“Pain must be regarded as a disease … and the physician’s first duty is action – heroic action – to fight disease.”
– Benjamin Rush
Family physicians are on the front lines in the “war on pain.” It is estimated that chronic pain may affect 15 percent to 30 percent of the general population of the United States – as many as 70 million individuals.1 For many of these patients, controlled substances such as opioid analgesics are the mainstays of therapy because of their efficacy and relative freedom from end-organ toxicities, such as the serious gastrointestinal complications that too often accompany long-term treatment with non-steroidal, anti-inflammatory drugs. However, these medications may be double-edged swords. Specifically, the role of opioid analgesics, such as OxyContin, in pain management is currently a topic of debate.
The potential for misuse of opioid analgesics and other medications used to treat pain is high – by patients who abuse their own medications or by pseudopatients or “diverters” who try to obtain these medications under false pretenses for the illicit purpose of reselling the drugs to others. A 1999 survey by the Substance Abuse and Mental Health Services Administration revealed that approximately 4 million people in the United States use psychotherapeutic drugs for nonmedical reasons – nearly double their estimate of Americans who use heroin or cocaine.2 Diversion and abuse of pain medications is costly to abusers and to society, and it endangers patients who are in pain.
Although subtle, there is an important difference between patients who abuse their own medications and those who divert them. This article focuses on medication diversion, which has recently been a problem with OxyContin in particular. Of course, many of the article’s tips for diversion prevention may also apply to patients abusing their own medications.
Some physicians deal with medication diversion by simply refusing to treat any patients with opioid analgesics, but this harms honest patients who need these medications to function better in daily life. Other physicians who are willing to provide compassionate care for pain patients run the risk of being deceived by diverters. As frontline participants in both the “war on pain” and the “war on drugs,” family physicians need to know how to spot and prevent diversion in their practices.
Diverters try to obtain medications under false pretenses for the illicit purpose of reselling the drugs to others.
The potential for diversion and abuse of opioid analgesics and other medications used to treat pain is high.
Family physicians can prevent medication diversion with patient medication agreements and prescription safety, among other things.
Signs of diversion
Although it’s important to trust your patients and accept what they tell you at face value, it is also important to maintain a healthy degree of skepticism. Diverters come in many forms, so appearances may be deceptive. Better indicators are their behaviors and their stories, which are often similar. Unpleasant as it is to consider, people who work for you, other physicians, friends and even family members may be diverting pain medications. Following are some of the signs to watch for in your practice:
Strange stories. Be wary of new patients with stories that don’t seem quite right. Diverters often claim to be traveling through town on business or visiting relatives. Occasionally, they’ll pose as government officials or pharmaceutical company representatives. They may be excessively complimentary about the office facilities or your appearance or medical reputation in the community. They may deliberately request appointments toward the end of the day or may show up just after regular office hours. One common ploy diverters use is to ask to be seen immediately or to be given a prescription right away because they have to “catch a plane” or “get to an important appointment.” They may claim that they have lost a paper prescription, forgotten to pack their medication or had their medication stolen.
Reluctance to cooperate. Diverters often refuse a physical exam and are unwilling to give permission to access past medical records or allow contact with previous providers. If pressed, they may claim they cannot precisely remember where they were last treated or that the previous clinic, hospital or provider has gone out of business. In many cases, these patients leave the office suddenly if things are not going their way.
Unusually high (or low) understanding of medications. Be alert when patients appear to be extremely well-informed about specific medications. While it is true that people who have been sick for a long time often learn much about their disease process and know the medications that work best for them, this is also true of diverters. They often appear to have a familiarity with diseases that comes straight from textbooks rather than real life. Some diverters may feign naiveté by deliberately mispronouncing medication names or seeming to be uninformed about their underlying medical condition.
Strange symptoms. Diverters may exaggerate or feign symptoms. Certain complaints are typical, such as back pain, kidney stones, migraine headaches, toothaches or post-herpetic neuralgia. Some diverters may even attempt to alter urine samples by pricking a finger and putting a drop of blood in the specimen to corroborate their story of renal colic.
Specific drug requests. Because many diverters are very knowledgeable about controlled substances, they may request specific medication brands and resist any of your attempts to prescribe generic forms and substitutes, stating that they are “allergic” or that a particular alternative has never provided relief for them in the past.
There are a number of things you can do in your practice to prevent medication diversion from occurring: provide thorough care, use patient medication agreements, protect your prescriptions, work with local pharmacists, involve your staff and play by the rules. Some of the anti-diversion measures described below may seem to be in conflict with your mission to provide compassionate care, but diversion does exist and poses a significant risk to you (since you can be held accountable for your prescribing practices), your patients, your practice and society.
Provide thorough care. Diversion prevention begins with consistent and thorough care for every patient complaining of pain. This includes verifying past provider information, taking a complete medical history, providing a thorough physical examination and fully documenting each visit.
You should contact previous health care providers and pharmacists to confirm the information provided by each new patient. Obtaining the previous providers’ telephone numbers directly from directory assistance or other national sources, rather than from the patients, provides a reasonable assurance that real providers are being contacted (not just confederates of drug-seeking individuals). This may also help you spot “doctor shoppers” – patients seeing multiple providers in an attempt to obtain greater numbers of medications. Keep in mind, though, that not all doctor shoppers are diverters; some may be real patients trying to control their pain. You might also consider requesting an official form of identification (preferably one with a photo) from patients who need treatment with psychoactive medications. Photocopy the identification and include it in the chart.
When taking a patient’s medical history, try to elicit information about the nature and intensity of the pain, current and past pain-related treatments, coexisting diseases and other medical conditions, the efficacy of past treatment for pain, overall level of function and any substance-abuse history. Even though a thorough physical exam may not verify the existence of a painful condition or reveal the underlying pathophysiology, it does provide you with an opportunity to look for potential signs of drug abuse, such as inflamed nasal mucosa, nasal septum perforation, unusual jitteriness or sedation, pupillary changes and recent needle puncture sites. Always carefully document everything in the medical chart that was said and done during a visit, including the patients’ answers to questions asked. A few moments of extra charting with new patients may prevent later problems.
Use patient medication agreements. In addition to fully discussing with patients the risks and benefits of a chosen medication therapy and obtaining a signed informed-consent document, many physicians choose to have all of their patients sign a medication agreement outlining the goals for therapy, the overall therapeutic plan and other conditions for treatment. Such conditions might include periodic screening of urine for illicit substances or medication adherence, serum medication levels for dose titration and/or the frequency of prescription refills. Some medication agreements might also request that patients bring all of their medications in the appropriate pharmacy containers to appointments for periodic pill counts, agree to fill all of their prescriptions at one pharmacy, obtain all opioid analgesic prescriptions from only one physician, and immediately inform that physician when another prescriber becomes involved in their care for any reason.
Medication agreements should also state the reasons for which therapy may be discontinued, including violations of the agreement, evidence of illicit street drug use or prescription medication abuse or outright diversion. It is important that you follow through if violations occur. Not doing so could leave you open to allegations of enabling a drug addict and failing to prescribe for therapeutic purposes.
Even if you choose not to use a medication agreement with all of your patients, it is particularly important to use one in cases where patients are at a high risk for misusing medications (i.e., those patients with a current or past history of substance abuse, with comorbid psychological disorders or whose chaotic living arrangements pose a risk for misuse or theft). In these situations, extra monitoring and perhaps referral to a pain specialist or someone who specializes in addictionology is highly recommended.
Protect your prescriptions. Diverters may try to steal blank prescription pads or alter physicians’ written prescriptions. They may write their own prescriptions, write new prescriptions for fictitious patients or photocopy or scan blank prescriptions in order to have an unlimited supply of prescription forms. Sometimes diverters will remove physicians’ writing with solvents and then write new prescriptions for what they want to divert. But even without removing any of the physicians’ writing, it is often easy for diverters to change certain quantity numbers, such as 10, which can easily be changed to 40, 70 or even 100 on the way to the pharmacy.
Here are some tips for protecting your prescriptions:
Keep the number of prescription pads used in the office to the minimum necessary, and keep extra pads in a locked area.
Make sure unlocked prescription pads are with you or other physicians at all times. Never leave them sitting on desks or countertops.
Use prescription pads only for prescribing. Make other notes or patient instructions on stationery.
Never sign blank prescriptions in advance.
Consider writing the quantity and strength of medications in numerals and letters.
Do not leave the refill space blank or fail to circle the appropriate number of refills on a prescription.
Use sequentially numbered prescription pads to make it easier to detect missing forms.
Use prescription pads that have more than one color of ink. These are more difficult to reproduce than standard black lettering on white paper.
Have prescriptions pads printed on different colors of paper, and write the color of the paper somewhere on the form.
Use tamper-resistant prescription pads that expose the word “VOID” when prescriptions are photocopied.
Record the name of the medication, the dose strength, the number of pills dispensed and the dosing frequency in the patient’s chart.
Contact the company that prints your prescription pads to find out what kinds of prescription-safety options are available to you.
Work with local pharmacists. Often it is the pharmacist who first detects a diversion attempt. Diverters may try to call in their own prescriptions by claiming to represent a physician’s office and providing his or her personal telephone number for call-back confirmation. A close, working relationship between your office and local area pharmacies may help to prevent these maneuvers from succeeding. Specifically, try writing the name of the patient’s pharmacy on the prescription and sending facsimile copies of prescriptions to pharmacies upon request so that pharmacists can authenticate questionable prescriptions. It’s also good to avoid calling in prescriptions for opioid analgesics. If you don’t routinely call in such prescriptions, pharmacists will know to be suspicious of anyone who tries to do so.
Involve your staff. Your staff members are also important allies in preventing diversion, especially since diverters will likely be on their best behavior when they are in your presence. Ask your staff to pay attention to what patients say and how they behave in the office and promptly report any suspicions to you.
Play by the rules. You can do a lot to prevent diversion in your practice by simply maintaining standards of good medical practice and professional ethics. Never prescribe controlled substances to patients unless clinically indicated. Inform patients that it is illegal for you to prescribe opioid analgesics without performing a meaningful physical examination. Follow a protocol for history taking, performing a physical examination and ordering necessary diagnostic tests before prescribing opioid analgesics. And when you or your staff suspect patients of attempting to obtain medications for non-therapeutic purposes or trying to steal prescription pads, notify the local police.
Upholding the covenant. Many of these measures may seem Draconian and in conflict with your mission to provide compassionate care. Unfortunately, the magnitude of the drug-abuse problem in the United States and the costs to everyone dictates that you make a meaningful collective effort to prevent diversion and abuse. That is also the covenant between prescribers and regulators. By upholding the covenant, you safeguard the availability of these life-affirming medications for patients whose function and quality of life depend on them.
TEN TIPS FOR PRESCRIBING OPIOID ANALGESICS
For more information about each of the following tips, see “Ten Tips to Survive Opioid Prescribing” in The Pain Practitioner newsletter, Fall–Winter 1998.1
Obtain a thorough history and perform a complete physical examination.
Document everything you see, think, feel and hear about the patient without resorting to judgmental or pejorative labels (being mindful that accurate and complete medical records allow subsequent readers or reviewers to understand how you made medical decisions).
Obtain informed consent for long-term opioid therapy.
Get a second opinion from a colleague to verify your care plan, if you feel at all uncertain about it.
Ask the patient to use only one pharmacy and to obtain opioid analgesics only from you.
See the patient regularly (at least every 30 to 90 days).
Prescribe controlled-release medications to stabilize the blood levels and limit the “buzz” associated with immediate-release medications.
Keep the dosages controlled to the amount necessary to provide comfort without unacceptable side effects.
Check the patient’s urine drug screen to make certain that what you are prescribing is being taken and illicit substances are not being used.
Learn as much as you can about the use of opioid analgesics.