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

Published date01 October 2016
Date01 October 2016
Subject MatterArticles
Journal of Drug Issues
2016, Vol. 46(4) 457 –472
© The Author(s) 2016
Reprints and permissions:
DOI: 10.1177/0022042616661836
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
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.
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.
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
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

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