Pulse
Contract Work
Some physicians are using opioid agreements to help ensure that their patients don’t misuse controlled substances.
Jon Hallberg, M.D., still remembers the first patient he saw on his very first day practicing medicine. The man came in to the clinic without an appointment. “He had pinched his skin [to make it look injured] and had a great story about how he got pinned between his boat and the dock. He asked for Percocet,” says Hallberg, a family physician with the Primary Care Center at the University of Minnesota Medical Center. The patient turned out to be a drug seeker.
Since Hallberg began practicing nearly a dozen years ago, abuse of prescription drugs has been a growing concern. The U.S. Department of Health and Human Services estimates that abuse of prescription painkillers such as oxycodone and hydrocodone by people age 25 and younger has grown five-fold, from 400,000 in the mid-1980s to 2 million in 2000.
Appropriate Prescribing
Last November, the Minnesota Board of Medical Practice (BMP) submitted to the Minnesota Legislature a report on appropriate prescribing of controlled substances. The document was produced by a work group convened by the BMP and chaired by Alfred V. Anderson, D.C., M.D., of Minneapolis-based Medical Pain Management. The work group was mandated by legislation that establishes an online database to record and monitor Class II and Class III controlled-substance prescriptions written in Minnesota. The report includes the following principles:
1. Appropriate pain management is the treating provider’s professional, legal, ethical, and moral responsibility.
2. Controlled substances, especially opioid analgesics, are legitimate and necessary for carrying out this responsibility.
3. There is compelling evidence that both acute and chronic pain either go untreated or undertreated because of fear of legal and regulatory reprisals on the part of providers.
4. Controlled substances for pain management must be prescribed on a case-by-case basis, using a thorough clinical methodology to determine the cause and severity of pain based on the patient’s history, physical examination and test results, and diagnosis. A treatment plan that includes appropriate follow-up to determine response, appropriate adjustment of medication, if necessary, and other clinical processes needed to monitor and document the treatment and its effectiveness may also be necessary.
5. Untreated or undertreated pain is as serious a departure from the standard of care and as serious a violation of the Minnesota Medical Practice Act as is excessive prescribing of controlled substances or prescribing of controlled substances for nontherapeutic purposes.
6. Health care providers are insufficiently educated and trained in appropriate pain management, and professional schools should be required to work toward more adequate education on the subject.
7. The recent Minnesota legislation requiring that prescriptions of Class II and III controlled substances be recorded and monitored in an electronic, real-time database needs to be monitored closely by the Legislature in order to determine whether it makes health care providers less willing to prescribe these substances when they are medically necessary.
The full report can be accessed at www.state.mn.us/portal/
mn/jsp/home.do?agency=BMP.
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Although patients who deliberately mislead physicians comprise a small percentage of most medical practices, some physicians feel they’ve been burned too often. “It’s such a small part of what I do,” says Hallberg. “But it consumes me as a provider in a way nothing else does. This is not why you went to medical school. You don’t want to be a cop. But [when patients willfully mislead you] you feel violated, like someone’s breaking into your home.”
Making the distinction between patients who genuinely need pain medications and those who seek drugs for other reasons is a challenge. Pain is a highly subjective, complex experience that involves body, mind, and spirit, and is an inescapable part of the human condition. And the very drugs that are epidemically abused can, when taken as prescribed, make life worth living for millions of people for whom pain is a constant reality. Indeed, many argue that pain is undertreated. A recent Board of Medical Practice report on pain medication prescribing notes there is “compelling evidence” that this is the case (see “Appropriate Prescribing”). All this presents physicians with an ethical dilemma: “As physicians, we are sworn to alleviate suffering,” Hallberg says. “But is it the suffering from the lack of getting high? Are we aiding their addiction?”
Sign on the Dotted Line
Hallberg and his group have taken a number of steps to resolve this issue, one of which is having patients who use painkillers sign an opioid agreement. Modeled after one created by Fairview Health Services’ Pain and Palliative Care Center, the agreement is designed to help clarify how patients should use controlled medications. “It’s an opportunity for us to show patients what they signed up for and hold them responsible to follow through,” says Miles Belgrade, M.D., a neurologist and medical director of Fairview’s Pain and Palliative Care Center, about the agreement, which has been used for the last decade.
Although the contracts are not legally binding, Hallberg and Belgrade say they greatly reduce miscommunication and confusion regarding controlled medications, which Belgrade says likely account for much of their improper use.
Using agreements consistently with all patients also prevents physicians from having to decide who might misuse medication. “Do you need to have it with the sweet little old lady or just with the ex-con?” asks Belgrade, who explains that profiling patients is not very effective. Indeed, more than 17 percent of adults older than 60 wittingly or not also abuse prescription drugs, according to a March 2003 report by the U.S. Department of Health and Human Services. “Miscommunication about how meds should be used affects all people, including the sweet little old lady,” Belgrade says.
But such agreements don’t stop the career drug seeker from deliberately conning an unsuspecting physician into writing a prescription for a controlled drug—especially one with a high street value. “A lot of patients can be very manipulative when it comes to drugs,” Belgrade says.
How Effective?
Belgrade explains that having mechanisms such as monitoring and screening plans in addition to an opioid agreement takes some of the guesswork out the physician’s job. Both the Fairview and University of Minnesota Primary Care Center contracts include a provision stating that the patient will bring in the containers of all medications each time they see their provider even if there is no medication remaining. If physicians suspect that the patient is taking the medication incorrectly or selling it on the street, they ask the patient to bring in the unused pills in order to count them.
It is also common for physicians prescribing controlled medications to run drug screens. Agreeing to such testing is included in Fairview’s opioid agreement. “What you’re looking for are other drugs in their system like marijuana and cocaine,” Hallberg says. “And we’re looking for the drug we’re prescribing to make sure it’s being taken as prescribed and not diverted to the street.”
Although some might argue that this puts physicians in a Big Brother role, Belgrade says studies prove such screening is essential for safe and responsible prescribing.
Belgrade conducted his own study several years ago that looked at the results of random drug tests for nearly 100 consecutive patients who were prescribed narcotics. “About one-third of them had aberrant drug screens [either illegal drugs in their urine, urine that was devoid of the prescribed drug, or urine that contained unauthorized prescription narcotics],” Belgrade says. “These were people we thought were being compliant.” This likely meant the patient was selling the drug or not taking it as prescribed.
The agreements also spell out clear consequences for patients whose tests turn up positive. Patients who sign the Fairview contract agree that in such a case their treatment may be terminated. If the violation includes obtaining any controlled substances from other health care providers or individuals, a report may be made to the physician, pharmacy, and the police.
Belgrade says he has not found it necessary to contact law enforcement. “It’s generally not our job to blow the whistle on their illegal drug use,” he says. “But it is our obligation to contact other physicians who are prescribing drugs to that patient.”
Addiction or Pain?
One of the biggest challenges for physicians is treating patients who have both addiction and chronic or acute pain. “For the person who is addicted, it is harder to separate what is pain and what is addiction. But it is unethical to undertreat anyone with chronic pain,” Belgrade says.
Narcotics are only one element of a comprehensive pain management plan. Accessing alternative modalities is essential for the addicted patient, says Greg Amer, M.D., a family physician and medical director of Fairview Recovery Services. Treatments such as acupuncture, physical therapy, healing touch, and steroid injections are important for those with the dual diagnosis of pain and chemical dependency. “Narcotics aren’t the only treatment for pain,” he says, “just as penicillin isn’t the only antibiotic.”
Signs of a Drug Seeker
Greg Amer, M.D., a family physician and director of Fairview Recovery Services, teaches residents to recognize the signs of a drug seeker. “The main red flag for me,” Amer says, “is when the entire purpose of the patient’s visit to the doctor is to walk out of there with that drug. You can kind of tell in the first few minutes of the visit that that’s what the intent is. The classic drug seeker has the same story. They might have the kidney stone story, a chronic low-back-pain story. The good ones know the story perfectly. A person who is not a drug seeker is mostly concerned with, What’s wrong with me, and what can I do about it?”—S.G.
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Better understanding of addiction medicine and pain management would help improve treatment for those with a dual diagnosis, Belgrade says. Hallberg adds that a national system for tracking a patient’s narcotic use across pharmacies and geographic regions would also help.
For now, Hallberg sees the contracts as one more way he and his colleagues can keep their patients from misusing narcotics and other controlled substances. A growing number of other physicians and clinics are coming to the same conclusion, according to Belgrade, who says he is frequently approached about how to write such an agreement. “To have a document between the prescribing clinic and the patient is important for drugs like this,” Hallberg says. “But it’s just one element.”
—Susan Gaines