A Systems Approach to Identifying Inappropriate Use of Controlled Substances: The Need for Balance

Abstract

The diversion, abuse, and inappropriate use of controlled substances remain of concern among health care practitioners, insurers, and policy makers in the United States. The principle of "balance" represents a need to establish a system of control to prevent abuse, trafficking, and diversion of controlled substances, while ensuring their medical availability for legitimate patients. Some models employ pattern recognition within administrative health databases, for example, to examine outcomes and quality of medical care and monitor fraudulent behaviors and inappropriate medical care. Patients' use of resources or variations in practitioners' practice patterns can be examined. A systems approach would require collaboration with medical and pharmacy directors, systems analysts, coding experts, legal experts, and clinicians to develop the claims-based model. Once a patient and/or practitioner with possible diversion or abuse are identified, a second step is required to distinguish inappropriate and appropriate behaviors and medical care. Programs to detect misuse of controlled substances must be validated through clinical research, and a consensus should be reached as to what constitutes a breach of accepted medical practice.