Patients rightfully believe that the medications prescribed for them are safe and appropriate, and most follow their doctor’s directions to take medications safely. Sometimes, however, patients abuse medications or become addicted to them, or engage in drug diversion and illegal activities involving prescription drugs. Physicians can take steps to help prevent abuse of the opioids they prescribe, while improving safety for their patients and reducing their own medical-legal risk.
Patients may abuse or become addicted to several different types of medications. While very important for the relief of pain, opioids are often scrutinized for their risks and potential for abuse. A common sense approach may help to manage these risks, and this generally includes careful patient evaluation, a clear treatment plan, informed consent, periodic review (monitoring), consultation with other physicians or providers when necessary, careful documentation, and compliance with applicable laws and regulations.1
Physicians who prescribe opioids can consult the Canadian Guideline for Safe and Effective Use of Opioids,2 which offers guidance for prescribing opioids to treat patients with chronic, non-cancer pain. The guideline recommends approaches for initiating and monitoring opioid therapy, managing opioid misuse and addictions, precautions to reduce prescription fraud, and how to work collaboratively with pharmacists.
Some medical regulatory authorities (Colleges) have guidelines on the use of opioids for management of non-cancer pain, with which physicians should be familiar. The College of Physicians and Surgeons of Newfoundland and Labrador, for example, also provides other resources for doctors, such as patient agreement letters and narcotic flow sheets.3
Physicians should be familiar with and follow College standards and guidelines related to prescribing in general.
Talking to patients about pain medication
When initially prescribing opioids, or restarting a prescription after a long absence, physicians should talk to patients about such things as the reason for the medication; the drug’s benefits, risks, and interactions; the symptoms and signs that might indicate an adverse reaction; and any ongoing monitoring that may be required. Physicians may also consider whether creating an opioid treatment contract with specific patients would be appropriate.
It is important to understand the underlying motivation of a patient who is seeking pain medication. A physician may, for example, assume a patient has addictive tendencies when in fact the patient may misunderstand the normal course of recovery, be unaware of treatment alternatives, or have failed to adhere to a treatment program such as physical therapy.4 The actual discussion with the patient regarding drug use can be difficult.
The following strategies may be helpful in discussing medication use — including opioids — with a patient:5
- Be empathetic and acknowledge the patient’s suffering.
- Maintain a respectful relationship with the patient and avoid being paternalistic.
- Be firm and confident in the presentation of information and encourage honest responses by using simple, open-ended questions.
- Clearly communicate any opioid use and refill policies.
- Discuss your intentions to contact the patient’s other physicians or healthcare providers to advance the patient’s care, and obtain the patient’s permission to do so.
- Maintain privacy and strict confidentiality to make patients comfortable and open to sharing their concerns.
- Document all discussion and treatment decisions, and verify that the patient understands and accepts any agreement letters or contracts.
Identifying drug-seeking behaviour
All physicians, and pain management specialists in particular, face significant challenges when assessing and treating patients experiencing pain. It is not always simple to determine if patients legitimately require opioid medication to help treat their condition.
To help identify drug-seeking behaviour, physicians should be vigilant when patients say they have lost their prescription or medication, or request specific opioids or precise dosages.
When examining patients seeking opioid medications, physicians should consider the extent to which a patient’s pattern of pain and overall clinical condition has changed. It is important to obtain a thorough understanding of the patient’s past and present condition, and look for consistency in the results of physical or psychological assessments. Appropriate tests, possibly including a risk assessment for substance abuse, may also be warranted.
A patient who repeatedly returns with unresolved complaints, or with symptoms that worsen or are not responding to treatment as expected, may signal an unsuspected serious medical condition. Physicians should keep an open mind and reflect on any diagnosis, being careful to consider other possibilities, including those that may be life-threatening. Physicians should also be mindful of their own emotional responses, as well as those of other team members, which may interfere with the objective assessment of a particular patient.
Preventing drug diversion
The term “drug diversion” refers to the use of prescription medication for unauthorized purposes, or the transfer of medication from lawful to unlawful distribution or use.6 Patients may divert both opioids and non-opioid medications for their own use, or to give or sell to others. Patients may “doctor-shop” or “double-doctor.” Physicians should be vigilant about the security of their prescriptions — whether electronic or paper-based — as well as their office formulary supplies.
Patients who abuse opioids or who divert drugs may visit clinics specifically in an attempt to obtain opioids. Some individuals may indicate they are on long-term opioid therapy and have run out of their medication or are unable to access their usual care provider, and ask for a temporary prescription.7 Physicians should remember they retain the professional responsibility for every prescription they write. Physicians working in clinics and facilities should familiarize themselves with any organizational policies concerning opioid prescribing, as this may enable a consistent response from all physicians at the facility. Adoption of e-prescribing, which incorporates additional controls and audit capabilities, may also help to effectively curb prescription fraud.
Drug diversion, particularly for opioids, can also occur in patients’ homes. For instance, some individuals have been known to self-medicate or to take the medications of others with whom they live, to use themselves or to trade or sell.8 When appropriate, physicians should discuss the importance of secure medication storage and the risk for drug diversion in the patient’s home.
There is often a delicate balance between relieving a patient’s pain, anxiety, and discomfort and the possibility of contributing to or compounding an addiction. Physicians can take steps to help achieve this balance and manage their risks:9
- Maintain an up-to-date knowledge base about medications, including opioids, as well as treatment indications and contra-indications.
- Write opioid prescriptions carefully, including prescribing exact amounts of medication to carry through to the next appointment. Consider instituting a one-doctor/one-pharmacy treatment plan with the patient.
- Document all medication-related discussions and decisions in the health record.
- Consult with peers, supervisors, or experts when needed.
- Obtain informed consent from patients. Provide patients with information about the benefits and risks of opioids or other medications (including risks related to operating machinery and driving), as well as other treatment choices.
- Toombs, James D., “Commonsense opioid risk management in chronic non-cancer pain,” Practical Pain Management (2008) Vol.8, No.3. Accessed December 12, 2014 from: http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/commonsense-opioid-risk-management-chronic-non-cancer-pain
- National Opioid Use Guideline Group, “Canadian Guideline for Safe and Effective Use of Opioids For Chronic Non-Cancer Pain,” April 2010. Accessed October 28, 2014 from: http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf. The Guideline is also available in app formats
- College of Physicians and Surgeons of Newfoundland and Labrador, “Guideline – Safe and Effective use of opioids for chronic non-cancer pain,” 2010. Accessed December 12, 2014 from: http://www.cpsnl.ca/default.asp?com=Policies&m=329&y=&id=68
- Marks, Michael R., Phillips, Donna, Wong, Andrew, “Tips for dealing with the drug-seeking patient,” American Academy of Orthopaedic Surgeons Now (March 2014)
- Forschini-Field, Darlene, Inciardi, James A., “Prescription drug abuse and diversion: An expert interview with James A. Inciaridi, PhD,” Medscape Neurology (September 2008)
- Shehnaz, S.I., Agarwal, A.K., Khan, N., “A systematic review of self-medication practices among adolescents,” Journal of Adolescent Health (2014) Vol. 55 No.4, p.467-483
- Longo, Lance P., Parran, Ted, Johnson, Brian, Kinsey, William, “Addiction: Part II. Identification and management of the drug-seeking patient,” American Family Physician (2000) Vol. 61 No.8, p.2401-2408