How do you confront patients after receiving confidential tips about their misuse of medication?

[SpongeBob DoctorPants]

---

Members do not see this ad.

I have an adult patient who was taking Adderall, Klonopin, Suboxone, and Zyprexa when she first came to see me. (Awesome, right?) Each of the controlled meds were verified in the state database. There is a history of narcotic and benzo dependence. Initially I was only prescribing the Zyprexa, because she was being tapered off the controlled meds by another physician.

At the second visit she informed me that her other physician wanted a psychiatrist to manage her Adderall. Of course, we have had a number of discussions about the particular combination of medications she is on, especially with her history of misusing prescriptions. But her husband reassured me she was doing well, and needed the Adderall in order to function at work; without it she would be completely disorganized and unable to focus. We continued along with her current meds, and things have remained pretty stable.

Fast forward to today: I received a message from the patient's mother, informing me that the patient has been misusing her Adderall, selling it and sharing it; she doesn't have solid proof, but has seen text messages related to this. Also, the mother wants this to remain confidential and doesn't want the patient to know that she called.

I was never really very comfortable with continuing her Adderall in the first place, but in light of this new information, I'm ready to pull the plug on it. But how do I go about having this conversation with the patient? Her mother has shared valuable and important information but doesn't want her to know I have this information. I doubt the patient would confess to misusing it if I asked her, and I don't know if I can simply state that I have reason to believe she is in violation of our treatment agreement. Any suggestions?



TL/DR: Informant believes patient is sharing/selling Adderall but doesn't want patient to know we talked. What would you do?

 

[littlefred]

Urine drug testing for starters, non-compliance with random testing and random pill counts are grounds for discontinuing the med.

 

[birchswing]

If I were a doctor, I would work without this information because it really isn't information.

The assumption is that this person is the mother, and the assumption is also that this person has altruistic intent. It could be someone causing a problem.

That's probably less likely than the alternative. But if you act on the information you would be making a treatment choice based on something that could be untrue.

Think of how many patients you see who don't have informants giving you an alternate angle on what you see the patient presenting with. If you don't act on the information, you haven't worsened the pre-existing ambiguity in treating a patient without being to know completely how they behave outside of a session. If not for this call you wouldn't have had that extra color, which is true for any of your patients. So if you act on it, you might be acting on a more complete picture but not necessarily a more accurate one.

 

[TexasPhysician]

The information itself is worthless in my opinion. Based on the information provided, what percentage of your future income would you wager on this patient selling her Adderall?

Is the patient requesting early refills?
Is the patient getting other controlled meds from other docs?
How is concentration during appointments relative to baseline off meds?
What does the drug screen say?

 

[calvnandhobbs68]

I agree with the above.

The suburban college student/mom with a simple Adderall/Klonopin prescription can be selling it just as easily as the multi-drug abuser who comes in on the regimen you have above. I would weight anonymous tips from random people on each of them the same...I don't actually think the background of the person should even be a consideration in this case since you're worried about diversion, not the patient snorting the adderall or something. Random drug tests to make sure amphetamines show up in the urine is a good idea but of course you should let the patient know you're going to start performing random drug tests from now on before you suddenly hand them a cup or else your trust is shot.

If the tests come back positive for amphetamines, she's obviously taking it often enough to come back positive...so unless you have real hard proof she's selling a few pills here and there, there's not much more to be done. Somebody who's significantly diverting should have the more serious signs noted above (consistent early refills, attempting to get controlled drugs from multiple people, trying to get "refills" from the ED, etc).

 

[Mad Jack]

"Hey what's up you lying sack of gsrbage?"

Really though, this is very dependent upon your personal relationship with a patient. I have patients that I could call out and they'd just be like, "awww you got me, I've been doing all the drugs" and ones that would require a very careful approach and documentation. It's so personal and individualized

 

[Bartelby]

Having received the information in a message puts you in a slightly tougher spot. When I speak with collateral sources I let them know that I will share what they tell me with the patient (including the source). They can then choose whether or not they speak with me.

In this case I agree with the above posters, look at the whole picture and realize that confidential tip may not carry much weight if it does not fit the rest of the picture.

 

[Old&InTheWay]

How do you know the person who called is actually the patient’s mother?

 

[FlowRate]

Having received the information in a message puts you in a slightly tougher spot. When I speak with collateral sources I let them know that I will share what they tell me with the patient (including the source). They can then choose whether or not they speak with me.

In this case I agree with the above posters, look at the whole picture and realize that confidential tip may not carry much weight if it does not fit the rest of the picture.

I'll take this a step further and say that the patient has to be told that you received this information, unless there's a really compelling reason not to. Compelling reasons do not include it being awkward and the patient's relationship with their parent is already screwed up so that doesn't fly, either.

 

[Sushirolls]

The treatment agreement with buprenorphine should have already had a clause about random UDS. Start doing random UDS, and even send off for quant levels of the amphetamines.

I won't permit controlled substances with buprenorphine. No benzos, no stimulants. But since you are already here, amend the treatment agreement that pill counts for the other controlled substances are possible, too. Invoke the clause and do pill counts.

Can also reduce the adderall refills to #7, with 4 refills. Puts a kink in some folks diversion behaviors.

Haven't done this one yet: But some pharmacies do have the ability to bubble wrap their pills for daily use. Send the Rx there, and little easier to see person is on daily compliance and not opening the bubble packs in advance. I bring this up because there are 'loan' services where pts will beat the random pill counts by loaning from some one else, and then giving them back after their pill count.

 

[Trismegistus4]

Here's a related question: do we have an obligation to "do something" when we discover a patient is getting inappropriate prescriptions from other doctors who may not know? Today I reviewed the PDMP on one of my patients, and noted that she is getting clonazepam from both a pain management practice and a neurology practice. I am not prescribing this woman any controlled substances (in fact, I took her off the Xanax she was on when she came to me.) Do you think I have an obligation to notify either of these two docs, who apparently are not checking the PDMP? If so, how would you phrase the letter or note, such that it doesn't come across as "hey, check the damn PDMP, you *****?"

 

[Sushirolls]

Good question. I'd nix it out here and start a new thread.

 

[shahseh22]

Here's a related question: do we have an obligation to "do something" when we discover a patient is getting inappropriate prescriptions from other doctors who may not know? Today I reviewed the PDMP on one of my patients, and noted that she is getting clonazepam from both a pain management practice and a neurology practice. I am not prescribing this woman any controlled substances (in fact, I took her off the Xanax she was on when she came to me.) Do you think I have an obligation to notify either of these two docs, who apparently are not checking the PDMP? If so, how would you phrase the letter or note, such that it doesn't come across as "hey, check the damn PDMP, you *****?"

If you aren't prescribing the substances, are you obligated to check the PDMP? I was under the impression you only check it if you are prescribing something controlled.

 

[WisNeuro]

If you aren't prescribing the substances, are you obligated to check the PDMP? I was under the impression you only check it if you are prescribing something controlled.

Depends on the reason they are coming to see you. Many of my referring docs will run it before sending a patient to me for neuropsych evals. Good to know if they are on multiple CNS affecting medications even if you aren't prescribing them, if you are trying to find out a cause for their reported cognitive complaints.

 

[Trismegistus4]

If you aren't prescribing the substances, are you obligated to check the PDMP? I was under the impression you only check it if you are prescribing something controlled.

I wasn't saying I was obligated to check the PDMP. I don't remember exactly why I did so in this patient's case; it may have been because there was a line in my plan that I'd been copying forward, reading "hold Ambien since she is sleeping with Doxepin," I noticed that I had not prescribed Ambien for her in a long time, and I got curious about when the last time was that she actually filled a prescription for it.