I thought I would present a case that occurred recently at our practice. For the purpose of anonimity, we can assume that all of the identifying details have been changed.
A very pleasant 68-year-old female with past history of obesity, HTN, HLD, sleep apnea (not using CPAP due to "claustrophobia")Stage 1 COPD, osteoarthritis, chronic low back pain, Type II DM, anxiety and depression is being seen for regular follow-up appointment. She has been receiving hydrocodone/apap 5/325 for 18 months.
Medications are lisinopril, hctz, simvastatin, metformin, advair, albuterol, famotidine, escitalopram and hyd/apap 5/325.
She lives with her grown son and daughter-in-law, and 2 young grandchildren.
She presents today reporting stiffness and tenderness of her fingers and low back. She has not suffered any recent trauma, and has not had any change in her overall condition. She denies fever, chills, weight change, loss of appetite, SOB, CP, dyspepsia, change in bowel or bladder, and reports her FBS has been
On exam, you find a pleasant, portly lady who has some difficulty getting to the exam table, and has mild tenderness of hands and low back on palpation. Otherwise, her physcial exam is as expected, and VS are WNL.
She asked for the hydrocone/apap to be increased to "10 mg" (her words).
So, how about that urine drug screeen? How many NP's are doing random UDS in their practice before prescribing opioids?
Initially, she tries to avoid the UDS. "I've never had to do this before. I'm not using any drugs. Why do I have to do this? I just used the bathroom, I can't go right now".
Reluctantly, she agrees.
Her UDS comes back positive for benzodiazepines, negative for opioids.
We use a contract, and check the PDMP database every time we see a patient for a controlled substance refill. There were no benzo prescriptions on the list for her. A couple of comments that stand out, in no particular order.
1. "the benzo is not my problem", post 8. In our contract, having another controlled substance by any other prescriber is cause for a warning to the patient. Having an old script and using it after signing the contract is also a warning. Having no prescription, but positive urine screen results in a 7-day refill and follow up office visit. With benzo, which can stay in the system for a long time, I wouldn't do a repeat UDS at that visit, but it might leave the patient concerned about it.
2. "Does anyone count pills". post 11. I always look at the PDMP and say, "Ok, so you had 90 hydrocone filled on x, date, how many of those do you have now?". We don't do a physical count. But the most common answer we get it, "I just ran out yesterday". We write the new prescription for the correct date, even if they ran out early.
3. False positives. We send the UDS out for lab confirmation if it is suspect.
4. Negative result on UDS. Less of a problem, at least early on. Like someone pointed out, opiates can clear the urine in as little as 2 days, so if she ran out, she could explain that away.
5. Non-opioid alternatives. Clearly, her osteoarthritis and low back pain should be managed with other agents, and are likely different types of pain. Both are probably a combination of nociceptive pain and neuropathic pain, caused by inflammation. So other medications should be considered.
SO...what did I do. I warned her about the implications of not using her meds correctly. I refilled her hyd/apap at the 5/325 dose for 7 days. Gave her a medrol dose pack, and Lyrica, and arranged for a 7-day follow up. I will likely change her to tramadol at the next visit, since it is probably a better choice for her anyway.
Specializes in ICU, Telemetry, Cardiac/Renal, Ortho,FNP.
Ha...I'm in pain management. Everyone gets UDS with confirmation. Prescription records checked every visit. Psych evals every visit. Even with all these safeguards we are still pretty strict on what we prescribe. You can never control what happens after they pick up their meds but at least you can try to do your due diligence before you write for them.
Ha...I'm in pain management. Everyone gets UDS with confirmation. Prescription records checked every visit. Psych evals every visit. Even with all these safeguards we are still pretty strict on what we prescribe. You can never control what happens after they pick up their meds but at least you can try to do your due diligence before you write for them.
I feel for those of you who deal with the chronic pain issue and drug seekers. I remember in school how they carried on about the contracts, pill counts and urine tests for people on pain med contracts. In my clinical rotations it seemed to be a daily issue or daily headache.
In my clinical rotations it seemed to be a daily issue or daily headache.
One of our local doctors got fed up with it last year and she just decided to stop writing narctoics. She felt like it took too much time away from other patients. She can't stop talking about how much it made her work life better. She uses Toradol for acute pain/episodic visits and she refers to the local pain specialist for chronic issues.
Interesting, you refilled her narcotic even though she tested negative?
If the patient was using a short acting prn opiate appropriately it wouldn't be unusual for them to test negative on a UDS. I'm not sure why you would take away their medication because they were using it appropriately, although I would argue in general that opiates are not appropriate for long term use except for in rare situations.
If the patient was using a short acting prn opiate appropriately it wouldn't be unusual for them to test negative on a UDS. I'm not sure why you would take away their medication because they were using it appropriately, although I would argue in general that opiates are not appropriate for long term use except for in rare situations.
Speaking only for myself if a patient is tox positive for benzos when I'm prescribing opiates or vice versa that is reason enough for me to discontinue, with taper if indicated, whatever I'm writing. I'm not playing around with that and am upfront about that from the beginning.
Interesting, you refilled her narcotic even though she tested negative?
I did.
As others have said, we sent out the urine for confirmation and I gave her the one week refill and a follow up. I don't jump to any conclusions on a dipstick test, unless it shows an illegal substance.
When patient came back in a week, she admitted that she had some old alprazolam, and had run short on the hydrocodone, but she also had some relief from the medrol dose pack, and Lyrica.
Hydrocone was decreased to BID. She was counseled on using her medications appropriately, and not hoarding them. We'll see how she does.
As others have said, we sent out the urine for confirmation and I gave her the one week refill and a follow up. I don't jump to any conclusions on a dipstick test, unless it shows an illegal substance.
When patient came back in a week, she admitted that she had some old alprazolam, and had run short on the hydrocodone, but she also had some relief from the medrol dose pack, and Lyrica.
Hydrocone was decreased to BID. She was counseled on using her medications appropriately, and not hoarding them. We'll see how she does.
Sounds reasonable, I'm guessing you calculated and she didn't run out because she was taking too many. Hopefully she's amenable to non-pharm interventions. Good thread!
Interesting topic esp from those of you in office practices and/or prescriptive auth.
When I was looking for a new PMP provider because my insurance had changed, I selected one ,and told them I was to be a 'new pt'. Were they accepting new pts?
Their next sentences were "yes, we take new pts" but "no, we don't Rx opiods or benzos". Like the receptionist said it all in one breath!
OK for me because I don't use the heavy duty meds - they make me 'stupid'. Don't like them.
I think that sort of situation calls for direct frank discussion with the patient with two clinicians present, preferably with everyone seated so no one looks extra intimidating. Of course be sure the test is correct. If it was just a "dipstick" test, get a real one using gas chromatography, then start the conversation with virtually certain confidence the test results are correct.
Talk with her with a strong bias toward discovering a mental health problem that she is treating with the benzodiazepines. She might be using the benzodiazepines to relieve anxiety, and she might have been using the hydrocodone for the same reason. Maybe the benzodiazepines are just to fill in after she runs out of hydrocodone each month.
Have a referral ready for a mental health evaluation from either a psychiatrist or psychiatric NP, and offer to continue pain treatment while that referral is being planned, but insist on bi-weekly urinalysis and pill counts - she shows up, or she gets no Rx.
Drug abusers have a horrible problem, and I think we have a moral and clear ethical duty to help without just throwing them out. If this is her first time "caught" abusing two drugs (using benzo's and NOT using hydrocodone is TWO abuses in my opinion), then be frank but supportive. Include early in the discussion that you intend to keep treating her, and if she has a pain condition, even assure her you intend to keep using the hydrocodone with special arrangements to make sure she uses it correctly.
Unless you also are a lawyer, do not give her legal advice per se, but DO remind her that selling or sharing hydrocodone is a serious crime, and so is acquiring benzodiazepines without a Rx. Make it clear you intend to help her, and actually plan to do so. In all that you do and say to her, be genuinely biased toward helping her and not just getting rid of her.
Consider exotic scenarios, but those usually are not what's happening. Of course, be open to the possibility that she is being abused and forced to hand over the hydrocodone to someone. Benzodiazepines sure would make a person more cooperative with an abuser, so maybe the benzo's are being forced on her. That sort of thing certainly does happen. You might even want to start the next assessment with a focus on whether she is safe or being abused by anyone. If she is, that will sure affect how the interview continues.
casias12
101 Posts
All good answers and queries.
We use a contract, and check the PDMP database every time we see a patient for a controlled substance refill. There were no benzo prescriptions on the list for her. A couple of comments that stand out, in no particular order.
1. "the benzo is not my problem", post 8. In our contract, having another controlled substance by any other prescriber is cause for a warning to the patient. Having an old script and using it after signing the contract is also a warning. Having no prescription, but positive urine screen results in a 7-day refill and follow up office visit. With benzo, which can stay in the system for a long time, I wouldn't do a repeat UDS at that visit, but it might leave the patient concerned about it.
2. "Does anyone count pills". post 11. I always look at the PDMP and say, "Ok, so you had 90 hydrocone filled on x, date, how many of those do you have now?". We don't do a physical count. But the most common answer we get it, "I just ran out yesterday". We write the new prescription for the correct date, even if they ran out early.
3. False positives. We send the UDS out for lab confirmation if it is suspect.
4. Negative result on UDS. Less of a problem, at least early on. Like someone pointed out, opiates can clear the urine in as little as 2 days, so if she ran out, she could explain that away.
5. Non-opioid alternatives. Clearly, her osteoarthritis and low back pain should be managed with other agents, and are likely different types of pain. Both are probably a combination of nociceptive pain and neuropathic pain, caused by inflammation. So other medications should be considered.
SO...what did I do. I warned her about the implications of not using her meds correctly. I refilled her hyd/apap at the 5/325 dose for 7 days. Gave her a medrol dose pack, and Lyrica, and arranged for a 7-day follow up. I will likely change her to tramadol at the next visit, since it is probably a better choice for her anyway.