A Mixed-Method Analysis of Reports on 100 Cases of Improper Prescribing of Controlled Substances

• Author: Emily E. Anderson,James M. DuBois,Michelle Eggers,John T. Chibnall,Meghan Vasher,Kari Baldwin
• DOI: 10.1177/0022042616661836
• Published date: 01 October 2016
• Date: 01 October 2016
• Subject Matter: Articles

Journal of Drug Issues

2016, Vol. 46(4) 457 –472

© The Author(s) 2016

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DOI: 10.1177/0022042616661836

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Article

A Mixed-Method Analysis

of Reports on 100 Cases of

Improper Prescribing of

Controlled Substances

James M. DuBois1, John T. Chibnall2, Emily E. Anderson3,

Michelle Eggers4, Kari Baldwin4, and Meghan Vasher4

Abstract

Improper prescribing of controlled substances (IPCS) contributes to opioid addictions and

deaths by overdose. Studies conducted to date have largely lacked a theoretical framework

and ignored the interaction of individual with environmental factors. We conducted a mixed-

method analysis of published reports on 100 cases that occurred in the United States. An

average of 17 reports (e.g., from medical boards) per case were coded for 38 dichotomous

variables describing the physician, setting, patients, and investigation. A theory on how the

case occurred was developed for each case. Explanatory typologies were developed and then

validated through hierarchical cluster analysis. Most cases involved physicians who were male

(88%), >40 years old (90%), non-board certified (63%), and in small private practices (97%); 54%

of cases reported facts about the physician indicative of self-centered personality traits. Three

explanatory typologies were validated. Increasing oversight provided by peers and trainees may

help prevent improper prescribing of controlled substances.

Keywords

improper prescribing, opioid abuse, medical ethics, qualitative content analysis, mixed methods

This article advances understanding of improper prescribing of controlled substances (IPCS)

through a mixed-methods analysis of a set of 100 cases in the United States to identify the envi-

ronmental and individual factors associated with IPCS. The article relates findings to state and

federal policies in the United States, including the use of prescription drug monitoring plans

(PDMPs), the Controlled Substance Act, and professional guidelines meant to increase the ade-

quacy of pain treatment.

1Washington University in Saint Louis, MO, USA

2Saint Louis University School of Medicine, MO, USA

3Loyola University Chicago, IL, USA

4Washington University School of Medicine, MO, USA

Corresponding Author:

James M. DuBois, Washington University in Saint Louis, Campus Box 8005, 4523 Clayton Avenue, Saint Louis,

MO 63110, USA.

Email: jdubois@wustl.edu

661836JODXXX10.1177/0022042616661836Journal of Drug IssuesDuBois et al.

research-article2016

458 Journal of Drug Issues 46(4)

The United States Drug Enforcement Agency classifies controlled substances based on evalu-

ation of accepted medical uses and potential for abuse, misuse, and physical or psychological

dependence (“Controlled Substances Act 21 U.S.C. §§ 801-971,” 2006). The most frequently

prescribed controlled substances fall into category II, which includes prescription opioids such as

morphine, oxycodone, hydrocodone, methadone, and fentanyl. Category II drugs are deemed to

have accepted medical uses as well as high potential for abuse and severe dependence liability

(21 CFR §1308.12).

Opioids are an effective means of treating patients in acute severe pain and chronic pain. In

the 1990s, U.S. policies and professional association guidelines began to focus on the undertreat-

ment of pain, and accordingly, rates of opioid prescriptions increased: From 2007 to 2013, more

than 200 million opioid prescriptions were written annually in the United States (Dart et al.,

2015). Some evidence suggests that chronic pain is still undertreated (Institute of Medicine,

2011). Cheatle and Savage argue that “one of the barriers to effective pain management across

the spectrum of pain conditions . . . is the clinician’s fear of prescribing opioids beyond that mer-

ited by the actual risks” (Cheatle & Savage, 2012). Such fears may also be mixed with fear of

criminal prosecution (Hoffmann, 2008).

Yet, despite reports of physician fears regarding opioid prescribing (Dineen & DuBois, 2016),

in the decade from 2002 to 2011, approximately 25 million people initiated nonmedical use of

prescription opioids (Dart et al., 2015). In 2010, deaths attributed to nonmedical use of prescrip-

tion opioids exceeded 16,000 (Dart et al., 2015). Most people who abuse prescription opioids

obtain them from family members or friends who received a prescription (Substance Abuse and

Mental Health Services Administration [SAMHSA], 2014). However, among those who abuse

prescription opioids more than 200 days per year, physicians are the most common direct source

(C. M. Jones, Paulozzi, & Mack, 2014).

IPCS is a leading cause of physician review by disciplinary committees (Arora, Douglas, &

Dorr Goold, 2014). To find a physician guilty of a criminal violation, prosecutors must show that

the physician knowingly or intentionally prescribed a controlled substance outside of the “usual

course” of professional practice, rather than for a “legitimate medical purpose” (“Controlled

Substances Act 21 U.S.C. §§ 801-971,” 2006). However, medical boards can take disciplinary

action against a physician for IPCS if the prescribing simply falls outside of standards of practice

(Goldenbaum et al., 2008).

The American Medical Association (AMA) has adopted a “4D framework” to elucidate how

IPCS occurs and to establish culpability. The 4Ds are dated physicians misprescribe due to obso-

lete information, disabled physicians are impaired by their own use of psychoactive drugs, dis-

honest physicians use their license to deal drugs, and duped physicians are tricked into prescribing

medically unnecessary opioids (Council on Scientific Affairs, 1982; Wesson & Smith, 1990).

The last category in this list suggests that a physician may make a good faith effort to practice

according to standards of care, yet be “duped” by a clever patient into behaving in a manner that

creates risk of criminal prosecution or loss of medical licensure (Dineen & DuBois, 2016)

It is unclear to what degree this typology is evidence based. Moreover, insofar as this typology

aspires to be explanatory, it falls short as it ignores completely environmental factors that might

help to explain misprescribing. Nevertheless, it has been used widely since the early 1980s to

categorize physicians who improperly prescribe opioids (Hellmann, 2009; Heumann, Pinaire, &

Burger, 2009; Heumann, Pinaire, & Lerman, 2007-2008; Hoffman, 2008-2009; Hoffman &

Tarzian, 2003; Wesson & Smith, 1990).

Very few studies of IPCS have been conducted. Most studies of professional lapses by physi-

cians focus on factors associated with any criminal activity by physicians (Jung, Lurie, & Wolfe,

2006), or on general disciplinary action taken against physicians (Arora et al., 2014), or on physi-

cians who have a substance use disorder (SUD), regardless whether they engaged in IPCS

(Holtman, 2007). Goldenbaum and colleagues conducted the largest study to date focused