driving on drugs

[NEPain]

If this has been discussed already, I apologize and would appreciate the link....

I'm wondering if there is any specific wording one can use in a note to protect against patients having accidents either while on prescribed meds, or if they have marijuana on board and I have urine tox screens that show thc.

I think that I saw this discussed and the most common response to thc on urine tox was to dismiss the patient. Is this really the only way to safely deal with these patients? I have no trouble discharging pts on cocaine, heroin, etc., but marijuana actually has been shown to help pain, etc. I'd also lose half of my patients. I really think that half of the US is smoking pot.
Also, the providers in our practice are divided on whether it makes sense to dismiss an otherwise model patient who is using marijuana with reported benefit.

This problem can't be just here. What do you all do?

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[PMR 4 MSK]

"The patient was told in no uncertain terms that s/he should not drive while taking this medication. S/he was informed that driving while taking this medication could result in collisions resulting in serious injury or death to the patient or others. S/he agreed to not drive while taking this medication."

People on pot don't usually get into accidents - they get pulled over for doing 15 mph in a 65 zone.

 

[Pain Applicant1]

I also add not to sign or agree to any contracts while using opioids.

 

[pretenda]

not to highjack this thread but what about in states where marijuana is medically legal? does anyone working in these states, say michigan, use the same type of policy?

 

[Jitter Bug]

I have never discharged someone for marijuana use. But I won't give them controlled substances or anything sedating, I do advise they quit and make sure they understand it has no role in my treatment plan for their pain.

If they still want to work with me knowing those ground rules, we go forward. If they don't like it, they move on.

 

[facets]

federally mj is illegal, case closed, no controlled drugs

 

[Jcm800]

I have never discharged someone for marijuana use. But I won't give them controlled substances or anything sedating, .

I have killed for less

 

[jj337]

federally mj is illegal, case closed, no controlled drugs

1+

 

[drf]

I spoke to a local colleague with 30 years of pain experience regarding this. This is a MJ state. He runs a very respected FRP program and has a referral network of at least 100 pain/PMR/occ med docs who send him patients. Often the most challenging workers comp patients.

His solution is to specifically exclude THC from his UDS panel. He tests frequently and all new pts. All abnormal GC/MS get fully evaluated by addiction medicine and often sidetracked to drug rehab before returning to the FRP.

His reasoning is that he wants to create an honest therapeutic relationship with patients and doesn't personally feel MJ is that terrible if it helps some of these folks. By not testing he side steps the federal implications.

He doesn't ever recommend MJ nor prescribe it.

I sometimes feel that 50% of my more disabled patients test positive for MJ in this area. As such I also wonder if there is a little bit of financial incentive to get these folks into the FRP program despite MJ use.

 

[drf]

A bit off topic but kinda funny.

30 yo M for B occipital pRF. Third go, each time previous it worked great. 6-8 months apart. His wife is an APRN and got angry in preop because the RN wouldn't let the wife start the IV. Wife also complained when the pt was asked about medications (how many norcos a day do you take) feeling it implied the preop RNs thought he was drug seeking.

Procedure went fine. Patient happy. I get a call 30 minutes later stating that the wife had a headache so she took a norco and two Benadryl and was now altered. She was nodding off mid sentence. The problem was that she was the ride and they live 2 hours away.

No local friends. Refused cab voucher and hotel. Ended up leaving AMA but promised to go drink some coffee locally so risk management was cool with it.

Fun times.

 

[ghost dog]

If this has been discussed already, I apologize and would appreciate the link....

I'm wondering if there is any specific wording one can use in a note to protect against patients having accidents either while on prescribed meds, or if they have marijuana on board and I have urine tox screens that show thc.

I think that I saw this discussed and the most common response to thc on urine tox was to dismiss the patient. Is this really the only way to safely deal with these patients? I have no trouble discharging pts on cocaine, heroin, etc., but marijuana actually has been shown to help pain, etc. I'd also lose half of my patients. I really think that half of the US is smoking pot.
Also, the providers in our practice are divided on whether it makes sense to dismiss an otherwise model patient who is using marijuana with reported benefit.

This problem can't be just here. What do you all do?

I agree with what other posters have written here: if they are using THC, they are likely not good opioid candidates.

Does this constitute an automatic discharge from the pain practice ? Of course not. Will they self terminate once they discover you won't prescribe them opioids? Frequently. There's lots of other things we can do apart from slingin pills at yur pilehole partner - but this population doesn't want to hear it.

In my experience, I find that pts who use THC are at high (or higher) risk for misusing opioids. The lit supports that peeps who abuse illegals drugs are at higher risk for manifesting aberrant opioid behavior - I'm not sure where you're going with the argument that "half the country uses it". Do you script narcs to half the country ? Nuff said.

Moreover, the literature is weak in regards to THC and managing pain. Even weaker than opioids and chronic non-malignant pain.

 

[deleted185747]

I have heard the argument that smoking pot all day, every day, is expensive so people may "subsidize" their MJ use by selling some of their opioids to pay for the MJ.

Another useful argument is that the meds we use are not tested with MJ and thus side effects and interactions cannot be predicted and should not be used together.

 

[facets]

studies have shown that pts who smoke pot are 2-3 times more likely to divert or misuse their presription drugs

 

[NEPain]

So the consensus is pretty tough. No opiates for patients smoking pot.

Is anyone aware of any articles or editorials discussing this issue?

I can see the rationale, but for some reason it just doesn't seem as bad as using more hard core drugs like cocaine. The fact that it's even legal in some states makes it seem less bad. However, the fact remains that it is illegal in most states and I got my answer. It's use is not tolerated, at least by the people on this forum.

How can you tell someone on daily opiates not to drive? I read a study (I'll try to find the reference) that looked at reflexes, etc. in patients on chronic stable doses of opiates and they were no different from non-opiate users.

There is a company that offers a blood test to document a stable blood level in patients so that if they do have an accident, you can see if they were running a higher blood level than their normal one. I don't know if they take urine concentration and other factors into account.

My comment about half the country smoking pot has no agenda. It just seems that it is used by an awful lot of people.

 

[Mister Mxyzptlk]

How many people here prohibit alcohol use while taking opiates? How many people are naive enough to think anyone actually complies with the prohibition? Is anyone testing for alcohol in the urine?

 

[NEPain]

I was thinking along the same lines, but alcohol is legal, so we don't wory about it even though it is synergistic with most cns depressants and impairs driving ability.

I would love to sit outside a nice restaurant and do breathalyzers on everyone coming out to drive home.

 

[PMR 4 MSK]

How can you tell someone on daily opiates not to drive? I read a study (I'll try to find the reference) that looked at reflexes, etc. in patients on chronic stable doses of opiates and they were no different from non-opiate users.

There is a company that offers a blood test to document a stable blood level in patients so that if they do have an accident, you can see if they were running a higher blood level than their normal one. I don't know if they take urine concentration and other factors into account.

Pt on opioids gets into an MVA. Someone gets hurt. They sue. Discovery shows the patient is on opioids. Now they go after the doctor for 2 reasons: Much deeper pocket and media exposure.

The doctor can read that study in the courtroom, and the plaintiff's lawyer will find 12 "expert" docs to say the patient should not have been driving on opioids. Judge instructs doc to take out his checkbook and bend over.

The simple explanation is it is up to the police, not a doctor, to determine if someone was intoxicated when there is a question. If they believe the person was intoxicated, and get urine or blood tests that show there are opioids in the patient's system, he's dead in the water without a really good (i.e. expensive) lawyer.

An analogy is the one lawsuit I had - a patient died after being on OxyContin for 1.5 years, same dose for 1 year. He had an MVA with subarachnoid hemorrhage that went undetected. He died in his sleep 4 days later. Pathologist reported the blood in the brain, but also noted oxycodone in his blood and urine. Cause of death: Acute Oxycodone Overdose.

The system doesn't care about your studies. They like easy explanations, and those that get them money and/or headlines.

Due to peaks and troughs, and a great deal of individual variation, as well as potentially daily variation within an individual, it will take a long time, many thousands of patients and years of research to prove blood levels valid.

 

[Apollyon]

I was thinking along the same lines, but alcohol is legal, so we don't wory about it even though it is synergistic with most cns depressants and impairs driving ability.

I would love to sit outside a nice restaurant and do breathalyzers on everyone coming out to drive home.

Just a comment on this. Every patient for whom I Rx opiates in the ED gets the same mini-speech. "Don't drive while taking these. Even though they are prescribed, you are still liable for DUI drugs if you get stopped or are in an accident. It's legal to drink beer, but not drink beer and drive. This is the same idea."

 

[NEPain]

apollyon, I would imagine that pts in the ED are on short courses of opiates so it's less of an issue.

PMR, what you say is sadly true I guess. What do your patients say if you start them on oxycontin (or gabapentin) and tell them not to drive while taking the med? Feel free to answer privately if you want.

One of my favorite lines is Al Pacino in some movie (Justice for All?) "If you want justice, go to a whorehouse. If you want to get f@**ed, go to court"

 

[Apollyon]

apollyon, I would imagine that pts in the ED are on short courses of opiates so it's less of an issue.

PMR, what you say is sadly true I guess. What do your patients say if you start them on oxycontin (or gabapentin) and tell them not to drive while taking the med? Feel free to answer privately if you want.

One of my favorite lines is Al Pacino in some movie (Justice for All?) "If you want justice, go to a whorehouse. If you want to get f@**ed, go to court"

But you mentioned as an aside about breathalyzing people outside of restaurants. It's the same thing - whether opiates or chronic drinkers - whether they are "good at driving drunk" or not. Even if at a functional level and not intoxicated on chronic opiates, there it is.

 

[PMR 4 MSK]

apollyon, I would imagine that pts in the ED are on short courses of opiates so it's less of an issue.

PMR, what you say is sadly true I guess. What do your patients say if you start them on oxycontin (or gabapentin) and tell them not to drive while taking the med? Feel free to answer privately if you want.

One of my favorite lines is Al Pacino in some movie (Justice for All?) "If you want justice, go to a whorehouse. If you want to get f@**ed, go to court"

I do tell people not to drive while taking them. If they argue they have to be able to drive to work, I tell them I don't write the laws, and the laws state if they are found to be intoxicated while driving they are liable for any damage they cause, and I am therefore liable for writing the med. Doctors have been sued for the damage their patients caused while under the influence of the drugs they prescribed.

 

[ghost dog]

studies have shown that pts who smoke pot are 2-3 times more likely to divert or misuse their presription drugs

Interestingly, a lot of the literature on MVA / THC related crashes seem to be intentionally mis-represented by the " legalize it " / pro-marijuana crowd.

Briefly:

" Ramaekers and colleagues found that although crash culpability was not elevated for low concentrations of THC, risk of involvement in a traffic crash increased as drivers' THC levels increased, and became significantly (up to 6.6 times) greater than that for drug free drivers, at higher concentrations of THC.

A more recent study revealed that increasing instances of driving under the influence of cannabis are associated with an increased risk of motor vehicle accidents. More specifically, after adjusting for confounding variables, young adults in a New Zealand birth cohort who drove under the influence of cannabis more than 20 times across a 4 year period had a risk of collisions 1.4 times greater than did those who had never driven under the influence of cannabis.

Finally, driver culpability studies have suggested that drivers testing positive to cannabis are significantly more likely to be responsible for fatal car crashes than are drug-free drivers. "

source: http://ncpic.org.au/ncpic/publicati...-of-cannabis-a-brief-review-of-the-literature

Now, combine this with narcs - and you've got a bit of a problem.

 

[Ducttape]

most of the literature they quote is either from the 1990s or from limited studies that are comparing the drug to placebo.

i hear the "its natural" argument a lot... but then again, so is cocaine, as is the base compound for heroin...

 

[PMR 4 MSK]

most of the literature they quote is either from the 1990s or from limited studies that are comparing the drug to placebo.

i hear the "its natural" argument a lot... but then again, so is cocaine, as is the base compound for heroin...

Whenever someone tells me anything is "natural" - pot, herbs, whatever, I tell them, so is:

curare
cyanide
strychnine
botulinum toxin
ergotamine

All perfectly "natural", so they must good for you, right? Can I serve you up a dish? Would you like to smoke some?

 

[SSdoc33]

Whenever someone tells me anything is "natural" - pot, herbs, whatever, I tell them, so is:

curare
cyanide
strychnine
botulinum toxin
ergotamine

All perfectly "natural", so they must good for you, right? Can I serve you up a dish? Would you like to smoke some?

arsenic

 

[Mister Mxyzptlk]

How do you do a study on DUI with THC? The article cited was a review article so it doesn't say what blood levels were considered significant. Blood levels drop to single digits within an hour after use. A range of 3.5 - 5 ng is considered impairment in many jurisdictions. In chronic users blood levels can run at the 1-2 ng range for a week after cessation. Anyone have details?

 

[ghost dog]

How do you do a study on DUI with THC? The article cited was a review article so it doesn't say what blood levels were considered significant. Blood levels drop to single digits within an hour after use. A range of 3.5 - 5 ng is considered impairment in many jurisdictions. In chronic users blood levels can run at the 1-2 ng range for a week after cessation. Anyone have details?

Excellent point.

Whomp here it is:

" Dose related risk of motor vehicle crashes after cannabis use "

http://www.ukcia.org/research/DoseRelatedRiskOfCrashes.pdf

While some of the study numbers are small, mechanism of action and a dose / response seems apparent.

In clinical practice:

1. A patient tests positive for THC. We simply don't know if they are an episodic "recreational user" or constantly puff / puff passing.

2. Considering the synergistic effect between ETOH and THC, the same effect would seem to make sense in regards to opioids + THC. For that reason alone - a policy of no narcs for this pt makes sense.

 

[Mister Mxyzptlk]

Thanks for the paper. However, this is an experimental dose-response study. What I want to know is what BLOOD LEVEL is associated with MVAs. I also wonder how many real life instances there are of MVAs where THC was the only drug found in the blood.

For example, in the overdose literature THC O.D. seems to be extremely rare (nonexistent?), but it is commonly found along with the drugs that probably caused death. Anyone have a reference on blood THC levels in MVAs? Most likely it will under-state the problem since by the time someone is transported and the blood drawn the levels could drop significantly.

 

[Jcm800]

Whenever someone tells me anything is "natural" - pot, herbs, whatever, I tell them, so is:

curare
cyanide
strychnine
botulinum toxin
ergotamine

All perfectly "natural", so they must good for you, right? Can I serve you up a dish? Would you like to smoke some?

great answer!

 

[fozzy40]

Do you guys document some sort of disclaimer with respect to driving/operating heavy machinery when prescribing medications that could potential affect alertness? If so, does it necessarily hold up in a court of law?

 

[PMR 4 MSK]

Do you guys document some sort of disclaimer with respect to driving/operating heavy machinery when prescribing medications that could potential affect alertness? If so, does it necessarily hold up in a court of law?

This is my template:

We discussed the risks and benefits of opioids, including side effects such as sedation, confusion, dizziness, constipation, nausea, sweating and itching. The patient was informed that they may not drive while taking this medication, nor operate dangerous machinery. We discussed the risks of, and concepts of tolerance, dependency, abuse and addiction. We discussed taking this medication exactly as prescribed and not to take it in excess of how it was prescribed. The patient agreed not to allow the medication to be lost or stolen, acknowledging that I will not replace lost or stolen medication, and that should this happen, they may experience withdrawal symptoms that can be treated medically. They also agreed not to receive or attempt to receive opioid pain medication from any other physician or any other person without notifying me.

 

[Ducttape]

i talk about driving, and safe use.

also, in the treatment agreement that all patients sign and recieve a copy, i have this bullet point:

• Do not use alcohol while on these medications. Please refrain from driving while on these medications.

i thought about making it even tougher, like telling them "absolutely no driving while on these medications", but then those people who do work while taking these meds (i think i have her chart around here somewhere) wouldnt be able to get to work....

 

[Tenesma]

chronic narcotic use alone doesn't impair the driving - if you believe the danish studies...

however, problem is people mix ETOH and Benzos and then drive - and when there is an injury/lawyer involved they go after who ever has the biggest pocket - ie: doc who prescribed the pain meds...

it really doesn't matter what you write in the note... what does matter is if you take them off the narcs/benzos, you will be saving their life and your sanity...

 

[PMR 4 MSK]

Chronic pain pt on opioids long-term. No sedation, functions well. On way home from work swerves to miss a deer, wraps his car around a tree. Post-mortum shows "High levels" of opioid in his system and ME lists CoD as "Acute high-velocity blunt force trauma secondary to acute opioid intoxication."

Widow sues you.