This document discusses the abuse of prescription drugs in the United States. It makes three key points: 1) An estimated 3% of the US population misuses or abuses prescription psychoactive medications, with severe health consequences. More than half of drug treatment and overdose deaths in 1989 involved prescription drug abuse. 2) Physicians can unintentionally contribute to prescription drug abuse through injudicious prescribing practices, poor security of prescription forms, or acquiescing to patient demands for drugs. Manipulative patients also engage in prescription forgery, theft, and alteration to obtain drugs. 3) It is important for physicians to be aware of "conning" tactics used by drug seekers to obtain medications. Common

1. andthe PrimaryCare Physician
Abuse of Prescription Drugs
BONNIE B. WILFORD, Chicago
An estimated 3% of the United States population deliberately misuse or abuse psychoactive medica-
tions, with severe consequences. According to the National Institute on Drug Abuse, more than haffof
patients who sought treatmentordiedofdrug-relatedmedicalproblems in 1989 were abusingprescrip-
tion drugs. Physicians who contribute to this problem have been described by the American Medical
Association as dishonest-willfully misprescribing forpurposes ofabuse, usually forprofit; disabled by
personalproblems with drugs oralcohol; datedin theirknowledge ofcurrentpharmacologyortherapeu-
tics; or deceived by various patient-initiated fraudulent approaches. Even physicians who do not meet
anyofthese descriptions mustguardagainstcontributing toprescription drug abuse through injudicious
prescribing, inadequate safeguarding of prescription forms or drug supplies, or acquiescing to the
demands or ruses used to obtain drugs for other than medical purposes.
(Wilford BB: Abuse of prescription drugs, In Addiction Medicine [Special Issue]. West J Med 1990 May; 152:609-612)
The use ofdrugs in America is strongly influenced by the
social, economic, political, and scientific and techno-
logic environments that define our society. In fact, we are a
drug-taking society whose general outlook is that every mal-
ady has a treatment and that this solution lies mainly in the
use ofmedicinal agents. We have a social and cultural expec-
tation that there is a "pill for every ill." Medications have
come to play such an important role in the interchange be-
tween physicians and patients that often the prescription is
viewed as an expected medium of exchange between patient
and prescriber. A prescriber has not concluded his or her
application of skills until a prescription has been written for
the cure. The closure ofa visit between patient and physician
is symbolized by the prescription being handed to the pa-
tient. I
Recognizing patients who misuse such medications or
who seek psychoactive drugs for the purpose of intoxication
or resale to others constitutes a clinical problem for which
medical school preparation is lacking. Yet the number of
such patients is large-3% of the population, according to
federal estimates2-and the consequences ofsuch use severe.
In surveys by the National Institute on Drug Abuse, more
than halfofpatients who soughttreatment for or died ofdrug-
related medical problems were abusing prescription drugs.3
From the perspective of the health care system and clini-
cians, there are three variants of prescription drug abuse:
* Patients who present with an established dependence
on a prescription drug;
* Those in whom iatrogenic drug dependence develops
as the result ofinjudicious prescription practices or the use of
multiple physicians, or both, or self-medication rather than
compliance with a physician's directions; and
* Patients who seek drugs to divert them-that is, to
acquire drugs to sell.
Despite these differences in motive, the drug-seeking behav-
ior itself has many similarities.
The Council on Scientific Affairs ofthe American Medi-
cal Association clearly defined the sources of prescription
drug abuse in its 1981 report, "Drug Abuse Related to Pre-
scribing Practices."4 In that report, the Council described as
contributing to the problem those practitioners who engage in
willful and conscious misprescribing for the purposes ofdrug
abuse, usually for profit; accede to inappropriate demands
for medications by patients; prescribe in an uninformed way
because they have not kept pace with developments in drug
therapy; or whose professional judgment is impaired by vir-
tue ofpersonal problems with drugs or alcohol. The Council
also identified patient manipulation of prescription orders-
by theft, alteration, or forgery-and theft of drugs as major
elements of concern.
Having defined the dimensions ofthe problem, the Coun-
cil called on physicians to guard against contributing to pre-
scription drug abuse through injudicious prescribing prac-
tices or by acquiescing to the demands of certain patients for
instant chemical solutions to all their problems. Each physi-
cian should convey to patients the concept that all drugs-no
matter how helpful-are only part ofan overall plan oftreat-
ment and management.
Even when sound medical indications have been estab-
lished for using a psychoactive drug, three additional factors
should be considered in deciding on the dosage and duration
of drug therapy':
* The severity ofsymptoms, in terms ofa patient's ability
to accommodate them. Relief of symptoms is a legitimate
goal of medical practice, but using many psychoactive drugs
to achieve complete symptomatic relief requires caution be-
cause ofthe abuse potential and dependence liability ofthese
drugs.
From the Department of Substance Abuse, American Medical Association, Chicago.
Reprint requests to Bonnie B. Wilford, Director, Department of Substance Abuse, American Medical Association, 535 N Dearborn St, Chicago, IL 60610.

2. 61.RSRPINDU
* A patient's reliability in taking medication, noted
through observation and careful history-taking. A physician
should assess a patient's susceptibility to drug abuse before
prescribing any psychoactive drug and weigh the benefits
against the risks. The possible development ofdependence in
patients on long-term therapy should be monitored through
periodic check-ups and family consultations.
* The dependence-producing capability of the drug. Pa-
tients should be warned about possible adverse effects caused
by interactions with other drugs, including alcohol.
Compliance
The question of a patient's compliance with a prescribed
drug regimen becomes especially pertinent when the drug in
question has potential for abuse. Surveys of patient compli-
ance are not reassuring; as many as half of all patients sam-
pled have deviated from the physician's directions by never
obtaining a prescribed drug; never taking the prescribed
drug; taking the prescribed drug improperly, which involves
taking an incorrect quantity per dose or an incorrect number
ofdoses per day, omitting or "doubling up" doses, or discon-
tinuing the drug prematurely; or taking nonprescribed drugs
or discontinued medications in addition to or in place of the
prescribed drug.5 The use ofalcohol is frequently mentioned
in this last category.
Patient compliance is enhanced ifthe flow ofinformation
between physician and patient is open and reciprocal. Espe-
cially in prescribing psychoactive medication, a physician
should carefully describe the purpose and use ofthe drug, as
well as important adverse effects that might be experienced.
In situations where a patient's motives are not clear and a
history or physical examination indicates that the complaint
may be real, the physician should prescribe the smallest pos-
sible amount of an appropriate drug pending the results of
confirming diagnostic procedures.6
Identifying 'Conning' in a Patient
Aside from patients who fail to comply with a prescribed
drug regimen through lack ofinformation or insufficient mo-
tivation, prescription drug misuse has another face-long-
term drug abusers who approach physicians for the specific
purpose ofsecuring drugs to support their dependence. In the
drug culture, such an approach is known as "working" or
"making a doctor." Almost every physician will encounter
these "conning" patients, whether in private practice, a
clinic setting, a neighborhood health center, a busy emer-
gency department, a rural area, or a large metropolitan hos-
pital. Manipulative approaches used by such patients are
outlined in Table 1.7"8
Feigning Physical Problems
A variety of physical problems can be convincingly por-
trayed by drug-seeking patients. These run the gamut from
bleeding-often stimulated by the use ofanticoagulants-and
self-inflicted skin lesions, to gastrointestinal and muscu-
loskeletal disorders. Three of the most common presenting
ailments among patients seeking narcotic drugs are renal
colic, toothache, and tic douloureux.
A patient feigning renal colic complains ofpain on the left
side of the body (to avoid a diagnosis of appendicitis) and a
burning sensation on urination. If the physician asks for a
urine specimen, the patient might even prick his or her finger
and drop a little blood into the urine.
Patients presenting with toothache often claim to be from
another town and to have left at home the medications pre-
scribed by their dentist. Should the physician wish to verify
this claim, the telephone number supplied for the hometown
dentist often is that of an accomplice. If the person actually
has an abscessed tooth, he or she usually makes full use of it
by visiting a series of physicians and dentists to ask for pain
medication.
Tic douloureux is a favorite approach among patient
"hustlers" because it has no clinical or pathologic signs.
Patients complain of recurring, intense episodes of facial
pain lasting several seconds to several minutes. Some pa-
tients are able to contort their faces to simulate an attack of
pain.
Feigning Psychological Problems
Most drug seekers who feign psychological problems are
attempting to obtain stimulants or depressants rather than
analgesics. The psychological symptoms most often pre-
sented include anxiety, insomnia, fatigue, and depression.
Deception
Manipulative techniques used to deceive physicians in-
clude prescription theft, forgery, and alterations, concealing
or pretending to take medications, and requesting refills in a
shorter period oftime than originally prescribed-often with
the excuse that the medication was lost or stolen.
Pressuring the Physician
Coercive tactics include eliciting sympathy or guilt, such
as by suggesting that medical treatment caused the patient's
drug dependence, direct threats of physical or financial
harm, the offer ofbribes, or using the names offamily mem-
bers or friends.
Forging Prescriptions
Prescriptions are forged in one of the following ways9:
Altering a prescription written by a physician. Figure 1
shows three prescriptions, before and after forgery. In each
case, the drug seeker used a pen with the same color ink. In
the first example, the dispensing number, written only in
arabic numberals, is easily altered by the forger. The second
example shows that, contrary to popular belief, dispensing
numbers written in longhand also can be changed. Some drug
seekers alter the number of refills on the prescription.
Forging prescriptions from scratch. The forger begins
with either a blank piece ofpaper or a legitimate prescription
blank from a practicing physician. In the former case, the
forger stencils a physician's name and address (as well as the
telephone number ofan accomplice) in black lettering onto a
blank page and then uses a photocopier to reduce the sheet to
the usual size of a prescription. Because the Drug Fnforce-
TABLE 1.-Disorders Feigned by Drug Seekers
Migraine headaches Sicide cell crisis
Tic douloureux Metastatic cancer
Back pain Bronchitis
Colitis P i disorders
Renal colic Atention defict syndrome
kAute or chronic pain from Narcolepsy
orthopedic injury Concem over obesity
Toothache
PRESCRIPTION DRUG ABUSE
610

3. ment Agency registration is now valid for three years, drug
seekers are always on the lookout for the names ofphysicians
who have retired, left the state, or died. Some drug seekers
use desktop publishing to produce clever forgeries using such
assumed identities.
To a drug seeker, a blank prescription is like a blank
check. Prescription blanks are frequently stolen from emer-
gency departments and clinics, in part because of the care-
lessness ofthe medical staff. The Missouri Task Force on the
Misuse, Abuse and Diversion ofPrescription Drugs has pub-
lished the following guidelines for the care and use of pre-
scription blanks10'ppl-3):
* Store all unused prescription pads in a safe place;
* Limit the number of pads in use at one time;
* Number prescription blanks so that missing blanks
may be detected easily;
* Never sign prescription blanks in advance;
* Write prescriptions in ink or indelible pencil;
* Use a combination oflonghand, plus arabic and roman
numerals, to indicate the amount of drug precribed; and
* Do not use prescription blanks for instructions to pa-
tients or memos.
Although many "conning" tactics seem obvious when
described, they can be used convincingly, especially in the
midst of a busy medical office or emergency department.
Physicians can protect themselves, however, ifthey are alert
to certain behaviors that are common among drug seek-
ers. 3.5.8
The Transient Patient
Frequently a patient is from out of town and has lost or
had his or her medication stolen. The patient tries to create a
sense ofurgency and pressures the physician for an immedi-
ate response by claiming intense pain. Frequently ordinary
clinical intuition will alert the physician that there is a large
discrepancy between the patient's report ofthe severity ofthe
pain and the level of pain actually being experienced.
Some patients' manipulativeness can be detected by ob-
servation. For example, when a physician has the impression
that his or her responses are being studied by the patient as
intensely as the physician is studying the patient's situation,
the physician should be suspicious that a "doctor shopper"
or "conning" patient is at hand. The ordinary patient does
not scan the physician for responses in the same way in which
those trying to "con" may. This difference is detectable if a
physician maintains a reasonable level of awareness.
The 'Spell-Binding' Patient
Patients with pseudologica fantastica or Munchhausen's
syndrome, or those who are adept at deceit, can be persua-
sive to a degree that is unusual in comparison to ordinary
clinical encounters. When the physician has the feeling that
the patient has extraordinary persuasive and dramatic
powers, suspicion that a manipulator may be present is
justified.
The patient who has no interest in diagnosis, fails to keep
appointments for x-ray films or laboratory tests, or refuses to
see another physician for consultation should be suspected.
Most manipulative patients shun real workups and resist at-
tempts to verify history, whereas genuine patients rarely
refuse such efforts.
The pressure drug seekers can bring to bear on a physi-
cian are considerable. A physician who is alert to the tactics
employed by these persons usually can avoid being deceived
or manipulated, however. When a patient uses such tactics,
the physician should maintain control of the physician-
patient relationship, remain professional despite the ploys for
sympathy or guilt, and regard the drug seeker as a patient
with a serious illness. 4
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THE WESTERN JOURNAL OF MEDICINE - MAY 1990 e 152 e 5 611

4. Confronting the Drug Seeker
It isusually difficult toprove that apatient is adrug seeker
from the information obtained during a single visit. Although
most ofthe time the diagnosis is at best a guess, a physician
may find the following strategies useful when confronting
suspected drug seekers:
* Always give advice with reference to the patient's chief
complaint. For example, physicians who do not ordinarily
prescribe narcotic-containing cough syrups for bronchitis
should say so to the patient.
* Maintain a professional demeanor throughout the en-
counter. Drug seekers who are frustrated in their attempts to
obtain drugs often become angry. This response is so typical
that some clinicians consider it diagnostic of drug-seeking
behavior. Frustrated drug seekers may shout obscenities at
the staff; others threaten violence, but such threats are sel-
dom carried out. If necessary, security staff or the police
should be summoned.
* Confront thepatientin a gentle, respectful manner. It is
important to avoid beingjudgmental or showing antagonism.
A variety of confrontation techniques may be used. Some
examples are inquiring as to whether the patient believes that
he or she has a problem with prescription drugs, noting the
addictive properties ofthe medications sought, and express-
ing concern for the patient's welfare. When confronted,
some patients admit that they are addicted to prescription
drugs and claim that they want to stop taking them. These
patients should be referred for formal assessment and treat-
ment.
A dilemma commonly encountered is whether to provide
a patient with a supply of drugs until he or she can obtain
treatment for the underlying dependence. What to do de-
pends in part on which prescription drugs the patient abuses.
Withdrawal from narcotics can be debilitating, but it is rarely
fatal. Withdrawal from barbiturates or benzodiazepines, on
the other hand, can be fatal, and patients addicted to these
drugs should be held in a medically supervised setting for
management ofwithdrawal. In addition, there are important
legal issues to be considered.2
Another dilemma for a physician is whether to believe
drug seekers' claims that they wish to stop their drug use.
The admission itself may be genuine, but it also may be
another ruse. When in doubt, patients should be referred to a
specialist in drug rehabilitation for expert consultation.
In all cases, patients should be given the benefit of the
doubt. It is important to remember that even drug seekers
may present with illness not related to their drug addiction
and that addiction is a chronic, relapsing disease.
REFERENCES
I . Manasse HR: Medication use in an imperfect world: Drug misadventuring as an
issue of public policy, part 2. Am J Hosp Pharm 1989; 46:1141-1152
2. Drug Enforcement Administration: Guidelines for Prescribers of Controlled
Substances. Washington, DC, US Dept of Justice, 1987
3. Wilford BB: Prescribing Controlled Drugs. Chicago, American Medical Asso-
ciation, 1987
4. Proceedings ofthe House ofDelegates 269. Chicago, American Medical Asso-
ciation, 1971
5. Cohen S: Drug abuse and the prescribing physician, In Buchwald C, Cohen S,
Katz D, et al (Eds): Frequendy Prescribed and Abused Drugs: Their Indications,
Efficacy and Rational Prescribing. Nad Inst Drug Abuse Monogr Ser 1980; 2:1-6
6. AMA Department ofDrugs: AMA Drug Evaluations, 5th Ed. Chicago, Ameri-
can Medical Association, 1983, pp 5-10
7. Chappel JN: Patient Manipulation ofthe Physician. Workshop on the Ethics and
Practice of Prescribing Psychoactive Drugs. San Francisco, Haight Ashbury Training
and Education Project, 1980
8. Wilson SJ, Gilmore R: Manipulative tactics of narcotics addicts. Med Times
1974; 102:81-84
9. Goldman G: Frustratingprescription drug seekers. Emerg Med Rep 1988; 9:26-
32
10. Physician Handbook. Jefferson City, Mo, Missouri Task Force on the Misuse,
Abuse and Diversion of Prescription Drugs, 1988
612 PRESCRIPTION DRUG ABUSE