It’s important to trust your patients and accept what they tell you, but when it comes to prescription medications, particularly controlled substances, you have to maintain a healthy degree of skepticism. Medication diversion is all too common and can be difficult to spot, but look for these signs:
• Strange stories. Be wary of new patients with stories that don’t seem quite right. They may claim they’re traveling through town on business or visiting relatives. They may deliberately request appointments toward the end of the day or show up after regular business hours. They may request a prescription right away because they have to “catch a plane” or “get to an important appointment.” They may also claim that they lost a paper prescription, forgot to pack their medication, or had their medication stolen.
• Reluctance to cooperate. Patients who intend to divert medication often refuse a physical exam and are unwilling to give you permission to access their past medical records or contact their previous providers. If pressed, they may say they can’t remember where they were last treated or that the provider has since gone out of business. In many cases, these patients will leave suddenly if you ask too many questions and things are not going their way.
• Unusually high (or low) understanding of medications. Be alert when patients appear to be extremely well-informed about specific medications. Patients who have been sick for a long time often learn much about their disease progression and know which medications work best for them, but this is also true of patients involved in diversion. Alternatively, they may deliberately mispronounce medication names or seem uninformed about their underlying medical condition.
• Strange symptoms. Be wary of patients who exaggerate or feign symptoms. Among those seeking controlled substances, common complaints include back pain, kidney stones, migraine headaches, toothaches, or post-herpetic neuralgia.
• Specific drug requests. Patients involved in diversion may request specific medication brands and resist your attempts to prescribe generic forms or substitutes. They may claim that they have a drug allergy or that these alternatives have never provided relief in the past.
Excerpted from the FPM archives: “Recognizing and Preventing Medication Diversion” (October 2001).
Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights," featuring practical, peer-reviewed advice for improving practice, enhancing the patient experience, and developing a rewarding career.