Staying vigilant

Prescription drug epidemic: 20 red flags physicians should watch for

With abuse of opioids and other controlled substances on the rise, physicians should look for these signs that something’s amiss.


The U.S. is currently in the throes of a prescription drug epidemic and physicians are on the front lines, working to prevent abuse while providing access for patients who legitimately need medications.

To assist physicians, the AOA partnered with the National Association of Boards of Pharmacy, the U.S. Drug Enforcement Administration and other groups to prepare a list of red flags to watch for when treating, prescribing to and monitoring the progress of patients.

Initial visit and presentation:

  • Patients travel to the physician’s office as a group and all request prescriptions for controlled substances on the same day.
  • The patient declines a physical exam and diagnostic tests and won’t give the physician permission to obtain past records.
  • Speech and conduct of the patient suggest abuse of controlled substances. The patient may appear sedated, confused or intoxicated. Withdrawal symptoms or physical signs of drug abuse may also be present.
  • The patient insists on paying cash though he or she has health insurance.
  • Unnecessary travel: The patient travels an exceptionally long distance or out of state for the visit and doesn’t explain why.

Medication taking:

  • Multiple unexplained dose escalations or other nonadherence to the treatment plan.
  • The patient chooses a route of drug administration other than the method prescribed, such as injecting or inhaling oral formulations or ingesting transdermal formulations.
  • Repeatedly, the patient seeks medications from noncoordinated sites of care such as the emergency room, urgent care facilities or walk-in clinics.
  • The patient suffers a drug overdose.

Patient behavior and communication:

  • A Prescription Drug Monitoring Program report provides evidence that the patient is obtaining controlled substance prescriptions from multiple health care practitioners without the prescribers’ knowledge of the other prescriptions.
  • The patient was discharged from another physician practice for egregious behavior.
  • Threats: The patient pressures the physician or the practice staff to prescribe drugs.
  • The patient has an unusually vast knowledge of opioid medications or other controlled substances, uses drugs’ street names, or requests large quantities of drugs.

Treatment plan:

  • The patient repeatedly resists changes in the treatment plan despite evidence of adverse physical or psychological effects from the drug.
  • Refusal to sign or failure to comply with an opioid pain care agreement governing use of opioid analgesics.
  • The patient claims to be allergic or intolerant to alternative nonopioid pain medications.
  • Refusal to try nonpharmacologic therapies.

Illicit behavior:

  • Attempts to alter, forge or rewrite prescriptions.
  • Diverting or selling medication or borrowing drugs from others.
  • The patient requests prescriptions written in the names of other people for whom the patient is not the designated caregiver.

For a more detailed list of red flags and more information on prescribing controlled substances, email the AOA’s Bureau on State Government Affairs.


  1. Dan

    Surely these two groups could have presented a list of red flags that aren’t 100% “duh” common sense. How about filling early? Most overlooked are those who fill once per calendar month but are always 4-5 days early. Not a terrible sign of abuse but something that needs to be addressed to the patient if the assessment doesn’t justify additional pain relief to correspond with what amounts to two month of extra pills over the years course. It’s the discreet signs that we need to pick up as often people who aren’t junkies and contributing members to society become a victim to the drug without necessarily desiring to. That’s what we need to pay more attention. That’s an important responsibility we have to society.

  2. Rob

    Gee, do you think you could have seen this coming? How many years were we indoctrinated that we are “undertreating” pain? Pain is the “fifth vital sign”. After close to thirty years as an Emergency Medicine doc I’ve seen too many people with 10/10 pain smiling and carrying on normal conversations who had normal vital signs who insist on large quantities of narcotics. Hospital administrators who only care about their scores want us to keep their customers happy at all costs don’t help matters either. I predict we will soon be seeing TV ads from law firms wanting you to sue the people responsible for causing your addiction.

  3. Dudley W. Goetz,D.O.

    As a dermatologist, I have not written for an opoid (or a triplicate Rx) in at least thirty years. I refer those with “pain” to a “pain specialist” for treatment of their “pain”. It is truly amazing how few, if any, of those in “pain” actually persist in their request for “pain meds”.

  4. Sanaa

    Our group has found that checking Urine Drug Screens are very helpful for not just checking for illicit drugs but to identify patients who are either trading the pain meds or selling them. I have been amazed yet saddened by those patients I thought were trustworthy.

    1. Toni Wilson

      Drug addiction has nothing to do about being trustworthy. I am disappointed in your response as you are a Dr. Perhaps you should get more education.

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