Diversion of Pain Medications

From Clinicaltools.com

Contents 1 Course 4: Preventing and Detecting Diversion of Pain Medications 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 A. Identify patients who are diverting medication or whose medication is being diverted 1.3.2 B. Follow a clinical protocol that reduces diversion of medications by patients or their family members 1.3.3 C. Follow practice management guidelines that reduce risk of diversion 1.4 Case Study/Simulated Patients - IN DEVELOPMENT 1.4.1 Sam Seller: 29 YOBM 1.4.2 Bob Backache: 52YOWM 1.4.3 Ozzie Oblivious Taking Oxycodone for Neck Pain and With a Teenage Son Diverting the Medication: 55 YOWM

Course 4: Preventing and Detecting Diversion of Pain Medications

Need

Many clinicians do not take steps to ensure that patients are taking and storing their pain medication correctly to avoid contributing to the problem of diversion of pain medications. Only a minority use urine drug testing, pill counts when abuse or diversion is suspected (CASA, 2005).

The majority of physicians did not receive specific training on diversion in medical school, residency, or continuing education (CASA, 2005). Many physicians find it difficult to discuss abuse of prescription drugs with patients (Petrecca, 2004).

Goal

The learner will be able to educate patients about proper use and storage of pain medications and assess for signs of diversion of pain medications.

Objectives

After completing this course, the learner will be able to:

A. Identify patients who are diverting medication or whose medication is being diverted

1. Conduct thorough patient interview to determine history and course of treatment
2. Contact patient's prior treatment providers to determine dosing and duration of past treatment
3. Use sensitive interviewing techniques to inquire about patient's use of medications
4. Identify red flags that suggest illicit drug-seeking behavior
5. Review patient records of chronic pain patients for patterns suggestive of diversion before prescribing refills
6. Use urine drug testing where indicated
7. Bring special attention to patients taking extended release drugs due to their greater risk for abuse

B. Follow a clinical protocol that reduces diversion of medications by patients or their family members

1. Provide refill prescriptions only with verification of continuation of pain diagnosis
2. Decrease the size of prescriptions and increase the frequency of follow-up visits according to severity of addiction, suspected diversion, or risk for diversion
3. Explain to patients the proper medication storage and monitoring that should occur in their homes

C. Follow practice management guidelines that reduce risk of diversion

1. Keep careful prescribing records for all pain medicine prescribed
2. Follow an office protocol that safeguards prescription pads and sample medications
3. Verify identities of patients receiving a prescription for pain medication
4. Utilize state-based reporting systems for pain medication prescriptions

Case Study/Simulated Patients - IN DEVELOPMENT

Sam Seller: 29 YOBM

• Chief Complaint: Requests prescription for phantom limb pain.
• Narrative: Sam claims his phantom limb pain is severe and the only thing that helps is hydrocodone. Sam lost his right lower leg during friendly fire combat in Iraq. He is new to the area and is a new patient in your practice, and is vague about where he has obtained his prior medication.
• Physical Exam* There are marks suggestive of needle tracks on his skin but it is not conclusive.
• Objective Addressed: 1. Identify drug-seeking patients and/or patients who are diverting medication
• Skills-Training Goals:

1. Conduct thorough patient interview to determine history and course of treatment
2. Contact patient's prior treatment providers to determine dosing and treatment provided
3. Use sensitive interviewing techniques to inquire about patient's use of medications
4. Identify red flags that suggest illicit drug seeking behavior

• Objective Addressed: 4. Follow practice guidelines that reduce risk of diversion
• Skills-Training Goals:

1. Keep careful prescribing records for all pain medicine prescribed
2. Follow an office protocol that safeguards prescription pads and sample medications
3. Verify identities of patients receiving a prescription for pain medication
4. Utilize state-based reporting systems for pain medication prescriptions

Bob Backache: 52YOWM

• Chief Complaint: Flare up of chronic back problem.
• Narrative: Bob is a long-term back pain patient (20+ years) who calls sporadically and asks for a refill. Within the past year he has had 4 back injuries that has exacerbated the problem and thus he has called for refills more frequently.
• Objective Addressed: 1. Identify drug-seeking patients and/or patients who are diverting medication
• Skills-Training Goals:

1. Review patient records of chronic pain patients for patterns suggestive of diversion before prescribing refills

• Objectives Addressed: 2. Establish a treatment contract that spells out the rules and patient's responsibilities in treatment
• Skills-Training Goals:

1. Discuss with the patient the necessity of establishing a treatment agreement
2. Identify the core components of a written treatment agreement
3. Discuss consequences of breaking a treatment contract with the patient

• Objectives Addressed: 3. Follow a clinical protocol that reduces diversion of medications by patients or their family members
• Skills-Training Goals:

1. Establish additional prescription monitoring system for patients who request frequent refills for pain medication or show other signs of diversion
2. Provide refill prescriptions only with verification of continuation of pain diagnosis

Ozzie Oblivious Taking Oxycodone for Neck Pain and With a Teenage Son Diverting the Medication: 55 YOWM

• Chief Complaint: Regular evaluation for refill on pain medication.
• Narrative: Ozzie comes in for a regular visit to refill his oxycodone, which he takes for chronic pain related to neck pain. His treatment agreement includes pill counts due to past addiction. This is the second time that his pill count has been too low - last time he was 2 pills short, and this time he is 5 pills short. Ozzie insists that he has not been taking more than his usual dose. Ozzie is divorced but his 17-year-old son stays with him on weekends.
• Objectives Addressed: 3. Follow a clinical protocol that reduces diversion of medications by patients or their family members
• Skills-Training Goals:

1. Follow guidelines related to monitoring of pain medication prescriptions for all patients
2. Decrease the size of prescriptions and increase the frequency of follow-up visits according to severity of addiction, suspected diversion, or risk for diversion
3. Explain to patients the proper medication storage and monitoring that should occur in their homes
4. Refill prescriptions only after verification of continued pain diagnosis