Would you give this guy opioids?

[PMR 4 MSK]

Depends:
If they have illicit drugs in UDS other than marijuana, no more opiates.
If they have marijuana in UDS, then 1 warning

I disagree, they've already been told it in writing and verbally at the initial prescription. When I used to give warnings, 75% were still + for MJ at a later UDS.[/quote]

If they have unprescribed opiates in UDS, then no more opiates.

What do you say when they tell you it was from as "old" Rx they still have? I used to get that all the time.

If they have none of the prescribed opiates in UDS, one chance to explain and if reasonable, will retest later.

"I don't know why, I swear I took it yesterday..."

If patient states UDS test is incorrect, we have the lab run a GC/MS for confirmation.
If there is a report (anonymous) that the patient is selling drugs, pill count within 24 hours of the call unless they are to be seen the next day, then pill count one week later. .

Agree, but so many patients don't have working #'s, no voice mail/answering machine, or "didn't check my messages."

If our state INSPECT report shows chronic (more than one month) double dipping without disclosing this or without our assent, no more opiates.

Near zero-tolerence for this one for me - I've never gotten a good enough excuse.

If patient is absolutely known to us to be selling drugs or alters a prescription or steals prescriptions, discharge at once and report to both DEA and local police in addition to their PCP.
If patient runs out early of meds, we will prescribe tizanidine for withdrawal until their next script time is due, and for 6 months revert to monthly or biweekly scripts. Repeatedly running out early requires reassessment of the patient and at times withdrawal from all opiates if the patient does not have control over their use of the drugs.

Our policy of no more opiates is not discharging the patient from our practice (since we would be required to give an additional 30 day supply to abuse or sell). We don't discharge- we simply change their therapy. We are happy to prescribe all the PT, psych, injections, acupuncture, yoga, non-controlled substances the patient needs but will never again prescribe opiates.

Agree with the rest.

My Law of Opioid Management - "For every violation of the opioid agreement, there is an equal and opposite excuse."

This just shows, everyone's tolerence for game-playing vs compassion is at a different spot on the continuum. I became jaded. I've always been cynical.

---

Members don't see this ad.

 

[Aether2000]

Marijuana is a thorny issue since several states have legalized it, contrary to the federal government. The US Supreme Court has not weighed in in a definitive fashion on this matter....I wish they would. They have danced around the issue and the narrowly focused decisions regarding marijuana are not broad enough to countermand the state initiatives toward legalization.
I agree that many patients will continue to smoke marijuana after the first warning, and therefore find themselves without prescription opiates after the second UDS.
Available telephone contact is a condition of treatment in our clinic. If patients give us bad or non-working telephone numbers (we query them each visit), then they are no longer candidates for prescription opiate treatment, and in many cases, any treatment since they no-show for their scheduled appointments.
Old prescription opiates being taken are treated as unauthorized prescription drugs and patients therefore receive no more opiates from us, regardless of the source of the old drug.
The lack of a prn drug in the UDS means the drug was not detected due to insensitivity of the screen, the levels are too low to trigger the screen as positive, the patient has not taken the drug for more than 2-3 days, the patient may have run out early, the patient may not need the prescribed amount since they are not taking it regularly, or the patient may be selling. Part of the issue is resolved by writing "maximum _ per day". In that way, if they take more, they are abusing the drug. We have instructed our testing lab to automatically perform GC/MS for all patients to which we prescribe opiates. That way there are never any false negatives.
If the opiate was not a prn drug but was scheduled and the patient does not have the drug in their urine, and lost the drug but did not call us due to our policy of no early refills, then perhaps that is a valid excuse, but it does put up a red flag for future prescribing.
No system is perfect, and the placement of the boundaries is difficult. Ours have not always been so rigid, but over the past 3 years we have found the rigidity will eliminate the vast majority of substance abusers and diverters within a matter of a few months or earlier. We also have some legitimate pain patients that had unfortunate catastrophies whose consequences eliminated them from our prescribing of opiates. It is sometimes a difficult balance to strike.

 

[Tenesma]

this is a soft point - but one i'd like to point out...

so many on this board rant and rave about how important it is to offer opioids to treat XYZ conditions - and yet, it seems we are also very quick to withdraw the medication based on underlying mis-behaviors...

while those mis-behaviors may have criminal components (ie: diversion, selling) a lot of the mis-behaviors are due to underlying personality disorders, anxiety, bipolar, "chemical" coping, etc...

so it appears that once a patient demonstrates these misbehaviors, that many of you will discontinue opioids but still continue with other therapies (ie: PT, acupuncture, chiropractic, non-narcotic meds and/or injections)...

so the argument could be made that opioids are really non-critical tools for pain management since we can so easily remove them from a chronic pain patients armamentarium...

which supports my point that opioids are really poorly indicated for chronic pain (and also supports PMR MSK's, et al) if we can so easily take them away...

 

[Aether2000]

For a contrarian view, read this months edition of Pain Medicine in which a doctor nurse strongly advocates not dropping patients, but instead physicians becoming ersatz addiction specialists and using a kinder, gentler approach. I cannot disagree more with this type of pandering to drug abusers, but the ultra soft touch liberal rules-be-damned group of those that will prescribe to virtually anyone is out there...