Deception and Drug Acquisition

Abstract

Purpose: Most research examining patient-based drug diversion neglects to assess physician deception directly. We attempt to determine if motives for deception are linked to success, and, similarly, if any health, demographic, or substance use history characteristics of the patients are predictive of being able to successfully deceive a physician. Methods: Stratified random sampling was utilized to obtain a sample of 2349 young adults. Respondents completed a survey detailing their substance use histories and whether they had ever deceived a physician for medication. Ninety-three of these respondents reported attempting to deceive a physician for a medication and compose the analytic sample for the study. Results: Of the 93 young adults who reported having attempted to deceive a physician for pharmaceuticals (4.0% of the general sample), 64 (68.8%) were successful. This included 24 only seeking medications for their own use, 9 only for financial purposes, and 31 with both motives. Respondents who reported recreationally using pharmaceuticals in the past were more likely to report successful attempts at obtaining a prescription compared with respondents without a history of abuse. With respect to demographic characteristics of the respondents, only race/ethnicity distinguished between successful attempts and failure. Conclusions: Although a rare occurrence in the overall sample, significant correlates of successful deception did emerge. Respondents motivated to obtain a prescription in order to sell it to others were overwhelmingly likely to succeed in their pursuit to deceive as compared with respondents who sought prescriptions for their own abuse. Successful deceivers were also more likely to have been legitimately prescribed medication in the past. Successful respondents were more likely to be Caucasian than any other race/ethnicity.

Introduction

Prescription medication abuse, a practice both driving and facilitated by new and creative methods of drug diversion and acquisition, appears to be growing in the United States.^1,2 While theft,³ fraud,⁴ unethical prescribing practices (ie, “pill mills”),^5,6 and online outlets⁷ contribute to the issue, physicians must often determine whether a patient has a legitimate medical concern or is drug-seeking for the purpose of misuse, recreational use, and/or diversion. The technique of “doctor shopping,” broadly defined as attempting to obtain prescription drugs from multiple physicians or the exaggeration, or even complete feigning, of symptoms in order to acquire a prescription for which there is no legitimate medical need,^3,8 appears to be widespread and a major concern of physicians.⁹

For physicians, attempting to identify those engaging in doctor shopping is a daunting task. Relatively healthy individuals may be efficient deceivers, well-versed in fabricating or inflating symptoms¹⁰ to obtain pharmaceuticals for themselves, to sell to others, or both. Those seeking care from additional providers for a single legitimate condition are challenging to identify in areas without an effective prescription drug monitoring program. Since it is difficult to determine if medication was previously prescribed in these areas, standard care could easily yield a second prescription.⁶ Current efforts to curb deception focus on physicians engaging in “patient selection” and being able to identify those who are deceptive in their account of pain and symptoms.^9,10 However, such methods of selection create concern; suspicious physicians may undertreat patients generally and may specifically undertreat patients with either unusual presentations of legitimate issues or those with certain demographic or personality traits.^6,9

Most research examining patient-based drug diversion neglects to assess physician deception directly. Many rely on case or cohort studies,¹¹ retrospective self-reports of identified heavy users,¹² or secondary analysis of records,¹³ and thus cannot give an accurate estimate of attempted deception in the general population nor detail the proportion of these individuals who are successful at obtaining medications. Stogner et al.¹⁴ describe the motives associated with attempting to deceive a physician among members of a university population, but only examined predictors of attempted deception. The present study seeks to detail what portion of those who attempted to deceive a physician in that data set were successful in obtaining the medication. More importantly, we attempt to determine if the motive for deception (financial or recreational use) is related to success, and, similarly, if any health, demographic, or substance use history characteristics of the patients are linked to being able to successfully deceive a physician.

Methods

An anonymous, voluntary self-report survey exploring substance use and high-risk behaviors was administered to students at a single large public university in the Southeastern United States (IRB #H12032). Courses were randomly selected from 2 strata (25 courses with 30-99 students and 15 courses with 100 or more enrolled students). Laboratory, online, physical education, and low-enrollment courses were not eligible for inclusion. A research assistant administered the pen and paper survey to each class. Students in multiple courses were asked to only complete the survey once. Respondents had access to campus health care, but likely utilized other practices for primary care, suggesting that an array of health care providers interacted with this group. Data collection within the forty courses yielded a final sample (response rate of 80.4%) of 2349 students (48.4% male, 68.9% white, 24.4% black, 2.8% Hispanic, and 4.0% other races) largely representative of the university’s undergraduate population (48.5% male, 65.5% white, 25.0% black, and 4.2% Hispanic).^14-16 The sample yielded a higher prevalence of alcohol (87.8%) and marijuana (58.1%) than national level data (81.0% and 49.1% respectively as reported by Monitoring the Future¹⁷ in 2012).

Of the 2349 respondents, 93 (4.0%) reported attempting to deceive a physician for a medication.¹⁴ These respondents responded in the affirmative to at least 1 of 2 questions: “Have you ever attempted to get a prescription from a physician for a medication that you did not need and intended to sell?” and “Have you ever attempted to get a prescription from a physician for a medication that you did not need and intended to abuse?” As other items in the survey used the word “recreationally” when asking about pharmaceutical abuse, respondents would be unlikely to answer “yes” if they were self-diagnosing or modifying therapy to treat a malady. Forty-five of these had reported only being motivated for their own abuse (48.4% of attempted deceivers), 11 reported deception only for the purpose of selling the medication (11.8%), and 37 reported both motives (39.8%). Our analysis focuses only on these 93 respondents and evaluates potential factors linked to success at deceiving physicians among those attempting deception. Table 1 presents the number of individuals that were both successful and unsuccessful at deceiving a physician across demographic categories, substance use histories, motivation type, and legitimate medical histories. Odds ratios were calculated to indicate the magnitude of association while χ² tests were used to determine whether these relationships were significant. Odds ratios were calculated as (Group 1 Deception Success ÷ Group 1 Deception Failures) ÷ (Group 2 Success ÷ Group 2 Failures) whereas the 95% confidence intervals were calculated as e^{(ln(OR) − 1.96(SEln(OR)))} to e^{(ln(OR) + 1.96(SEln(OR)))}, where OR is odds ratio and SE is standard error.

Table 1.

Success at Using Deception to Obtain a Prescription From a Physician.

Characteristic	Failed to obtain a Prescription	Obtained a Prescription	χ2, P Value	Odds Ratio	Characteristic	Failed to Obtain a Prescription	Obtained a Prescription	χ2, P Value	Odds Ratio
Motivation					Demographics
Abuse					Gender
Yes	27	55	χ2 = .983	.453	Male	18	36	χ2 = .199	.815
No	2	9	P = .322		Female	11	27	P = .656
Financial gains					Race
Yes	8	40	χ2 = 9.741	4.375	Caucasian	14	45	χ2 = 4.628	2.679
No	21	24	P = .001		Other	15	18	P = .031
Both					Family income
Yes	6	31	χ2 = 6.414	3.601	≥$100k/yr.	12	33	χ2 = .962	1.558
No	23	33	P = .011		<$100k/yr.	17	30	P = .327
					Age
Health/ Legitimate Prescription History					18-20	23	42	χ2 = 1.721	.481
Self-reported poor health					21-25	5	19	P = .190
Yes	4	8	χ2 = .030	.893	Sexual orientation
No	25	56	P = .863		Heterosexual	26	55	χ2 = .369	.604
ADHD diagnosis					LGBT	2	7	P = .544
Yes	6	22	χ2 = 1.776	2.008
No	23	42	P = .183		Recreational substance use history
Adderall, Ritalin					Alcohol
Yes	4	31	χ2 = 10.21	5.871	Yes	28	62	χ2 = .007	1.107
No	25	33	P = .001		No	1	2	P = .935
Opioids					Marijuana
Yes	9	33	χ2 = 3.396	2.366	Yes	26	59	χ2 = .163	1.362
No	20	31	P = .065		No	3	5	P = .687
Antidepressants					Recreational pharmaceutical use
Yes	1	21	χ2 = 9.154	13.186	Yes	18	56	χ2 = 9.007	4.889
No	27	43	P = .002		No	11	7	P = .003

Abbreviation: ADHD- attention deficit/hyperactivity disorder; LGBT- lesbian, gay, bisexual, transgender.

Results

The 93 respondents that had attempted deception (58.7% male; 64.1% Caucasian) were asked whether they had ever been successful in obtaining a medication they did not need. More than two-thirds had been successful (64, 68.8%) including 31 with both motives, 24 only seeking medications for their own abuse (totaling 55 seeking medications for abuse), and 9 only for financial purposes (yielding 30 successful drug seekers intending to sell medications).

Respondents motivated to seek prescriptions for economic reasons were generally more likely to succeed than respondents only concerned with abuse. Respondents who reported being motivated by the desire for abuse or both for abuse and economic reasons had lower odds of successfully obtaining a prescription than respondents motivated by economic reasons alone. This difference, however, was not significant (OR 0.453, 95% CI 0.09-2.24, P = .322). Respondents who sought a prescription to sell, or, both to sell and to abuse, were found to have significantly greater odds of successfully obtaining a prescription than respondents motivated by only the desire for abuse (OR 4.375, 95% CI 1.68-11.41, P = .002). Respondents who reported both motives were significantly more likely to obtain a prescription than those who did not (OR 3.601, 95% CI 1.29-10.02, P = .011).

No differences in the odds of successful deception were found between respondents who reported a history of alcohol or marijuana use. However, successful deception was more likely among respondents who reported recreationally using pharmaceuticals in the past (OR 4.889, 95% CI 1.65-14.49, P = .003). Furthermore, respondents who reported being prescribed Adderall/Ritalin (OR 5.871, 95% CI 1.83-18.80, P = .001) or antidepressants (OR 13.186, 95% CI 1.68-103.77, P = .002) at some point in their lives were more likely to report successful deception compared to respondents who were never prescribed either of these medications. Respondents who reported poor health, were diagnosed with attention deficit/hyperactivity disorder, or were previously prescribed opioids were no more likely to actually obtain the sought prescription than respondents who did not report these.

With regard to demographic characteristics of the respondents, only race/ethnicity distinguished between successful attempts and failure. In particular, Caucasian respondents reported significantly more success than non-Caucasian respondents (OR 2.679, 95% CI 1.08-6.66, P = .031). Males, respondents from affluent families (earning >$100 000 per year), and self-identified LGBT individuals were no more or less likely to report successfully obtaining a prescription.

Discussion

Building off of previous research,¹⁴ which identified characteristics of patients who were likely to attempt “doctor shopping,” we explore patient characteristics that tended to correlate with successfully obtaining an unneeded prescription. Foremost, we find that respondents who had financial motives were overwhelmingly likely to report successful deception (83.3%) compared with respondents who sought prescriptions solely for abuse (53.3%). Although it is not possible to determine why these respondents were more successful, it is possible that their success may be linked to a high number of doctor deception attempts (as the survey only asked whether they were ever successful). As such, it would be beneficial for future research to investigate multiple dimensions of success, including frequency of both successful and failed attempts at doctor deception.

Furthermore, successful deceivers were also more likely to have been legitimately prescribed medications sometime in the past. This suggests that greater odds of success may be attributable to experiential knowledge making it easier to feign appropriate symptoms. Alternatively, past history of legitimate use might make physicians less cautious in prescribing. In either case, this finding suggests that the impact of effective, operational prescription drug monitoring programs could make a difference in a prescriber being able to detect which patients have been frequenting multiple physicians, receiving medication, and consequently which patients may be attempting to abuse or divert medication.

Our results show successful deceivers were more likely to be Caucasian than any other race/ethnicity. Furthermore, unlike attempting to deceive, success was neither related to gender nor sexual orientation. Thus, the traits associated with attempting deception identified within the previous study¹⁴ are not the same as traits linked to successful deception among those attempting deception. Overall, the findings of this study could possibly be attributed to some groups (non-Caucasians) being perceived as more suspicious by physicians and therefore given increased scrutiny. This may be problematic in that individuals equally or more deserving of scrutiny might be overlooked. This result further suggests a need to evaluate whether patients from marginalized groups are more frequently underprescribed or undertreated due to inappropriately heightened suspicions and discriminatory practices.

Additional research is also necessary to address some of the limitations associated with this study. First, it was not possible to determine the frequency of deception, the type of drugs sought, or the particular methods of deception. Being able to assess these features will likely aid physicians in identifying patients attempting to fraudulently obtain prescriptions. Second, like all self-report research, this study is vulnerable to the possibility of inaccurate or underreporting of deception due to social desirability on the part of respondents. Correlating patient data with self-report data to determine if a prescription was actually received might be one fruitful avenue for addressing this concern. Along the same lines, it cannot be determined with certainty that respondents were accurately reporting their intent to obtain prescriptions for abuse. Despite efforts to convey a focus on recreational use and not on self-treatment, it is possible that these were not mutually exclusive motivations. Given that a history of legitimate use was related to successful deception, it is not possible to determine if the original condition persisted at the time of attempted deception. Future studies should attempt to validate the extent to which respondents sought an unneeded prescription and their motives for doing so, since a profile of successful deception may vary on the basis of motivation. Third, given the apparent rarity of attempted deception (~4% in the current study), future studies based on general populations should attempt to obtain as large a sample as possible in order to obtain larger numbers of deceivers, which would also allow inferences to be extended beyond the university population. Finally, since physician characteristics likely play an important role in whether an attempt to deceive will be successful or not, future research should attempt to gather information on both the patient and the physician.

These limitations notwithstanding, this study investigates an important public health problem and concern for legitimate medical practitioners. Although the prevalence of attempted deception in this sample was relatively low, university students have high levels of substance abuse in general^18,19 and specifically prescription drug abuse^20,21 making them a well-suited population for an exploratory study such as this. This study was able to add to the literature by assessing factors associated with successful acquisition of prescription drugs in one population. Of direct relevance to clinicians, greater awareness of doctor shopping tactics, especially those that are successful, is needed. It is unlikely that the demand for prescription drugs (especially on college campuses) will decline—putting physicians at the front lines of pharmaceutical diversion and creating a need for greater awareness and vigilance of successful diversion tactics.

Author Biographies

Amber N. Sanders is a PhD student in the Department of Sociology and Criminology at Pennsylvania State University. She completed her MS in Criminal Justice at UNC-Charlotte in 2013. Her research interests include substance use and peer influences on deviant behavior. Her recent works have examined misperceptions of peer novel drug use, drug-based moral panics, and pharmaceutical diversion resulting from “doctor shopping”.

John M. Eassey is an assistant professor of criminology at Missouri State University. His research interests include peer influence, employment across the life course, and substance use and abuse.

John M. Stogner PhD, MPH, is an assistant professor in Criminal Justice and Criminology at the University of North Carolina at Charlotte. His research interests include substance use, criminological theory, biosocial criminology, and the interplay between health and deviance. He is coauthor of Emerging Trends in Drug Use and Distribution and his recent publications have appeared in Pediatrics, Alcohol and Alcoholism, Addictive Behaviors, Justice Quarterly, and Beverages.

Bryan Lee Miller is an associate professor of Criminology and Criminal Justice at Georgia Southern University. His research has evaluated novel psychoactive drugs, prescription drug abuse and regulations, drug panics, and restrictions on ex-offenders reintegrating into the community. He is an author or co-author of over 35 peer-reviewed publications in criminal justice, criminology, and drug journals, as well as the books Emerging Trends in Drug Use and Distribution (Springer) and Synthetic and Novel Drugs: Emerging Issues, Legal Policy and Public Health (CRC Press).