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Aberrant Drug-Related Behaviors: Unsystematic Documentation Does Not Identify Prescription Drug Use Disorder

Authors

  • Ellen C. Meltzer MD, MSc,

    1. Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
    2. Division of Medical Ethics, Weill Medical College of Cornell University, New York, New York
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  • Dennis Rybin MS,

    1. Data Coordinating Center
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  • Lidia Z. Meshesha BA,

    1. Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
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  • Richard Saitz MD, MPH,

    1. Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
    2. Departments of Epidemiology
    3. Youth Alcohol Prevention Center, Boston University School of Public Health, Boston, Massachusetts
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  • Jeffrey H. Samet MD, MA, MPH,

    1. Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
    2. Community Health Sciences
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  • Sonia L. Rubens MA,

    1. Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
    2. Clinical Child Psychology Program, University of Kansas, Lawrence, Kansas, USA
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  • Jane M. Liebschutz MD, MPH

    Corresponding author
    1. Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
    2. Community Health Sciences
      Jane M. Liebschutz, MD, MPH, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA. Tel: 617-414-6910; Fax: 617-414-4676; E-mail: jane.liebschutz@bmc.org.
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  • Disclosures: The study was funded by K23 DA016665 from the National Institute of Drug Abuse. Dr. Jane Liebschutz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. This work was previously presented at the Society of General Internal Medicine 32nd Annual Meeting in Miami, Florida on May 15, 2009, where it was a finalist for the Mack Lipkin Sr. Associate Member Awards.

  • Conflict of Interest: The authors all report no conflicts of interest. R. Saitz is a consultant for Medical Directions Inc. and BMJ Publishing Group.

  • All work was performed at Boston University Medical Center.

Jane M. Liebschutz, MD, MPH, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA. Tel: 617-414-6910; Fax: 617-414-4676; E-mail: jane.liebschutz@bmc.org.

Abstract

Objective.  No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD.

Design.  A cross-sectional study of PC patients at an urban, academic medical center.

Subjects.  Two hundred sixty-four English-speaking patients (ages 18–60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits.

Outcome Measures.  Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD.

Results.  Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only “appearing intoxicated or high” documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, “emergency visit for pain,” did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6).

Conclusions.  EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.

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