6 Use pain agreements to help guide therapy and as a diagnostic tool for problem patients. Pain agreements are different from informed consent. These are the rules the patient needs to live by, which may include no refills afterhours or on weekends. Address lost prescriptions, getting meds from multiple prescribers and using different pharmacies.
7 Do random urine toxicology screens. These are useful in two ways. Are there illicit substances in the screen? Are the prescribed medications showing up, or are meds being diverted? Oxycodone 5 mg is now worth more than $10 a pill on the street, so this may be strong incentive for diversion.
8 Check the Prescription Drug Monitoring Program (PDMP) database. This is a valuable tool that allows you to know whether a patient is seeing other clinicians and using other scheduled drugs. Forty-nine states have a PDMP database. This allows you to see how much and from whom a patient is obtaining controlled substances.
9 Make sure you have a bona fide physician–patient relationship. Do not prescribe controlled substances to friends or family. Medical boards frown on this. Verify the patient’s identity before prescribing opioids, and keep clear and thorough records.
10 Take the proper steps when terminating the physician–patient relationship. If you decide to terminate the relationship, offer and document a tapering schedule, as well as pain or substance-use referral. Send a dismissal letter with “return receipt” requested. Do not cut the patient off suddenly unless there is evidence of stolen scripts or similar malfeasance.
Summary
There is a national transformation occurring in how we are approaching and treating pain. Rheumatology patients often have chronic pain and deserve safe and effective pain relief. In many ways, our job is to place ourselves in suffering’s way.
Opioids should be part of a multifaceted approach to pain relief, and we should have a regimented and informed approach to the use of these medicines.
Dennis J. Boyle, MD, is an associate professor of medicine and rheumatology at Denver Health and the University of Colorado.
References
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- Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. The National Academies Collection: Reports funded by National Institutes of Health. 2011.
- The Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, U.S. Department of Health and Human Services. Addressing prescription drug abuse in the United States. Current activities and future opportunities. http://www.cdc.gov/HomeandRecreationalSafety/pdf/HHS_Prescription_Drug_Abuse_Report_09.2013.pdf
- Franklin GM. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology. 2014 Sep 30;83(14):1277–1284.
- Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010 Jan 19;152(2):85–92.
- Gomes T, Mamdani MM, Dhalla IA, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011 Apr 11;171(7):686–691.
- Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011 Apr 6;305:1315–1321.
- Washington State Agency Medical Directors’ Group. Opioid dose calculator. http://agencymeddirectors.wa.gov/mobile.html.
