I’m interested in how folks are handling UDTs in conjunction with low-dose PRN opiates. I mostly abstain from prescribing but do have a small population of patients on COT. I feel like I’m well within guidelines, and of this small population receiving opioids, the majority are prescribed on a PRN basis and are maintained under 40MME. Saw a patient earlier this morning on hydro/APAP 5/325. Patient is receiving #45 every 2 months PRN for severe OA. Long time patient with no red-flags. His last two UDTs (LC/MS) came back negative for hydro. Due diligence is being performed and I have no reason to suspect aberrancy. Obviously, given the dosage and frequency, this is not entirely unexpected. None-the-less, I can’t help but feel that this looks somewhat suspect. I’m doing my best to ascertain time of last dose, but this still leaves a bit of a gray area due to metabolic differences etc. I’m interested in how others are handling low-dose PRN opioid patients and UDTs. Am I being overly paranoid?
It all depends on the context. The lower you go on dose, and frequency and duration of action, the more likely you are to have appropriate, but negative UDSs. Prior to sending the UDS, if they tell you, "I had a good past few days and my last hydro 5 was 36 hrs ago," then that's right on the edge of the detection window (depending on the lab you're using), and either a positive or negative would be appropriate. Or, the low dose prn patient who missed his last appointment due to the hurricane, couldn't come to the appointment, is a week past his 30 day refill, ran out of meds for a week and told you so. That's an example of someone not getting extra rx's to divert. It's someone out of medications with no meds to divert. Both UDS's are negative. But there's a big difference and the chart must make that clear.
Make sure you document that. If, on the other hand he tells you, "I took it 4 hours ago" and he tests negative, then something isn't right.
In that case, you probably do need to do a random pill count, require them to come in by days end for a pill count and repeat UDS, or you discontinue opiates. If they say they're out of town or give some other excuse, tell them to go to their nearest pharmacy with their pills, have the pharmacist count them and call you. No excuses. More than a few hours, gives them a chance to rent or borrow pills and renders your surprise pill count worthless. I also agree you need to do a pill ID with each pill count, because they can easily bring in dummy pills (tylenol, random white pill, etc) and unless you check what it is, you can be easily fooled. The epocrates app, has an easy way to do this. When I'm to the point of requiring a random pill count, I'm already 99% likely to discontinue prescribing and it's the patient's job to do everything perfectly to win my trust back. Anything that's off, or any excuses offered, equals discontinuation of opiates. It's right in their signed prescribing agreement that they agree to pills counts and discontinued prescribing if they're unable to comply.
It's all about context and what you document. If it's reasonable and appropriate, and you've documented why, you're likely fine. If not, then you're not. The worst thing you can do, is document an inconsistent UDS (unexplained negative, illicit, etc), ignore it, and keep prescribing.
If you're uncomfortable, use all your tools to tighten the leash until they either make you comfortable that all is kosher, or until they make it clear it's time to stop prescribing. One of the two will happen. The worst thing is to sit there unsure, uncomfortable, and to continue prescribing in a state of uncertainty. You must tighten the monitoring until taking one of the two forks in the road (prescribe or stop) is obvious and justified. Then you then take that path, and document in detail why what you're doing is 100% reasonable, and beyond question by a reasonable person. Once you stop, you never, ever, ever, restart in that patient.
When in doubt, stop prescribing. Opiates are not oxygen.
