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A policy to detect opioid abuse
Dr Meddings's clinic's
policy was based on these steps:
- Create a registry of patients
receiving opioids for non-cancer pain
- Mandatory urine drug screening
— for new patients, before new script given;
for existing patients, at next appointment;
thereafter random annual testing
- Request medical records from
last prescriber
- If available, check online
prescription registry for past opioid prescriptions
- Patient-physician agreement
outlining clinic policy, including consequences
of violations
Source: Poster "Chronic
opioids in resident clinic" presented at Society
of General Internal Medicine meeting April 8
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As a doctor, building trust with
your patients is the key to a good relationship. But
what happens when you find out a patient's been lying
to you — to get narcotics?
Internist Dr Jennifer Meddings
recently found out the hard way. When she and some colleagues
decided to implement a new policy to detect drug abuse
in patients receiving narcotic painkiller prescriptions
at their primary care clinic in Columbus, Ohio, she
soon found out just how many of her patients had been
lying to her all along.
Fully 35% of patients violated
the clinic's new policy (see the next page for a rundown).
Violations included illicit drugs such as cocaine and
heroin in their urine; not taking meds as prescribed;
taking another prescription narcotic without informing
their doctor; and having no trace of the drug prescribed
in the urine at all — a sign they were probably
selling it.
"I was surprised," admits Dr Meddings.
"We were all especially surprised they were using illegal
substances." She presented her findings April 8 at the
Society of General Internal Medicine meeting in Pittsburgh.
CRIMINAL
MINDS
Dr Meddings says her primary care clinic's troubles
began when a nearby pain clinic closed its doors. "Suddenly
we had lot of patients who needed pain meds," she says.
"We also had patients driving hundreds of miles and
from out-of-state. If we refused their insurance, they'd
pay cash. That really raised a red flag." They got even
more worried when local police told them pill bottles
prescribed by their clinic were being found at crime
scenes.
When they started requesting records
from past prescribers (which she says doctors don't
do enough) under the new policy, things really started
to fall into place. "We found often there were problems
— they'd been doctor shopping or dismissed from
the clinic."
Dr Meddings says the reasons so
many patients lied about their drug use are manifold.
"One of the main reasons is it's very lucrative. Oxycodone
and hydromorphone go for a dollar per milligram," she
says.
Another big problem is the lack
of training given to docs for non-cancer chronic pain.
"There are too many patients on 100% short-acting meds
like oxycodone. They last only a few hours so they're
not appropriate for chronic 24-hour pain. The patient
develops a tolerance and needs higher and higher doses."
Dr Meddings says long-acting drugs like slow-release
morphine sulphate or methadone may be more appropriate
for these patients.
TOO
FAR?
Dr Rob MacNeill, an anesthetist at Cape Breton Regional
Hospital in Sydney who was part of the Nova Scotia government's
2006 Chronic Pain Working Group, isn't convinced a punitive
approach is the best one. "The majority of patients
have the best of intentions. You do this and they'll
feel like some kind of druggie." He thinks Dr Meddings'
35% violation rate wouldn't turn up in his clinic.
Policies like Dr Meddings' could
end up backfiring if you lose the patients' trust, he
says. "This seems easy when you first look at it, but
detox only works if you have buy-in from the patient."
Dr Meddings insists that normalizing
the policy — making it something that applied to
everyone — took away that stigma. She says confronting
patients who violate the policy, while not pleasant,
can be a useful starting point for a heart to heart
about addiction. Some patients react well, others not
so well. "Many patients were embarrassed and it became
a starter for a discussion to get help. Others get angry
or bring up a lot of excuses. All you can do is discuss
it with them."
ABUSE'S
TOLL
Meanwhile, the increased pressure on doctors on the
front lines is taking its toll. "We still have a drug
problem in Cape Breton — I'd be lying if I said
there wasn't," says Dr MacNeill. "Doctors changed their
prescribing habits — a lot of good doctors who'd
had no problems are now more circumspect. Physicians
are afraid and end up undermedicating. Then on the other
side, they're seen as being too liberal with the prescription
pad."
Dr Meddings says easing physicians'
frustrations, like the ones Dr MacNeill has seen, has
been one of the biggest successes of her policy. "People
are happier and feel more empowered," she says, adding
she's in the process of setting up a similar program
at her new clinic in Michigan.
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