______________________________ Strategies for Appropriate Opioid Prescribing: The Florida Requirement
In addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [47; 48; 82]: • Selling medications • Prescription forgery or alteration • Injecting medications meant for oral use • Obtaining medications from nonmedical sources • Resisting medication change despite worsening function or significant negative effects • Loss of control over alcohol use • Using illegal drugs or non-prescribed controlled substances • Recurrent episodes of: – Prescription loss or theft – Obtaining opioids from other providers in violation of a treatment agreement – Unsanctioned dose escalation – Running out of medication and requesting early refills Behaviors with less association with opioid misuse include [47; 48; 82]: • Aggressive demands for more drug • Asking for specific medications • Stockpiling medications during times when pain is less severe • Using pain medications to treat other symptoms • Reluctance to decrease opioid dosing once stable • In the earlier stages of treatment: – Increasing medication dosing without provider permission – Obtaining prescriptions from sources other than the pain provider – Sharing or borrowing similar medications from friends/family INTERVENTIONS FOR SUSPECTED OR KNOWN DRUG DIVERSION There are a number of actions that prescribers and dispensers can take to prevent or intervene in cases of drug diversion. These actions can be generally categorized based on the various mechanisms of drug diversion. Prevention is the best approach to addressing drug diversion. As noted, the most common source of nonmedical use of prescribed opioids is from a family member or friend, through sharing, buying, or stealing. To avoid drug sharing among patients, healthcare professionals should educate patients on the dangers of sharing opioids and stress that “doing prescription drugs” is the same as “using street drugs” [84].
In addition, patients should be aware of the many options available to treat chronic pain aside from opioids. To prevent theft, patients should be advised to keep medications in a private place and to refrain from telling others about the medications being used. Communication among providers and pharmacies can help to avoid inappropriate attainment of prescription drugs through “doctor shopping.” Prescribers should keep complete and up-to-date records for all controlled substance prescribing. When possible, electronic medical records should be integrated between pharmacies, hospitals, and managed care organizations [84]. It is also best practice to periodically request a report from the E-FORCSE to evaluate the prescribing of opioids to your patients by other providers [84]. When dealing with patients suspected of drug seeking/ diversion, first inquire about prescription, over-the-counter, and illicit drug use and perform a thorough examination [46; 84]. Pill counting and/or UDT may be necessary to investigate possible drug misuse. Photo identification or other form of identification and social security number may be required prior to dispensing the drug, with proof of identity documented fully. If a patient is displaying suspicious behaviors, consider prescribing for limited quantities [46]. If a patient is found to be abusing prescribed opioids, this is considered a violation of the treatment agreement and the clinician must make the decision whether or not to continue the therapeutic relationship. If the relationship is terminated, it must be done ethically and legally. The most significant issue is the risk of patient abandonment, which is defined as ending a relationship with a patient without consideration of continuity of care and without providing notice to the patient. The American Medical Association Code of Ethics states, “Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured” [33]. The notice of termination should be sent in writing, should specifically note the causes for the termination, and should give a period of time prior to termination, usually 30 days [29]. Patients may also be given resources and/or recommendations to help them locate a new clinician. Patients with chronic pain found to have an ongoing substance abuse problem or addiction should be referred to a pain specialist for continued treatment. Theft or loss of controlled substances is reported to the DEA. If drug diversion has occurred, the activity should be documented and a report to law enforcement should be made [28].
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MDFL0626
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