How Physicians Can Better Protect their Patients, the Public and Themselves
Although larger societal forces may be causing the opioid epidemic, physicians still have a significant role to play in helping to end it. By improving their management of pain patients, doctors can significantly reduce drug abusers primary source of opioids—friends and relatives with legitimate prescriptions.
Addicts get their drugs any way they can. Surprisingly few buy them on the street from pushers. Some get them from dishonest doctors and pharmacists, who write and fill prescriptions for money—so called Pill Mills. But according to the annual National Survey on Drug Use and Health, “75% of all opioid misuse starts with people using medication that wasn’t prescribed for them.”
The CDC reports, “Most people who abuse prescription opioids get them for free from a friend or relative.” Even among those who are most at risk of an overdose, more than half get their drugs from friends and relatives, either free or by buying them. In some cases, addicts steal the drugs from friends and relatives.
All of which begs the question, why aren’t physicians stopping this practice? Some patients may be foregoing their own pain relief to “help” an addicted relative or to make some extra cash. More commonly, one assumes, patients find ways to restock their supply. They tell their doctor they lost their pills; they claim they need a higher dose; or they request early refills because of, say, an upcoming trip. Each of these strategies should be a red flag to doctors that diversion is a likely possibility, at which point, it is the physician’s obligation to discern what’s going on and take immediate action to stop any diversion.
The physicians (mostly primary care physicians) and pharmacists (see below) who fail to heed the warning signs, are the ones sent by their boards to remedial classes like the one Schneider teaches. What they learn in class, among other things, is how they can provide their patients with the most effective treatment and prevent the diversion of patient prescriptions. The following is an abbreviated list of these best practices:
Best Practices for Managing Chronic Pain Patients on Opioids
A thorough assessment is the first step in treating a pain patient. In addition to a detailed medical history and physical exam, it’s important to determine how pain has curtailed the patient’s functioning and to establish goals for the therapy. There should be a base line urine drug test and an assessment of the patient’s risk of opioid abuse (see Resources for opioid risk assessment tools).
Urine drug testing (UDT) should be conducted randomly and for cause. The tests can determine if the patient is taking prescribed medication or diverting it, or taking any drugs not prescribed. Physicians should be aware of the usual practices of labs they use and request additional tests as needed. A common problem is that some prescribed drugs yield metabolites that were not prescribed.
State monitoring programs are an important resource. All but one state have Prescription Monitoring Programs (PMP) that provide an up-to-date list of patients’ prescriptions for controlled substances. A check online will tell the physician if a patient is filling prescriptions from multiple providers.
Providing Structure. It’s important for the patient and physician to agree upfront to basic ground rules, usually by signing an agreement that spells out what each can expect. Breaches of the agreement are evaluated on a case-by-case basis. Typically, agreements include such items as:
- Only one physician prescribes opioids for the patient.
- The patient uses only one pharmacy of their choice.
- Patient will not change the dose without first consulting with physician.
- Physician will not give early refills (unless there is a valid reason).
- Patient agrees to consultations or physical therapy referral by physician.
- Patient does not use illegal drugs.
- Patient agrees to urine drug testing whenever requested by physician.
Initiating opioid therapy. To minimize negative side effects, it is often best to start out with low doses of immediate-release opioids, and titrate up until an effective dose is reached. At that point, Schneider recommends converting patients to sustained-release formulations, which now include abuse-deterrent factors (which ironically have led to increased heroin abuse among addicts, see “‘Safer’ OxyContin Caused Thousands of Heroin Deaths, Researchers Find”).
Follow-up visits: Evaluating treatment outcomes. Patents on opioids need to be seen regularly, usually every one or two months, to assess the effectiveness of the current plan and make changes as needed. The physician should ensure that the patient is following the plan agreed to, including any imaging studies, urine tests, physical therapy, etc. A handy way to remember the key elements of these follow-up visits are the five A’s:
- Analgesia — level of pain on a scale of 1-10
- Activities of daily living — be as specific as possible to assess improvements in functioning
- Adverse effects — ask about side effects, which commonly include constipation
- Aberrant drug-related behaviors — these might include requests for early refills or UDT positive for cocaine
- Affect — is the patient showing signs of depression, for example
Keeping thorough records is crucial when treating patients with opioids. In addition to documenting all of the items mentioned above, it is important to keep careful track of all prescriptions for a controlled substances, whether written or phoned in—preferably in one easily accessed section of the patient’s records.
Keeping accurate and complete records ensures the best possible care for patients and affords physicians important protections if decisions or actions are ever questioned by authorities. While keeping extensive records is time consuming, the growing use of specialty-trained scribes offers a possible solution. One study even suggests that scribes actually pay for themselves by enabling doctors to see an average of two more patients per day.
Exit strategies. Given the complexities of safely tapering patients off opioids, it’s best to establish a plan upfront for how this will be accomplished if needed.