufacturers to provide the REMS to
safeguard that the benefits of a medication outweigh the risks.
The REMS is essentially a safety strategy intended to help pa-
tients and health care professionals manage known potential
serious risks of a medication (FDA, 2014). The REMS may be
accessed by anyone and provide some guidance in the use of
potentially addicting medications.
In addition to the aforementioned tools, this study was
intended to give physicians insight into the addict’s behavior
so that it may be recognized earlier and an appropriate brief
intervention and referral to treatment made (if warranted).
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C 2015 American Society of Addiction Medicine 285