DEFINICIÓN DE MÚSICA Combinación de sonidos agradables al oído. Arte de combinar los sonidos de la voz humana o de instrumentos. Composición musical. Arte de combinar los sonidos y los silencios, a lo largo de un tiempo, produciendo una secuencia sonora que transmite sensaciones agradables al oído, mediante las cuales se pretende expresar o comunicar un estado del espíritu. 2. ETIMOLOGÍA El origen etimológico proviene de la palabra MUSA, que en idioma griego antiguo aludía un grupo de personajes míticos femeninos, que inspiraban a los artistas. Las musas tenían la misión de entretener a los dioses bajo la dirección de Apolo. Precisamente, Apolo era el jefe de las musas; él las dirigía para que entretuvieran a los dioses en las comidas. 3. HISTORIA DE LA MUSICA Para el hombre primitivo había dos señales que evidenciaban la separación entre vida y muerte. El movimiento y el sonido. Los ritos de vida y muerte se desarrollan en esta doble clave. Danza y canto se funden como símbolos de la vida. Quietud y silencio como símbolos de la muerte. El hombre primitivo encontraba música en la naturaleza y en su propia voz. También aprendió a valerse de rudimentarios objetos (huesos, cañas, troncos, conchas) para producir nuevos sonidos. Hay constancia de que hace unos 50 siglos en Sumeria ya contaban con instrumentos de percusión y cuerda (liras y arpas). Los cantos cultos eran más bien lamentaciones sobre textos poéticos. En Egipto (siglo XX a.C.) la voz humana era considerada como el instrumento más poderoso para llegar hasta las fuerzas del mundo invisible. Lo mismo sucedía en la India. Mientras que en la India incluso hoy se mantiene esta idea, en Egipto, por influencia mesopotámica, la música adquiere en los siguientes siglos un carácter profundo, concebida como expresión de emociones humanas. Hacia el siglo X a.C., en Asiria, la música profana adquiere mayor relieve gracias a las grandes fiestas colectivas. Es muy probable que hacia el siglo VI a.C., en Mesopotamia, ya conocieran las relaciones numéricas entre longitudes de cuerdas. Estas proporciones, 1:1 (unísono), 1:2 (octava), 2:3 (quinta), y 3:4 (cuarta), y sus implicaciones armónicas fueron estudiadas por Pitágoras (siglo IV a.C.) y llevadas a Grecia, desde donde se extendería la teoría musical por Europa. El término "música" proviene del griego "musiké" (de las musas). Por eso la paternidad de la música, tal como se la conoce actualmente, es atribuida a los griegos. En la mitología griega, las musas eran nueve y tenían la misión de proteger las artes y las ciencias en los juegos griegos. En la antigua Grecia la música abarcaba también la poesía y la danza. Tanto la danza como el atletismo se sabe que tenían su acompañamiento musical en tiempos de Homero. Hacia principios del siglo V a.C., Atenas se convirtió en el centro principal de poetas-músicos que crearon un estilo clásico, que tuvo su expresión más importante en el ditirambo. El ditirambo se originó en el culto a Dionisos (Baco). Las obras -tragedias y comedias- eran esencialmente piezas músico-dramáticas. La poesía, la música y la danza se combinaban y las piezas eran representadas en los anfiteatros por cantores-actores-danzadores. La poesía era modulada y acentuada por sílabas, e interpretada indistintamente en prosa común, recitado y canto. La melodía estaba condicionada, en parte, por los acentos de la letra, es decir, por la melodía inherente a la letra, y el ritmo musical se basaba en el número de sílabas. Es dudoso que hubiese diferencia real entre los ritmos musicales y los metros poéticos. Desde el siglo IV a.C., el músico comenzó a considerarse a sí mismo más como ejecutante que como autor. El resultado fue el nacimiento del virtuosismo y el culto al aplauso. La música, en general, se había convertido en mero entretenimiento, por lo que el músico perdió mucho de su nivel social. La enseñanza musical acusó un gran descenso en las escuelas, y los griegos y romanos de las clases elevadas consideraban degradante tocar un instrumento. La división entre el ciudadano y el profesional ocasionó el divorcio social y artístico que en nuestro tiempo todavía afecta a la música europea. Leer más: http://www.monografias.com/trabajos29/musica/musica.shtml#ixzz3hFIePzKY

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Women  Doctor Shop for Prescription Drugs

Julie Worley1 and Sandra P. Thomas2

Abstract

Doctor shopping is a term used to describe a form of diversion of prescription

drugs when patients visit numerous prescribers to obtain controlled drugs

for illicit use. Gender differences exist in regard to prescription drug abuse

and methods of diversion. The purpose of this phenomenological study

guided by the existential philosophy of Merleau-Ponty was to understand

the lived experience of female doctor shoppers. Interviews were conducted

with 14 women, which were recorded, transcribed, and analyzed. Included

in the findings are figural aspects of the participants’ experience of doctor

shopping related to the existential grounds of world, time, body, and

others. Four themes emerged from the data: (a) feeding the addiction,

(b) networking with addicts, (c) playing the system, and (d) baiting the

doctors. The findings suggest several measures that nurses can take to

reduce the incidence of doctor shopping and to provide better care for

female doctor shoppers.

Keywords

doctor shopping, prescription drug abuse, women and substance abuse,

phenomenology, addiction

The Lived Experience of Female Doctor Shoppers

Prescription drug abuse is a serious and significant worldwide problem.

Prescription drugs with abuse potential have been designated as controlled

drugs in the United States since 1970 (National Conference of Commissioners

on Uniform State Laws, 2012). Prescription drugs are diverted for illicit use

through a variety of methods such as theft, forgery, and doctor shopping

(Wang & Christo, 2009). Several studies have confirmed that diversion of

controlled substances for nonmedical use often involves doctor shopping

(Pradel, Delga, Rouby, Micallef, & Lapeyre-Mestre, 2010; Wilsey et al.,

2010; Wilsey et al., 2011). Doctor shoppers are at considerable risk having

twice the odds of drug-related deaths (Peirce, Smith, Abate, & Halverson,

2012). Historically, controlled prescription drugs have been targeted at

women for conditions such as menopause and stress (Kandall, 2010). More

than half of all Americans who first used prescription drugs nonmedically in

2010 were females (National Institute on Drug Abuse, 2012). Studies have

found that women are more likely to use doctor’s prescriptions for abuse

(Cicero et al., 2011) and/or engage in doctor shopping than men (Hall et al.,

2008). Despite this, little research has been conducted with doctor shoppers.

This is the first known study conducted with the purpose of describing the

lived experience of women who engage in doctor shopping.

The term doctor shopping is a commonly accepted term in the United States

used by health care professionals, the media, government, law enforcement, and

the public, denoting patients who visit numerous health care professionals for

multiple prescriptions of controlled drugs. Less commonly, particularly in Asia,

the term has been used to describe changing providers due to dissatisfaction with

care (Johnston, Leung, McGhee, & Caston-Cameo, 2007; Sato, Takeichi,

Shirahama, Fukui, & Gude, 1995). More commonly, the term doctor shopping is

heavily engrained in most cultures as referring to obtaining prescriptions from

multiple prescribers, not solely physicians. Therefore, doctor shopping is defined

using the attributes set forth in a concept analysis previously published as occurring

when (a) a patient repeatedly uses multiple prescribers to obtain controlled

drugs, (b) the patient does not report getting similar prescriptions from other prescribers,

and (c) the medications are overused or used in a way that was not

intended when prescribed (Worley & Hall, 2012). In the United States, as in other

countries, several groups of health care professionals have the authority to prescribe

medication, including advanced practice nurses (APNs), physician assistants,

dentists, and ophthalmologists. For the purpose of this paper, the term

doctor shopper refers to patients visiting any prescriber, not only physicians.

The recently released Diagnostic and Statistical Manual of Mental

Disorders 5th edition no longer used the terms abuse and addiction when

describing a diagnosis related to substance use. Currently, the term use disorder

is used related to each substance, such as opioid use disorder. A determination

of whether the use disorder is mild, moderate, or severe is based on the

number of criteria that are met. Criteria describe characteristics normally

associated with abuse and addiction such as taking larger amounts than

intended, continuing use despite negative consequences, tolerance, cravings,

and withdrawals (Diagnostic and Statistical Manual of Mental Disorders, 5th

ed.; American Psychiatric Association, 2013). For the purposes of this article,

the term “abuse” is used to indicate when a prescription is taking in larger

amounts or for a longer period than intended, and “addiction” refers to the

symptoms of tolerance, cravings, and withdrawals associated with continued

substance use.

The problem of doctor shopping is significant to APNs as prescribers who

have a legal and ethical obligation to prescribe responsibly. In addition, many

nurses in many clinical areas interact with patients who may be doctor shopping

such as family practice, emergency rooms, and inpatient hospital units

and therefore have the potential to intervene in this phenomenon.

According to the United Nations Office on Drugs and Crime (UNODC)

2012 World Report (2013), other than marijuana, in many countries, the rate

of nonmedical use of prescription drugs is higher than other drugs. In South

America, Central America, and Europe, nonmedical use of tranquilizers and

sedatives is higher in women than in men (UNODC, 2013). Prescription drug

abuse results in huge financial, personal, and societal costs. In the United

States, the cost of prescription drug diversion, which often involves doctor

shopping, is estimated at $72 billion per year (United States Department of

Justice, 2009). Deaths from overdose in the United States tripled from 1997

to 2007 (Centers for Disease Control and Prevention [CDC], 2010).

Hospitalizations from poisoning by prescription opioids, sedatives, and tranquilizers

from 1999 to 2006 rose 65% (Coben et al., 2010). Despite the

increasing incidence of prescription drug abuse, prescribing rates of controlled

drugs have risen 127% between 1997 and 2006 (Manchikanti &

Singh, 2008). The quantity of prescription pain killers sold to pharmacies,

hospitals, and doctor’s offices was four times larger in 2010 than 2009 (CDC,

2012). Little is known about the phenomenon of doctor shopping or the people

who engage in it. To increase understanding, a qualitative study with

female doctor shoppers was conducted.

This study was conducted using the existential phenomenology lens of

Merleau-Ponty. In this approach, the focus is on doctor shopping as seen

through the participant’s eyes in order to discover their perceptions of their

lived experience. Merleau-Ponty called perception “the miracle of a totality

that surpasses what one thinks to be its conditions or its parts” (cited in Hass,

2008, p. 49). According to Merleau-Ponty, figural aspects of perceived things

are only understood against the backdrop of existential grounds, which

include body, time, other people, and the world (Merleau-Ponty, 1945/2005;

Thomas, 2005). Figure and ground co-constitute one another, forming an

inseparable gestalt. Thus, the phenomenological researcher seeks to achieve

understanding of the wholeness of human experience, as described by individuals

who are willing to engage in dialogue about their experience (Thomas

& Pollio, 2002). According to Wertz (2005), “The most outstanding quality

of data sought by the phenomenological researcher is concreteness, that the

descriptions reflect the details of lived situations rather than hypotheses or

opinions, explanations, interpretations, inferences, or generalizations regarding

the phenomenon” (p. 171). Ultimately, phenomenology research provides

an opportunity for understanding the essence of experiences which are part of

the reflective life-world of the participants (Mottern, 2013).

Method

A qualitative phenomenology study was chosen for this study due to the paucity

of research available on the phenomenon of doctor shopping. Approval

for this study was obtained from the Institutional Review Board (IRB) at the

University of Tennessee (UT). We used the University of Tennessee method

of phenomenology (Thomas & Pollio, 2002), which is based primarily on the

philosophy of Merleau-Ponty. To our knowledge, the method has been utilized

in approximately 200 studies, by researchers in psychology, education,

nursing, and other disciplines (e.g., Davis et al., 2004; Mottern, 2013; Shattell,

Starr, & Thomas, 2007). The participation of the interdisciplinary interpretive

phenomenology group is an integral part of the data analysis process. The

interdisciplinary group is made up of professionals and educators from a variety

of disciplines, who have met weekly in the UT College of Nursing since

1994 to thematize interview transcripts from a wide variety of research projects.

The method also included a bracketing interview done with the first

author to improve the rigor of the study through increasing her awareness of

possible prejudgments and potential biases to facilitate an open nonjudgmental

attitude.

Participants

Participants for this study were recruited from flyers placed in a building

where substance abuse support groups were held as well as by personal invitation

of the researcher who attended approximately 15 Narcotics Anonymous

meetings at that building. The technique of snowballing was used in recruitment

wherein people who learned of the study through the flyers or through personal

contact with the researcher were encouraged to tell others about the

study. Some of the participants did report that they learned of the study

through word of mouth and therefore were not necessarily attending a substance

abuse support group. Inclusion criteria included women age 21 and

old, who were English speaking and self-identified as having engaged in doctor

shopping. All of the women who inquired about the study self-identified

as engaging in doctor shopping based on a definition that was provided to

them based on a concept analysis developed by the researcher (Worley &

Hall, 2012). Exclusion criteria included being a current or a former patient of

the researcher, who is an APN prescriber, and participants who presented for

their interview appearing to be acutely intoxicated or significantly impaired

by substance use, which did not occur. Demographic information was collected

following the interviews on age, race, education, and employment.

Participants were given a $25 gift card following their interviews.

The study consisted of 14 women ranging in age from 27 to 51 (see Table 1).

The sample size was determined by data saturation. There was a determination

that data saturation was met when new interviews did not reveal any new

findings but rather repeated what was found in prior interviews. Names used

in the study were pseudonyms chosen by the participants. In addition, it

should be noted that the participants consistently referred to themselves and

Table 1. Participant Demographic Characteristics.

Name Age Marital Status Education Level Occupation

Sue 29 Separated Some college Disabled

Summer 30 Single Some college Nursing

assistant

Tammi 27 Divorced Some college Cosmetologist

Jane 33 Divorced Some college Hair dresser

Melissa 29 Divorced Some college Unemployed

Flo 28 Married High school Homemaker

Becky 29 Single Some college Construction

Victorious 31 Divorced Some college Disabled

Mya 34 Married Some college Medical assistant

Londie 39 Single Some college Disabled

Desiree 51 Married Some college Unemployed

Rebecca 48 Separated GED Disabled

Susan 36 Married High school Unemployed

Samantha 30 Single Some college Factory

Note. GED = general educational development.

others that were engaging in doctor shopping as “addicts.” Therefore, that

term is used in this article, when referring to the participant’s description of

their experience, and is not meant to be used in a negative, judgmental, or

stigmatizing way. Twelve of the women were Caucasian and two women

were African American, which is representative of the geographic area in

which the study was conducted in the Southeast United States.

Although specific questions regarding what medications were sought

when doctor shopping or how the medications were used were not asked, it

is noted that most of the participants reported seeking prescriptions for opiates,

benzodiazepines, or in some cases both. Stimulants and sedative sleeping

medication were also mentioned as being obtained and abused through

doctor shopping.

Data Collection

Interviews were conducted by the principal investigator who is the first

author of this article, at a private unoccupied office, at a picnic table in a

private location near the recruitment site, and at the participants’ homes,

which included a half-way house for women. A half-way house is defined as

a house where residents pay a weekly rent to live with others, often sharing a

room, while recovering from substance abuse or other challenging life events.

Informed consent was obtained from each participant prior to the interview.

The location of the interview was determined based on the choice and convenience

of the participant. The questions asked of participants were chosen

based on the method of phenomenology and included, “Tell me what your

experience has been doctor shopping?” and “Is there anything that stands out

for you about your experience doctor shopping?” Asking what “stands out” is

a technique to elicit what is figural in a participant’s perception. These questions

were followed by further open-ended questions with an aim to facilitate

the participants’ elaboration of their experience. There was no time frame set

for the interviews. The average length of the interviews was 45 min. The

interviews were digitally recorded.

Analysis

Following the interviews, the transcripts were professionally transcribed.

Using the UT method of phenomenology, meaning units as short phrases,

ideas, or key concepts that emerged from the data were identified. Code

labels were assigned to identify categories which were then analyzed for the

presence of themes and interrelationships. Throughout the analysis, the

researchers continually moved back and forth from the parts (particular words

and phrases) to the whole interview text. Global themes were then developed

across interviews using the Thomas and Pollio (2002) rule, which specifies

that a global theme is present in every interview or at least not contradicted in

any interview. Portions of the transcripts were taken to the interdisciplinary

group and read aloud and analyzed. Themes were named with terms closely

aligned to participants’ own words and identified themes were supported with

verbatim quotes from participants (Thomas & Pollio, 2002). The transcriptionist

and members of the interdisciplinary group all signed a certificate of

confidentiality.

Rigor of the study was achieved using the standards set by Creswell

(2013). To wit, a clear phenomenon (doctor shopping) was selected; the study

was conducted with an understanding of the philosophical tenets of phenomenology;

the UT method of phenomenology was used in this study, which is

a well-established and rigorous method; the study findings resulted in the

ability to describe an overall essence of the experience of doctor shopping for

the participants; and the reflexivity of the researcher was taken into consideration

by the bracketing interview which elicited possible biases, and the

influence of the values and experiences, of the researcher.

Results

When analyzing the data, a particular emphasis was taken to consider the

existential grounds of world, time, body, and others in relation to figural

aspects of the participants’ experience of doctor shopping. As noted previously,

in Merleau-Ponty’s (1945/2005) philosophy, figure and ground form a

gestalt; one cannot be considered without the other. The world of visiting

prescribers and pharmacies was the contextual ground within which the

experience of doctor shopping took place. The participant’s world consisted

of going to new places when constantly seeking new sources of prescription

drugs. Because the entire focus of the participants is visiting prescribers and

pharmacies, the participants’ world in the experience of doctor shopping is a

limited and restricted one. No mention was made of interaction with nature,

recreational settings, or other locations as would be found in most people’s

descriptions of their world. Thus, the participants’ world being so consumed

by doctor shopping resulted in relative isolation from other aspects of their

surroundings.

The existential ground of time for the participants was driven by their need

for drugs, which prompted them to use most of their waking hours to engage

in doctor shopping. The time devoted to doctor shopping was great, often

involving traveling far distances to different locations. This engulfment left

little extra time for other activities in life. Time for the participants went slowly

when they described spending hours waiting to see prescribers or to have

their prescriptions filled. Yet, time spent with prescribers was often short, as

they described prescribers who spent only a few minutes with them when

writing them prescriptions.

The experience of the participants of their body is one associated with

addiction. They experienced cravings and overwhelming withdrawal symptoms

when they went without drugs. They continually sought opiate pain

medications to abuse, which resulted in severe bodily pain from withdrawals

when they did not have the drugs, leading to their consumption of more pain

medication. Other adverse bodily effects they experienced were seizures,

overdoses, and infections. The experience of these adverse bodily effects,

which produced suffering as well as the risks of overdose, was ignored and

accepted as par for the course, as they continued in their addiction.

Interaction with other people involved in drug use and doctor shopping

as well as prescribers is grounded in the experience of others. The participants

reported a tightly knit network or circle of “addicts” they networked

with to doctor shop. A central component to the relationship between the

“addicts” is that is involved benefit to the participants. Other people that the

participants interacted with during doctor shopping were merely seen as a

mechanism to obtain drugs with little regard to their well-being or value as

human beings. Participants described sponsoring others to obtain prescription

drugs, which is a stark contrast to how sponsorship is used in recovery

groups to maintain sobriety. The relationship participants had with prescribers

was based on falsehoods and deception. Prescribers were compared

and categorized as being either “writers,” who were sometimes referred to

as “pill doctors,” or those who were “not writers.” Notably missing from

the experience of the participants related to the existential ground of others

in this study were significant others who would normally be part of a person’s

world. Very little mention was made about significant others who

would normally be part of the world of others such as spouses, partners,

children, or friends. The experience of a limited and restricted world

focused on doctor shopping contributed to the participant’s isolation from

anyone other than other people involved in drug use or doctor shopping and

prescribers.

Figural Themes

Against these existential grounds, the meaning of doctor shopping comprised

four themes for the participants in this study: (a) “feeding the addiction”;

(b) “networking with addicts”; (c) “playing the system”; and (d) “baiting the

doctors.”

 “Feeding the Addiction”

The driver of the behavior of engaging in doctor shopping for all the participants

was addiction. Twelve of the 14 participants admitted to intravenous

(IV) drug use either at present or in the past. The process of addiction led to

doctor shopping, which fueled the addiction, which in turn led to more doctor

shopping. This process was described as a cycle, with addiction being a powerful

force that they could not resist. Melissa described her sense of being

overpowered by addiction:

I would have a prescription and go to another one, another doctor, knowing I

already had it, wanting to get more, just to feed my addiction.

Mya also described succumbing to the force of addiction which was met

in a detached manner, as was characteristic of the participants:

I don’t know, it’s not fun, it’s not enjoyable, but you do what you do to feed that

addiction.

The occurrence of painful withdrawal symptoms was commonly expressed

by the participants in relation to their addiction. Much of their experience

involved physical suffering. For Becky, her addiction was so strong as well as

her need to subdue withdrawal symptoms, she described how she would snort

her Xanax at red lights or pull her car over after leaving the pharmacies to

shoot up her opioids:

Cause you were like going to get sick or whatever if you didn’t. Being pill sick is

not fun. It’s no fun at all.

Many of the participants described serious physical harm they suffered as

a result of feeding their addiction such as lapses in memory, self-induced

comas, overdoses, weight loss, and almost dying due to drug use. Susan

talked about how sick she was from withdrawal symptoms:

Honey, you are deathly sick if you don’t have ’em. Deathly sick. You will not get

out of the bathroom for days, trust me.

Feeding the addiction was something to which the participants willingly

succumbed because they felt overwhelmed by the power of substance abuse

in their lives. They continued to feed their addiction despite significant risk

to their lives. They experienced their bodies as being empty vessels that

needed to be fed with drugs or else they would be sick. Their sense of personhood

or as individuals was primarily centered on the fact that they were addicted to

prescription drugs.

“Networking With Addicts”

The participants worked with people who they referred to as “addicts” in

their circle or network by getting information and acting together. They

described how they listened to each other and found out information about

where to go to doctor shop and how to do it. Information was also shared

about which pharmacies were more likely to fill prescriptions that were

obtained through doctor shopping. Summer described how she got information

from others:

I got some people talking about where they were going. I would get tips on what

to say. I would listen to people that were doctor shopping.

Rebecca also talked about getting information from other “addicts”:

I knew somebody that was doing it and he was giving me the name of another

doctor in another town. I mean, because this is passed around to all of us who gives

out drugs.

The participants also worked together when doctor shopping, either by

sponsoring others, sharing pills for pill counts or urine for drug tests, trading

x-rays or other diagnostic imaging results, or sharing rides to and from

appointments. Flo shared how she worked with others to obtain drugs while

doctor shopping:

I used to go to the hospital, me and my friends would go and we would switch out

so we could get more medicine. We would drive ’em and they would give us so

much pills. Whatever they did, if they snorted ’em we would snort ’em but if they

IV’d then we IV’d.

Tammi ran a sophisticated operation sponsoring others to doctor shop:

I sponsored people. I paid for other people to go so I could get half their pain

medicine. I had to make sure they had what they needed in their system for drug

tests and if someone got called in for a pill count I have to call somebody and

borrow pills.

When the participants talked about other people they got information from

or acted together with, they seemed to lack a sense of concern for the well-being

of others as evidenced by the detached manner in which they discussed serious

consequences of doctor shopping on others. The focus on these relationships

with others was primarily driven by what they could get from another

person in order to secure prescriptions and had little to do with compatibility.

These relationships were transient and easily replaced if someone was

arrested, died from a drug overdose, or left the drug using scene.

“Playing the System”

The participants used sophisticated means and measures to play the system in

order to elude detection. Playing the system came at a high price which

involved a lot of stress and hard work. When measures were taken by prescribers

to detect abuse such as pill counts, urine drug testing, or checking MRIs,

these were thwarted by the participant’s ingenuity. In addition to putting a lot

of effort into playing the system, the participants experienced fear of being

caught. Playing the system was described by Mya as being easy to figure out:

It took me no time at all to figure out how to play the system. I really learned to

play that system too, to get lots of things.

Jane had such an elaborate scheme for playing the system that it became

her full-time job:

It was my job almost. I had an appointment book and I had the doctor’s names, you

know, like he’ll be here this day and he’ll be here that day. I was putting some

thought into this. It was very stressful, hectic and expensive.

Becky talked about the tactic of borrowing pills or MRIs as well as ingenious

ways to fool urine drug screens:

If they want a pill count, get on the phone with everybody and try to come up with

them. You use other people’s MRIs. You can fix pee to pass a drug test, just squirt

some of the Roxy in clean pee, put it in a pill bottle, put foil around it and wrap

black electric tape around it and put it up in you. When you sit down to pee you

poke it open. The nurse has to be in the room but they’re not watching you that

close.

Samantha also put a lot of time and effort into doctor shopping in order to

play the system:

I would go to different pharmacies, one was 45 minutes away from the other one.

I told them I didn’t have insurance so I could pay for them and not get caught.

Fear stood out as significant to some of the participants, which was sometimes

expressed with disproportionate significance as opposed to other serious

adverse consequences such as physical illness, death, or losing custody of

their children. Sue described her ambivalence about being afraid and her

need to continue doctor shopping:

I was really scared. I was always afraid of being caught or going to jail. I have kids

and that was always a big fear, but the benefit always outweighed the risk.

The participants had the intelligence, insight, and ingenuity to play the

system through a serious of elaborate means which took considerable time

and effort. They experienced stress as a result of these efforts as well as fear

of being caught.

“Baiting the Doctors”

The final theme noted among the participants’ descriptions of their experience

was the act of conning and manipulating prescribers to write prescriptions

for controlled drugs which they needed to feed their addiction. Baiting

the doctors was accomplished by falsifying symptoms and denying or hiding

the fact that prescriptions had already been obtained from previous prescribers.

The participants played the role of an actress by dramatically

feigning symptoms of anxiety or pain. Summer talked about conning

prescribers:

Just hearing my sob self-pity story, they just fell into that and gave me all kinds of

narcotics due to that. They just fell for my sob story and I used that to bait them

doctors.

Melissa also described how she manipulated prescribers:

The manipulation is the key that anybody can turn. I was faking the tears an in an

instant I could cry or yell out in pain. I would milk it to the fullest extent.

Jane’s desperation for prescription drugs was evident in the fact that she

even went through unnecessary and painful elective surgeries. In addition,

she would use the tactic of becoming belligerent and making a scene until she

got the drugs she wanted:

I got so desperate I let them do surgeries on me. That’s part of being a con artist

and manipulator. I was going to get what I wanted and I would trouble as I could

until it went my way. They did it just to shut me up I think.

The participants exhibited a keen ability to read the prescribers in order to

get them to prescribe them medications they did not need. Sue described how

she baited the doctors:

I’d go to a doctor and you know, complain about aches I didn’t have. You got to be

a good actress. You got to have a poker face. You’ve got to learn how to read That

doctor so the doctor will give you what you want. You got to fake it.

Often the participants described baiting the doctors with a sense of pride

and accomplishment. They had few other successes in their lives. Their success

at conning prescribers was sometimes described as being fun, thrilling,

and exciting. Tammi said,

You feel great when you’re doing it. There’s a big thrill in that. Always look

forward to doctor day.

For some of the participants, doctor shopping was described as something

they thrived on, even to the point of feeling addicted to it. Summer said,

It became like a big hobby for me to see who I could and couldn’t manipulate. It’s

like being on the edge. I miss the rush of doing it. My drug of choice was doctor

shopping.

In many cases, the prescribers were complacent with the participants’ doctor

shopping because they failed to take any measures to prevent it. The participants

reported that prescribers did not check prescription drug monitoring

data, did not verify their identity or their insurance status, did not verify their

symptoms through old records or diagnostic tests, and did not perform drug

testing to determine if they were or were not taking their prescribed medication.

The prescribers were perceived as being uninterested and not being diligent

in thwarting their efforts. The participants were unconcerned with the

fact that this could indicate that the prescribers did not care or were not considering

the participants best interest. Jane talked about why she thought was

never caught:

My doctor didn’t run that narcotic check where they see what you have gotten

since the last time you were there. I think that’s because I had a trust built with him

that he felt he didn’t need to do that and my other doctor never did either.

In some cases, the prescribers developed relationships with prescribers,

staff at prescribers’ offices or pharmacies, to secure special favors or to

prevent detection. In these cases, the prescribers were collaborative with

the participants in doctor shopping. In cases where sexual favors were

exchanged for prescriptions, the participants viewed the prescribers rather

than themselves as the ones being used. Desiree engaged in extensive sexual

relationships with prescribers:

I started doctor shopping for multiple reasons, eventually it became an intimate

thing with the doctors. I developed sexual relations with them.

Summer also talked about having sexual relations and other special privileges

with the prescribers:

I dated a doctor and he would write anything I wanted. He would send me to one

of his friends that also prescribed to me. I became friends with a few other doctors

I could make house calls to. I got them right where I wanted them.

Baiting the doctors when doctor shopping was accomplished through conning

and manipulation, which was carried out in a dramatic manner by the

participants. Most of the time, the prescribers were easily fooled and could be

seen as being complacent when they failed to take measures to detect doctor

shopping. In other cases, prescribers were collaborative and traded sex or

money for prescriptions with the participants.

Discussion

The meaning of doctor shopping can be described as stemming from a powerful

and overwhelming addiction to prescription drugs. It involves a

restricted experience with the world and others, limited only to other “addicts”

and visiting prescribers, which leaves little time for anything else. Doctor

shopping is driven by a need to feed an addiction which takes a significant

toll. Without drugs severe withdrawal symptoms occur, which drive the

behavior of doctor shopping. The experience involves networking with others

who were described as “addicts” to obtain information and in the act of

doctor shopping, which involves hard work and fear of detection. Another

crucial component of the meaning of doctor shopping involves playing the

system to obtaining prescription drugs which is accomplished through baiting

the doctors. Conning and manipulating prescribers when doctor shopping

is described as being easy and sometimes thrilling and often involved complacency

or collaboration on the part of the prescriber.

This phenomenological study adds to the literature in that for the first

time, it provides a description of the meaning of doctor shopping for women.

Consistent with previous literature, doctor shopping involves networking

with others (Green et al., 2013). However, contrary to that study, which indicated

that coercion from others occurs in doctor shopping, no evidence of

coercion from others was noted in the findings from this study. Rather than

being coerced by others to doctor shop, these participants were independent

and at times used others to doctor shop for them. Also consistent with the

findings from other studies (Fountain, Griffiths, Farrell, Gossop, & Strang,

1997; Inciardi et al., 2009; Rigg, Kurtz, & Surratt, 2012), numerous tactics

were found to be engaged in while doctor shopping. Fountain et al. (1997)

were the only study that noted a sense of enjoyment from patients outwitting

prescribers during doctor shopping; however, a new finding from this study

not previously described in the literature is the concept of a sense of the experience

being thrilling and challenging. This is the first study where the act of

doctor shopping was described as having the potential of being addicting in

itself.

There are several implications that can be drawn from the results of this

study. Primarily a need for responsible prescribing practices is warranted. A

need exists to shift the focus of care from generous prescribing of controlled

drugs to the prevention and treatment of addiction because if prescribers

write prescriptions for controlled drugs to people who are abusing them, prescribers

are actually contributing to a serious and potentially deadly disease.

Better screening to detect prescription drug abuse is indicated. Patients can

be screened through judicious use of prescription drug monitoring programs

(PDMP) each time prescriptions for controlled drugs are written. These are

electronic databases set up in states to provide a way for health care professionals

to look up which prescriptions their patients have had filled at pharmacies

(Worley, 2012).

Other steps that could be taken to detect and deter doctor shopping would

be the implementation of more sophisticated drug testing methods. The use

of screening instruments completed by patients or prescribers should be

incorporated into the care of patients prescribed controlled drugs. Other

screening interventions include physical examination of patients for needle

track marks. More judicious determination of patient identities and insurance

status as well as discouraging the use of cash payments for visits or prescriptions

for controlled drugs is warranted. In addition, a mechanism to detect or

prevent patients routinely traveling out town to visit prescribers or to fill

prescriptions for controlled drugs would also help reduce prescription drug

abuse and doctor shopping.

There is a need for increased prescriber education on responsible prescribing,

identification and assessment of abuse, use of PDMPs and how to handle

the situation when abuse or addiction is detected. Additionally, prescribers

need training on how to effectively help patients who may have substance

abuse problems. Nurses in a variety of settings are often in key positions to

detect prescription drug abuse and to intervene when abuse is suspected. Education

on detecting and treating substance abuse, including detecting the phenomenon

of doctor shopping, should be incorporated in the education of nurses at

all levels. Nurses are well suited to design treatment interventions and recovery

options such as gender specific programs, support groups, and other after

care programs such as half-way houses for women.

Future research is needed in this area to determine what prescribers’ experiences

are with doctor shopping as well as prescriber characteristics related

to prescribing rates of controlled drugs. Studies are needed to assess prescriber

use of PDMPs and to identify barriers to PDMP use. Studying the

personality characteristics of prescribers would be helpful to determine risk

factors for prescribing controlled drugs to doctor shoppers. Likewise studying

the personality characteristics of doctor shoppers could help identify risk

factors for patients engaging in this high-risk behavior. Currently, there is a

lack of screening instruments to use with prescribing controlled drugs other

than opiates such as benzodiazepines or stimulants. Interventions also need to

be developed for prescribers and patients to reduce the incidence of doctor

shopping.

The strengths of the study include that it is the first of its kind to explore

the meaning of doctor shopping for women and that it was conducted using

high standards for qualitative research. Limitations of the study include that

the findings are gender specific and because the study was conducted in the

Southeast United States, the results may not be generalizable to men or other

geographic regions. A further limitation could be that the researcher was a

prescriber in the geographic area where the study was conducted and has

experience with doctor shoppers. The effect of this was minimized through

the bracketing interview and the interpretive phenomenology group input.

Additionally, the researcher was identified to the participants as a researcher

and nurse, not as a health care provider, and no current or former patients of

the interview were included in the study.

In conclusion, the findings of this study demonstrate that for the women in

this study, the experience of doctor shopping involves addiction, networking

with addicts, playing the system, and baiting the doctors. Furthermore, when

women engage in doctor shopping, they are at considerable physical risk. The

results of doctor shopping can be devastating including physical and social

isolation and the potential for serious physical harm or death due to addiction.

The women in this study were overwhelmed and driven to obtain prescription

drug by a powerful addiction that resulted in severe withdrawal symptoms

when they did not have drugs. Through ingenuity and hard work which was

stressful and frightening, the women successfully played the system and baited

prescribers to secure prescriptions for controlled drugs to abuse. Prescribers

were complacent or collaborative and seemed to ignore their legal and ethical

obligation to provide appropriate care. Further research and changes in prescribing

practices are needed to prevent and deter doctor shopping and to identify

people suffering from addiction, so that they can be provided the help they

need to be treated so they can recover from this potentially deadly disease.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,

authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication

of this article.