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

  • 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.

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, unprovoked and unpredictable / lack of ability to respond 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.

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