Patient's addicted to narcotics

[rn undisclosed name]

I had a pt the other day that was addicted to dilaudid. I'll also assume he was addicted to xanax since he does take that 4x/day. He also takes several other psych meds. He requested a pain management specialist see him in the hospital so I had that arranged. They saw the pt and they checked the prescription reporting service (I don't recall the exact name) and they determined the pt is addicted to dilaudid and has multiple subscribers for his medications. I know I'm not supposed to judge his pain. Subjectively he states he has a lot of pain all the time. Objectively he looks comfortable. Those are facts and not my opinion.

I was wondering if a pharmacy is legally required to always fill prescriptions when it is known that they get prescriptions from various providers and there is a pattern of "doctor shopping" for lack of a better term. I asked another nurse I work with who said "well they have the prescription so the pharmacist has to fill it". I just think there should be some accountability and don't really know who it should fall on.

Needless to say the pain doctor would only authorize the pt to have dilaudid 1 mg ivp q3h prn. The pt takes dilaudid 8 mg po q4h atc at home. Of course the pt left AMA because he was not getting the pain meds he wanted.

[klone, MSN, RN]

Don't most narcotic addictions stem from chronic pain?

[rn undisclosed name]

I am sure they do. I just think there should be a better way to manage someone's pain than dilaudid since it is more of a short acting medication. I have talked with pain mgmt specialists and they say if you have to take breakthrough pain medication more frequently than twice in a 24 hour period your pain is not well controlled. When you have multiple providers giving you medications it is difficult to treat someone appropriately.

[Mrs. SnowStormRN, RN]

If he is getting Rxs from multiple doctors than maybe he gets them filled at different pharmacies...

[klone, MSN, RN]

I am sure they do. I just think there should be a better way to manage someone's pain than dilaudid since it is more of a short acting medication. I have talked with pain mgmt specialists and they say if you have to take breakthrough pain medication more frequently than twice in a 24 hour period your pain is not well controlled. When you have multiple providers giving you medications it is difficult to treat someone appropriately.

I agree with you. I was speaking more towards your implicit judgment that he was not really in pain.

[rn undisclosed name]

I didn't say he wasn't in pain. I said he looked comfortable, but, the pt stated he was in pain. I was using my subjective/objective assessment of this pt.

[klone, MSN, RN]

I know you didn't state he wasn't in pain. That's kind of what I meant by "implicit." If I'm off-base and that's not what you were implying, disregard my last post. :-)

[newyorkgroove]

There is a national database where health care providers can look up a patient's records to see all the narcotics a patient has had filled, regardless of what pharmacy was used.

[Jeanne M P]

What you are referring to regarding multiple prescribers and multiple pharmacy's is known as "diversion". It is the growing problem with chronic pain medicine. Prescription drug abuse is a hot topic for the DEA these days and many new practice guidelines have been developed.

A pharmacist is not required to fill a prescription if there is proof that the patient has enough pain medication available based upon his previous prescription. ie the physician orders Opioid 10mg 1 tab po q 6hours 30 day supply (120tabs). The patient goes to another physician gets another script for an opioid and takes it to the same pharmacy two weeks later. The pharmacist could refuse to fill it. Insurance companies are doing that currently. The problem is most addicts will circumvent this by paying cash and using multiple pharmacies. It is probable that in the near future there will be a national data base for all citizens using opioids. Not sure how I feel about that as an american citizen but from a prescribers stand point I can certainly understand it.

[seizetheday]

Narcotics are so addictive. I am not sure how we solve this problem - if someone has chronic pain and needs the narcotics for quality of life how do we keep them from becoming addicted and needing more and more for pain control as their tolerance increases? Some people seem to have a greater propensity for addiction - so how do we treat their chronic pain? Also those with long standing chronic pain often objectively look to be comfortable - if you spend 24 hours a day in pain, pain is your baseline, you don't spend every minute grimacing and flinching as you would with more acute pain. The pain that an addict feels is not always just chronic physical pain but also the physiological and psychological pain of withdrawal and perhaps emotional pain that the drugs are masking. The drive for wanting more pain meds is not like wanting more ice cream - those additional drugs provide a relief and a break from whatever pain the patient is feeling, be it physical, emotional or withdrawal.

Once someone has reached the dosages your patient has - cutting them way back is pretty much useless and not going to help in any way. They need to be tapered off slowly if there is any hope of setting up a healthier pain management strategy. They also may need additional services to treat the addiction and to get them through withdrawal.

Addiction to narcotics in people with chronic pain is very complex as treatment for one problem (chronic pain) contributes to the another problem (addiction). You have to be able to see the situation as far more than just a guy who wants more drugs than you think he needs.

[Lovely_RN, MSN]

It's unfortunate that yet another law is needed to control deviant human behavior but it really is a huge problem. I used to work in methadone maintenance and many patients on methadone had a racket going with multiple narcotic scripts. They know we test for opiates and there is no way to distingush heroin from oxycontin/percocets etc on a drug test. So many patients say they have pain get scripts for narcotics and voila! They get to use and still get their methadone. They will sell some of the pills or if they have a pick up schedule they will sell the methadone bottles on the street and maybe drink one bottle of methadone the day before they come to pick up so we will see the methadone metabolites on their tox screen. I had one patient who slipped and brought in both narcotic scripts. Patient couldn't explain to me why they had a script for percocets from one MD and one for Tylenol #3 from another MD. Oh and please don't get me started on benzo abuse.

There are some crooked (most are honest) MDs out there who are running Rx mills. Word would get out about a "good" MD and at first one or two patients would have scripts from this MD and then next thing you know half the clinic patients have switched their MD to this new one who "understands" them. Many time the patients never even met that MD.

The Obama administration said on Tuesday that it would seek legislation requiring doctors to undergo training before being permitted to prescribe powerful painkillers like OxyContin, the most aggressive step taken by federal officials to control both the use and abuse of the drugs.

http://www.nytimes.com/2011/04/20/health/20painkiller.html

What you are referring to regarding multiple prescribers and multiple pharmacy's is known as "diversion". It is the growing problem with chronic pain medicine. Prescription drug abuse is a hot topic for the DEA these days and many new practice guidelines have been developed.

A pharmacist is not required to fill a prescription if there is proof that the patient has enough pain medication available based upon his previous prescription. ie the physician orders Opioid 10mg 1 tab po q 6hours 30 day supply (120tabs). The patient goes to another physician gets another script for an opioid and takes it to the same pharmacy two weeks later. The pharmacist could refuse to fill it. Insurance companies are doing that currently. The problem is most addicts will circumvent this by paying cash and using multiple pharmacies. It is probable that in the near future there will be a national data base for all citizens using opioids. Not sure how I feel about that as an american citizen but from a prescribers stand point I can certainly understand it.

[tyvin, BSN, RN]

Where I live it's very difficult to doctor shop. I know that the pharmacist will check the data base and if the person has had an allotted amount of the Rx already filled for that month they will refuse and they are suppose to call the docs. Pharmacist are not required to fill schedule II when they suspect foul play. I don't know if this is just our states policy but it's the federal drug registry that they check before filling any schedule II.

There is no reason that a person should have multiple Rxs for the same med from multiple docs; it only means one thing. The pharmacists can get away with filling them by saying they didn't check the registry but my neighbour told me that they are suppose to check it first.

My heart goes out to the addicted. When I worked in psych we would have the occasional opiate withdrawal. So sad especially since the policy was to wean them onto methadone. I don't agree with the substituting one drug for another. My own niece is on methadone.

Anyway, to be clear; the pharmacists are not required to fill any prescriptions they feel are questionable including the schedule IIs.