Dana Wiley, MD

Medications that psychiatrists routinely prescribe—such as benzodiazepines for anxiety and psychostimulants for attention-deficit/hyperactivity disorder—often are diverted and abused. In 2011, 6.1 million Americans age ≥12 abused prescription drugs.¹

The mnemonic LAST can bring to mind 4 clinical “red flags” that can assist you in determining whether prescription abuse or diversion is occurring. Incorporating these 4 warning signs in your clinical assessment and medication reviews will make it easier for you to detect when medications are not being taken as prescribed.

Lost or stolen prescriptions. Patients who want to obtain a new or replacement prescription may claim that their medication was lost or stolen. Although this can occur, the prescriber should be suspicious if this becomes a recurrent situation. Some clinicians require patients to produce a filed police report for stolen medications before they will consider writing a new prescription.

Alternating medications/providers. Patients may obtain similar medications from multiple providers. Prescription Drug Monitoring Programs (PDMPs), which are databases that allow physicians to track where patients are getting their prescriptions, may help prevent this. According to the Alliance of States with Prescription Monitoring Programs, as of January 2010, 48 states had instituted PDMPs or passed legislation to implement them.²

Specific medication. Patients may have an allergy or respond better to a particular drug; however, be cautious when a patient refuses to consider an alternate medication or claims he or she has taken a specific medication without a prescription and it was the only thing that worked for them.

Time between prescriptions. Patients may get a prescription for a medication, then shortly after their visit claim the medication doesn’t work and request a second prescription for a similar medication. One way to address this is to require the patient to return the unused portion of the first medication before writing a new prescription. A patient also may complain that they have to come to your office too frequently and ask for multiple refills of medication, which would decrease your ability to monitor his or her response to treatment.

A patient who meets ≥1 of the above criteria could be a higher risk for prescription drug abuse or diversion. Documenting these findings and talking with the patient could help justify the need to switch to a medication with a lower abuse potential or possibly referral to a drug treatment program.

In a 2009 survey, 56% of teens stated that prescription medications were easier to obtain than illicit drugs.³ Medications such as benzodiazepines and stimulants can be beneficial to patients, but because of their abuse potential, they may be underprescribed. Be vigilant when prescribing these medications, and monitor patients carefully to ensure that they are taking all medications as directed.

Disclosure

Dr. Wiley reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

1. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm. Accessed May 2, 2013.

2. Alliance of States with Prescription Monitoring Programs. http://www.pmpalliance.org/content/about-alliance. Accessed May 1, 2013.

3. Partnership for a Drug-Free America. 2009 parents and teens attitude tracking study report. New York, NY: Partnership for a Drug-Free America; 2010. http://www.drugfree.org/wp-content/uploads/2011/04/FULL-REPORT-PATS-2009-3-2-10.pdf. Accessed May 2, 2013.

Medications that psychiatrists routinely prescribe—such as benzodiazepines for anxiety and psychostimulants for attention-deficit/hyperactivity disorder—often are diverted and abused. In 2011, 6.1 million Americans age ≥12 abused prescription drugs.¹

The mnemonic LAST can bring to mind 4 clinical “red flags” that can assist you in determining whether prescription abuse or diversion is occurring. Incorporating these 4 warning signs in your clinical assessment and medication reviews will make it easier for you to detect when medications are not being taken as prescribed.

Lost or stolen prescriptions. Patients who want to obtain a new or replacement prescription may claim that their medication was lost or stolen. Although this can occur, the prescriber should be suspicious if this becomes a recurrent situation. Some clinicians require patients to produce a filed police report for stolen medications before they will consider writing a new prescription.

Alternating medications/providers. Patients may obtain similar medications from multiple providers. Prescription Drug Monitoring Programs (PDMPs), which are databases that allow physicians to track where patients are getting their prescriptions, may help prevent this. According to the Alliance of States with Prescription Monitoring Programs, as of January 2010, 48 states had instituted PDMPs or passed legislation to implement them.²

Specific medication. Patients may have an allergy or respond better to a particular drug; however, be cautious when a patient refuses to consider an alternate medication or claims he or she has taken a specific medication without a prescription and it was the only thing that worked for them.

Time between prescriptions. Patients may get a prescription for a medication, then shortly after their visit claim the medication doesn’t work and request a second prescription for a similar medication. One way to address this is to require the patient to return the unused portion of the first medication before writing a new prescription. A patient also may complain that they have to come to your office too frequently and ask for multiple refills of medication, which would decrease your ability to monitor his or her response to treatment.

A patient who meets ≥1 of the above criteria could be a higher risk for prescription drug abuse or diversion. Documenting these findings and talking with the patient could help justify the need to switch to a medication with a lower abuse potential or possibly referral to a drug treatment program.

In a 2009 survey, 56% of teens stated that prescription medications were easier to obtain than illicit drugs.³ Medications such as benzodiazepines and stimulants can be beneficial to patients, but because of their abuse potential, they may be underprescribed. Be vigilant when prescribing these medications, and monitor patients carefully to ensure that they are taking all medications as directed.

Disclosure

Dr. Wiley reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

1. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm. Accessed May 2, 2013.

2. Alliance of States with Prescription Monitoring Programs. http://www.pmpalliance.org/content/about-alliance. Accessed May 1, 2013.

3. Partnership for a Drug-Free America. 2009 parents and teens attitude tracking study report. New York, NY: Partnership for a Drug-Free America; 2010. http://www.drugfree.org/wp-content/uploads/2011/04/FULL-REPORT-PATS-2009-3-2-10.pdf. Accessed May 2, 2013.

Medications that psychiatrists routinely prescribe—such as benzodiazepines for anxiety and psychostimulants for attention-deficit/hyperactivity disorder—often are diverted and abused. In 2011, 6.1 million Americans age ≥12 abused prescription drugs.¹

The mnemonic LAST can bring to mind 4 clinical “red flags” that can assist you in determining whether prescription abuse or diversion is occurring. Incorporating these 4 warning signs in your clinical assessment and medication reviews will make it easier for you to detect when medications are not being taken as prescribed.

Lost or stolen prescriptions. Patients who want to obtain a new or replacement prescription may claim that their medication was lost or stolen. Although this can occur, the prescriber should be suspicious if this becomes a recurrent situation. Some clinicians require patients to produce a filed police report for stolen medications before they will consider writing a new prescription.

Alternating medications/providers. Patients may obtain similar medications from multiple providers. Prescription Drug Monitoring Programs (PDMPs), which are databases that allow physicians to track where patients are getting their prescriptions, may help prevent this. According to the Alliance of States with Prescription Monitoring Programs, as of January 2010, 48 states had instituted PDMPs or passed legislation to implement them.²

Specific medication. Patients may have an allergy or respond better to a particular drug; however, be cautious when a patient refuses to consider an alternate medication or claims he or she has taken a specific medication without a prescription and it was the only thing that worked for them.

Time between prescriptions. Patients may get a prescription for a medication, then shortly after their visit claim the medication doesn’t work and request a second prescription for a similar medication. One way to address this is to require the patient to return the unused portion of the first medication before writing a new prescription. A patient also may complain that they have to come to your office too frequently and ask for multiple refills of medication, which would decrease your ability to monitor his or her response to treatment.

A patient who meets ≥1 of the above criteria could be a higher risk for prescription drug abuse or diversion. Documenting these findings and talking with the patient could help justify the need to switch to a medication with a lower abuse potential or possibly referral to a drug treatment program.

In a 2009 survey, 56% of teens stated that prescription medications were easier to obtain than illicit drugs.³ Medications such as benzodiazepines and stimulants can be beneficial to patients, but because of their abuse potential, they may be underprescribed. Be vigilant when prescribing these medications, and monitor patients carefully to ensure that they are taking all medications as directed.

Disclosure

Dr. Wiley reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

1. Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm. Accessed May 2, 2013.

2. Alliance of States with Prescription Monitoring Programs. http://www.pmpalliance.org/content/about-alliance. Accessed May 1, 2013.

3. Partnership for a Drug-Free America. 2009 parents and teens attitude tracking study report. New York, NY: Partnership for a Drug-Free America; 2010. http://www.drugfree.org/wp-content/uploads/2011/04/FULL-REPORT-PATS-2009-3-2-10.pdf. Accessed May 2, 2013.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.

In the United States >33,000 people take their lives each year.¹ Depression is involved in 65% to 90% of all suicides;² however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.³ Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.⁴

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.⁵ Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.⁶ By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.