“Doctor shoppers”: at risk by any other name

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Competition in general practice: prescriptions to the elderly in a list patient system

Income motivation among general practitioners (GPs) is frequently discussed in the health economics literature. The question addressed in the present study on reimbursement drugs and addictive drugs is whether increased competition among GPs, which is part of a declared health policy to improve efficiency, contributes to more prescriptions for the elderly. The dataset comprises registered data of all prescribed drugs dispensed at pharmacies from the Norwegian Prescription Database merged with data on GPs. In choosing a method, particular attention is given to the fact that patients tend to be attracted to GPs who fit their preferences. Hence, we treat the composition of the patient list as endogenous. The results indicate that the stronger competition a GP faces, the more drugs are prescribed, which implies that GPs' prescription style may conflict with their role as gatekeepers, and even worse, it may be a hazard to patients' health.

The prediction of outcome in somatised patients undergoing elective lumbar surgery

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months.

Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.

[Prescription shopping of addictive drugs in Norway]

BACKGROUND

A Regular General Practitioner Scheme was introduced in Norway in 2001. One aim was to restrict patients from "shopping" doctors and prescription drugs.

MATERIAL AND METHODS

Data from The Norwegian Prescription Database (NorPD) for 2004 were used to assess the following: number of physicians each patient had used to obtain prescriptions for a drug, the relationship between number of physicians used and amount of drugs prescribed, and concomitant prescription of opioids and benzodiazepines during the same period to the same patients. The drugs studied were the prescription drugs with potential for abuse; diazepam, carisoprodol and codeine combinations. The information retrieved was compared to that for the supposedly non-addictive drugs esomeprazole, metformine and salbutamol.

RESULTS

More than 96 % (96.3 - 98.9) of the patients used one or two physicians for prescriptions of the same drug, and fewer than 0.5 % (0.01 - 0.26) used five or more physicians. However, the proportion of patients who used five or more physicians for the addictive drugs was 9.5 times higher than that for a comparable proportion of patients using the non-addictive drugs. The amount of dispensed drug increased considerably more with the number of physicians used for addictive drugs than for non-addictive drugs, as did the amount of concomitantly dispensed opioids and benzodiazepines.

INTERPRETATION

The occurrence of prescription drug shopping in the Norwegian population was limited. Among the few patients who used many physicians for prescription of drugs, the phenomenon was much more frequent for users of addictive drugs than for users of the non-addictive drugs. The study suggests that prescription drug shopping may be an indicator of a drug abuse potential.

Circuit breaking: pathways of treatment seeking for women with endometriosis in Australia

Pain resulting from endometriosis is experienced as both a chronic, ongoing condition and an acute episode at time of menstruation, often occurring in association with diarrhea, vomiting, nausea, heavy bleeding, and other reactions. Women expect pain with menstruation, however, and even if they experience major disruptions as a result, they find it difficult to distinguish normal from pathological discomfort. Drawing on qualitative research conducted from 2004 to 2006, we describe the "circuit breakers" that lead Australian women to seek medical advice. These include outside intercession, major disruptions to everyday life, changes in embodied experience, and difficulties in conception and pregnancy. Women's ideas of menstrual pain as "normal" are shared by doctors, resulting in further delays before a definitive diagnosis of endometriosis is made. During this time, women move between doctors and in and out of medical care, which they described through particular narrative styles to highlight the complexity of help seeking. We explore the ways in which ideas of gender, informed by women's embodiment but also the quality of their reporting of symptoms, influence their interactions with health professionals.