Avoiding Diversion

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Contents 1 Course 4: Avoiding Diversion 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Identify Diversion 1.3.2 Objective B. Follow a Clinical Protocol 1.3.3 Objective C. Use Practice Management Guidelines 1.4 Case Studies/Standardized Patients

Course 4: Avoiding Diversion

Protecting Your Medical Practice from Diversion Problems

Need

Many clinicians do not follow clinical and practice management protocols or provide appropriate patient education to avoid contributing to the problem of diversion of pain medications. For example, only a minority of physicians use urine drug testing and pill counts when abuse or diversion is suspected (CASA, 2005).

Many physicians find it difficult to discuss abuse of prescription drugs with patients. Contributing to this problem is the fact that the majority of physicians did not receive specific training on diversion in medical school, residency, or continuing education (CASA, 2005).

Goal

The learner will be able to educate patients about proper use and storage of pain medications, assess for signs of diversion of pain medications, and take steps to limit diversion from the practice.

Objectives

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

Objective A. Identify Diversion

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

1. Conduct thorough patient interviews 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 records of chronic pain patients for patterns suggestive of diversion before prescribing refills
6. Use urine drug testing where indicated
7. Continue to check prescription monitoring programs
8. Bring special attention to patients taking extended release drugs due to their greater risk for abuse

Objective B. Follow a Clinical Protocol

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

Objective C. Use Practice Management Guidelines

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
5. Work with pharmacists and law enforcement to detect and prevent diversion
6. Comply with DEA regulations
7. Understand responsibilities with respect to law enforcement vs patient confidentiality

Case Studies/Standardized Patients

Case 1: 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.
• Opioid Issue: Requests a specific opioid; vague history
• Relevant Past Medical, Psychosocial, Family History: No significant findings
• Objectives Covered: A, B

Case 2: Ozzie Oblivious - 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.
• Opioid Issue: Teenage son may be diverting his medication
• Relevant Past Medical, Psychosocial, Family History: Has been a model patient for many years since his pain started 8 years ago after an injury
• Objectives Covered: A, C