It is impossible to separate prescription drug abuse from other forms of substance abuse. Narcotics, stimulants, depressants, and unexpected drugs of abuse, such as antibiotics (used to treat patients with suspected intravenous drug abuse infections) and b blockers (used to limit debilitating subjective anxiety), are examples of abused agents. The magnitude of this problem has been cited as being huge, but the accuracy of the statistics has been called into question. 21 Physicians have been well implicated in this process. The "four D's" have been used by the American Medical Association to describe physicians who contribute to prescription drug abuse: (1) the disabled (impaired) doctor; (2) the dishonest ("script") doctor, who illegally sells drugs; (3) the duped doctor, who unwittingly prescribes drugs of abuse to drug-seeking patients; and (4) the dated doctor, whose obsolete prescribing practices may lend themselves to drug dependency or abuse. 22 Drug-seeking patients are very persistent and successful. A study conducted in Portland found that drug-seeking patients presented to the ED 12.6 times per year, visited 4.1 different hospitals, and used 2.2 different aliases. Patients who were refused narcotics at one facility were successful in obtaining narcotics at another facility 93 percent of the time and were later successful at obtaining narcotics from the same facility 71 percent of the time. 23

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