Guideline And Monitoring Prescribed Narcotics

[jO2006]

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Hello,

I know you must be a physician to post here, but I'm begging you to please leave this, so as to possibly find help. I have searched endlessly online and still cannot find the answer and I truly need the help by people who are in the field. Please, try and understand my situation....please.

My husband and I live in long island, ny. He has been in treatment with a pain management specialist for about 4 years because of his back. And is on prescribed narcotics.

I searched online and found alot of guidelines and other articles that suggest to monitor patient to prevent addiction and toxicity. They state things like 'monitoring is crucial to prevent the risk to kidneys and liver posed by long-term therapy' and 'opioids 4 treatment of chronic pain periodically assess functional status, opioids effects, and medication misuse' or 'as noted in the supreme court (gonzales v. Oregon) ensures patients use controlled substances under the supervision of a doctor so as to prevent addiction and recreational abuse'

but...

The guidelines and/or articles, don't discuss 'how' the physician should monitor, example: by performing xyz steps to patient, like check his blood pressure, take his pulse. How can you monitor for addiction?

The question: what are some required steps or guidelines, a physician could perform to monitor their patient for adversely affected signs of addiction? Also, is a physician required to routinely monitor medication levels, either by blood, urine, pill counts? Or run a diagnostic test and drug screening, if prescribing a controlled substance?

I hope I don't sound a little rude or nasty, its just becoming extremely frustrating not being able to find the answer. Its almost like this is a big secret.

I apologies for taking up any of your time and tried to find the correct words to express my concern, with the fewest words possible. I will be extremely grateful for any help.



Thank you so much,

lisa s

 

[NotAProgDirector]

Although I agree that this may not be the best place to discuss this topic, it's a good chance to review the basics of chronic narcotic therapy management, which is a difficult topic.

Using chronic narcotics to manage pain is a controversial issue. Some physicians simply refuse to do so in all cases. Some seem to indiscriminately write prescriptions, mostly to avoid the difficult discussions that need to occur around this topic. The best solution probably lies somewhere between these two extremes.

As far as physical safety is concerned, narcotics are actually very safe medications. The only serious side effects are respiratory depression, seen usually only with overdose. Constipation is very common. Confusion, sedation, falls, etc are also possible. There is no real risk of liver, kidney, heart, blood pressure, GI, or other major organ involvement (exception: combination narcs + tylenol/NSAIDS where organ toxicity is related to the other drug agent)

The major problem is addiction. There is no test for addiction -- it is virtually impossible to tell prior to prescribing chronic narcotics who will become addicted. I have managed patients with a history of alcoholism and other addictive behaviors successfully on narcotics, and I have seen otherwise healthy, well adjusted, stable patients spiral into addiction (luckily, so far, my experience is limited to helping patients in the recovery phase).

There is a major difference between addiction and tolerance. Tolerance is the fact that patients tend to require increasing doses over time, due to their bodies adjusting to the medication. Tolerance to the pain relieving effects of narcotics tends to be a limited phenomenon and has a ceiling -- a 20% increase in dose, and then it tends to stop. Of course, the underlying pain syndrome can worsen, which can also require increases in dose.

Addiction is a social and psychological situation where patients seek the euphoria or "high" that narcotics can deliver. Whereas the pain relieving properties of narcotics have low tolerance, tolerance to the euphoric effects of narcotics is very rapid and does not have a ceiling. This leads to rapid escalation of the dose, and when further narcotics are not prescribed, anti-social behavior such as lying, stealing, buying illegal drugs, etc. Patients who are addicted focus much of their efforts on obtaining further doses, escalate to intravenous narcotics (which have more euphoria), and can progress to heroin or other completely illegal drugs. Their lives crumble around them, as they exploit all of their financial and social resources.

So, what to do? There is no one, correct answer. Here's what I do:

1. Teach patients that pain control is a dynamic issue. It is unlikely that I am going to cure chronic pain, instead the goal is to have the patient live with the pain, and to help control it as much as possible. It is an imperfect science, and I will do the best that I can. I tell them that I consider a 50% decrease in their pain a "success".

2. Chronic pain, especially chronic neuropathic pain, does not respond well to narcotics. Part of any chronic pain management strategy is using antidepressants and/or anti-seizure meds (for neuropathic pain) to help with pain control, or other non-pharmacological therapies.

3. Maintaining the patient's functional capacity is vital. Keeping the patient at work, or finding a new line of work, is key to success. Chronic disability tends to exacerbate pain, by leaving the patient without anything to do for long periods of time, chronic inactivity and poor exercise habits, and creates a sense of failure and worthlessness.

4. Use long acting narcotics whenever possible. I avoid oxycontin due to the abuse issues. Methadone has the lowest street value (last I checked, hard to look up on www.drugstore.com) and is often the drug I use, but MS Contin and fentanyl patches can be used also.

5. All patients, no matter how young/old/diagnosis, must sign a narcotic contract with me. No exceptions. This contract states that:

1. I am the only PCP they are to see, or someone in my office if I am not available.
2. All narcotics are prescribed by myself or my peers. The patient is not allowed to accept narcotics from an ED, dentist, veterinarian, their cousin, or anyone else without my approval. In an absolute emergency, the patient can receive meds in an ED and call my office in the AM to report in.
3. Narcotics are prescribed 1, 2, or 4 weeks at at time depending on my history with the patient. All prescriptions are exactly 7, 14, or 28 days long, and all refills are scheduled on Wednesdays (there are almost no wednesday holidays). Patients need to call on Monday requesting a refill, which will be ready on Wednesday.
4. Lost prescriptions are not replaced. Never. Keeping your prescription safe is the responsibility of the patient.
5. After hour calls for refills are never honored.
6. Using pills too quickly without reporting in / follow up visit will not result in an early refill.
7. All prescriptions are to be filled in one pharmacy.
8. The patient consents to random drug testing at any time. Refusal to test will result in immediate discontinuation of narcotics, as will any illegal or unexpected substance in the test.
9. Coming to regularly scheduled visits, attending consultations, and attending non-MD referrals (PT, OT, work retraining, etc) are part of the treatment plan. Non compliance with these aspects will result in termination of narcotics.
10. It is the responsibilty of the patient to follow these rules. No excuses are accepted, and any violation will result in termination of narcotics.

Once in place, the contract makes dealing with problems easier. I am very tough -- once a patient has been stable with me for about 6 months, I'll tolerate a small violation. Any major violation, any positive urine drug screen, any early violation, etc, leads to immediate termination of all narcotics. I continue to provide other care, but will no longer prescribe narcotics. I usually extend this to my entire group -- if I violate them on a contract, no one in my practice will prescribe narcotics, and they have to find a new doc.

On that subject, anyone coming to my practice from another on chronic narcotics requires a doc-to-doc phone call. It's the patient's responsibility to have their prior doc call me, not the other way around.

To the OP -- I can't give medical advice over the web, but if this does not answer your question, please feel free to PM me.

 

[jO2006]

Hello,

Thank you, thank you, thank you! Finally, someone is willing to standup and not shy away from my question. It clearly shows in your response that you are extremely professional. I truly cannot express enough how much I appreciate, your honesty, efforts and time.

Physicians who prescribe narcotics are in the spot light and its horrible how things have become. I've read very sad stories of how some doctors have stopped prescribing to their patients, who have 'real' pain because of government or police concern. If some of these physicians handled their practice the way you do, they would have nothing to worry about.

I understand there is no test for addiction. But from what I have read in all the guidelines, is that there are certain signs or etc that might hint to the beginning of addiction. I believe they call them 'red flags'. If a physician was to do blood work, I think they could see if the narcotics levels are either too high or too low. If it was low, it might suggest the patient is selling them or if too high, might suggest patient is taking alot more then prescribed, yes?

Some of the things I'm saying, I only know from reading these guidelines. I'm not trying to come off like I know best. That is why I'm here asking for help.

One of the parts I'm having trouble understanding is what physicians are 'REQUIRED' to do. Because some people have said doctors don't have to monitor their patient, its the physicians own decision. But I cant see how this is possible. Meaning, if the pain management specialist prescribes a controlled substance to their patient and this goes on for (blank) months, and then the patient dies from liver damage. The physician is not concerned with the law or medical board, because he is not required to monitor. I know my example sounds very dumb, but I'm trying to make sense of how this works.

I hope you don't feel my response is rude. I'm finding it hard to express my question and feeling. You are the only person who truthfully answered me and I don't want to ruin this. I'm truly very, very thankful for your time.


Sincerely,

Lisa S

 

[Mumpu]

1) You cannot easily check blood levels of narcotics.
2) Addiction essentially means the patient has withdrawal symptoms if the drug is rapidly stopped.
3) Any normal healthy person will become addicted to narcotic pain medications given enough time (e.g. daily narcotics for several weeks will usually do it). This is not addiction in the junkie sense (more correctly, junkies are drug abusers -- that is, their addiction causes them to engage in behaviors that are detrimental to their personal safety, job, family, etc.). Rather, a person addicted to pain medications will have withdrawal (what that constitutes depends on the medication in question).
4) I believe you are confusing addiction and abuse.

 

[jO2006]

Hello,

Thank you Mumpu for taking the time out and trying to help out. To answer your last question, I am not confusing it at all. My husband and I clearly understand the difference between all the problem that might occur from taking narcotics. Actually, some of the things you were trying to express are not correct...or to better explain, I mean the labels you are using are incorrect.

I don't want to get into the whole list and etc...but for the most part. If you stop the meds quick, more then likely as for labels...the withdrawals will be from dependence. Addiction means, when you have no control of taking it...you finish the meds before due, as well you try to buy more on the street, as well, you sell your personal items, you loose your job, you only want and need the meds.

Simply going thru withdrawals does not mean your are addicted...at least that is how all the guidelines and articles I have read, explain it. From the stuff I read they also mention if you take blood work or lab work (I'm not a doctor) they can tell from the results if there is too much or too little of the type narcotic in your system. With this info, they then can try to figure if you are selling it or taking more then allowed.

Also, my main question has nothing to do with addiction. If I truly know what it is or not does not matter...my question was about the physician required to monitor their patient when prescribing controlled substances. If they don't have to monitor their patient, and they become addicted or even die....does this mean the physician is not responsible by the medical field or even law?


Thanks for helping out, please if anyone comes across info and where I can find the legal side to prescribing in New York and or if you know the answer please PM me or post it here...its important.


Lisa

 

[gutonc]

Simply going thru withdrawals does not mean your are addicted...at least that is how all the guidelines and articles I have read, explain it. From the stuff I read they also mention if you take blood work or lab work (I'm not a doctor) they can tell from the results if there is too much or too little of the type narcotic in your system. With this info, they then can try to figure if you are selling it or taking more then allowed.

Also, my main question has nothing to do with addiction. If I truly know what it is or not does not matter...my question was about the physician required to monitor their patient when prescribing controlled substances. If they don't have to monitor their patient, and they become addicted or even die....does this mean the physician is not responsible by the medical field or even law?

Lisa

The urine drug screen (UDS) is a qualitative test. It can only tell you if the person is taking the prescribed controlled substance. A quantitative test is meaningless as the "right" amount of a narcotic analgesic is whatever amount relieves the pain while still allowing someone to remain reasonably functional. For Person A that might be 10mg oxycodone daily while Person B might need 300mg of long-acting and short-acting morphine every day. Both of these people will have a +ve opioid UDS. The reason for monitoring is to ensure that you're not selling it all on the street. The way to determine whether someone is taking more than prescribed is if they call 15 days after their last (30-day) Rx saying they ran out and need a refill.

Physicans are responsible for laying out the risks and benefits of treatment w/ narcotic analgesics and for telling patients how to recognize the warning signs of potential overdose. That said, all patients need to be responsible for their own treatment as much as the physician. I can teach you how to take your meds and what will happen if you don't take them or take too many, but if you don't do what I told you, I can't be responsible for what does or doesn't happen. Lots of people die from OD's of prescribed meds, many of which aren't narcotics and OTC meds as well and physicans and pharmacists aren't generally held responsible (barring gross malpractice such as telling someone that 1g morphine is a perfectly reasonable starting dose to control back pain).

As far as rules for monitoring, the pain clinic I rotated through in NYC required monthly UDS for new patients for the first 6 months and then every 3-6 months after that. I don't know if this was a state, city, HHC (it was a public hospital) or institutional requirement. In my clinic now, anyone prescribed a restricted narcotic gets a UDS at baseline and at 3 and 6 months after starting it. After that it's up to the physician to determine how often to monitor (at least in my setting).

I think the most concerning thing here is that you don't trust either the physician who is prescribing the meds or your husband who is taking them. In either case, you will likely need more help than anyone on this board can offer you.

 

[jO2006]

Hello,

Again, I hope everyone who posts, does not get stick or annoyed with me thanking every time...I just don't want people to think I'm not a caring person, because it does mean alot to me that you are taking time out.

brooklyneric...I appreciate your advice. Going out of order to your post, your last mentioning of concern, is a bit off. I could understand why you might feel this way, and that's mainly because you don't have the full story. As for my husband...I have stated before, it has nothing to do with him. I trust him completely and he has been honest with me fully. I know he is not doing things behind my back. What sparked my interest to learning all about this, has to do ONLY with his physician. It has been stated here by other members, that there are some great caring doctors and some who just do their job...after going to about a year or so visits with my husband to see the PM doctor and noticing how the doctor treated my husband, it got me to start asking questions. I know for a fact how all visits go, because I go into the exam room also...every visits goes like this...'how are you' and 'whats new'...that's it. The dr doesn't take blood pressure, pulse, or weight. The dr. has not ordered lab work for about 9 months if not longer, he also has increased his meds on every visit....and its based on the same answer from my husband..."still have a bit of pain".

So, after going on all these visits...I started to wonder if this is normal practice. I had a feeling it could not be and this lead to my searching. I didn't want to go thru the whole switching of physicians unless I knew this one was not doing all that should be done. Now that we both know he is failing, we are making plans to find a new PM physician. And that's the only and whole reason for this.

I know some might think its alot of research just to find a reason to leave, but understand that this PM,was the one who was with my husband from before his operation, and after the operations...the dr knew my husband, so it made things easy...but again, now that we can see there are certain things not done...we think its time to leave....hope this clears it up.


Also, if anyone comes across the info I'm looking for...please either post it here or send private message. Thanks so much for all the advice and help.


Lisa

 

[jO2006]

Hello,

I have been still search online for the answers, and have found out as for monitoring goes, the physician is NOT REQUIRED to monitor their patient when prescribing narcotics. I have not been able to find out if this is true or not.

Also, I have re-vised some of the questions and came up with two:

1. Is there a minimum standard of care for pain management specialists? And how can I find it?

2. Is it a 'standard of care' to check blood pressure, pulse and weight for a pain management specialist?

Please if you might know, post it here. Or if you have any ideas on where I might be able to find the answer. Thank you again for helping me out, I do appreciate it.

Lisa Silko

 

[DrMom]

please do not use SDN for medical advice.