Patient Opioid Disengagement

By Tory McJunkin, MD, Paul Lynch, MD, Leila Micklos, MS, FNP-BC, Edward Swing, PhD

Dear Arizona Pain,

I have several patients who are not compliant with the opioid prescriptions I’ve written them.  I want to help all of my patients, but I’m concerned about the safety issues these patients present. How should I deal with patients who aren’t able to take their opioid medications responsibly?

Sincerely,

Struggling with Noncompliance

Dear Struggling with Noncompliance,

This is a great question and one that we frequently hear.  Managing opioid compliance is an essential piece for the practice and begins with the development of a robust management plan.  This plan is intended to improve the quality-of-life for the patient by meeting their pain management needs, as well as meeting the regulatory requirements of the practice. In an attempt to prevent noncompliance in your practice, it is best to develop a protocol designed to optimize patient selection and set the foundation for prescription opioid therapy compliance. 

Why monitor opioid compliance?

In the past 20 years, the use of prescription opioid therapy has significantly increased (Chou et al., 2009). Coupled with the increased use of opioids, clinicians and regulatory officials have seen an increase in prescription opioid abuse, diversion, overdose and deaths. Opioids are responsible for more overdoses in the US than all other illicit drugs combined (Paulozzi, Jones, Mack, & Rudd, 2011). It is our responsibility as clinicians to help our patient’s with the best and safest treatments available to them.  This implies that we screen for and identify patients who are high risk and/or poor candidates for opioid therapy. A thorough patient interview including psychosocial history must accompany the physical exam and review of past medical records.  Further patient evaluation and clinical consideration must be conducted in patients with histories of aberrant drug related behaviors (Chou et al., 2009). Patients who are typically considered poor candidates for opioid therapy include those with a history of illicit drug abuse as well as a personal or family history of illicit drug or alcohol abuse.  It’s also important to look at their overall condition.  Do they have pathology that warrants the risk associated with long-term use of opioids.   How active are they?  What are their short, moderate, and long-term goals for their pain?

Tools to help you monitor:

An appropriate opioid therapy program for your practice should be understood by all and documented. You should employ the use of the monitoring tools available to clinicians.  These tools include:

Opioid Therapy Agreement (Contract)

• An Opioid Therapy Agreement is a written and signed contract between the patient and the clinical practice that outlines the goals of treatment as well as the stipulations required by the patient in order to continue prescription opioid therapy. The agreement should lay out all the common and worst case problems that can occur do to opioids.  You may want to include an agreement that the patient will not receive prescriptions for pain medications from any other providers while they are under your care. This can help reduce the chances of the patient receiving prescriptions from multiple providers that add up to dangerously high doses of opioids.  This agreement should be discussed at length with the patient so that they appropriately understand the real risks involved with opioid therapy.

Regular Pharmacy Board Review

• Currently 48 US states and one territory either have active Prescription Monitoring Programs or are in the process of implementing such a program. (Alliance of States with Prescription Monitoring Programs, 2013). Once registered, the clinician will have access to a patient’s prescription history. This report will include name of opioid prescribed, the date prescribed and filled, the prescriber’s name, the quantity dispensed and the dispensing pharmacy (Lynch, McJunkin, Anderson, & Swing, 2012). This is a very helpful tool to see if the patient is honest, has received medications from multiple providers, what dosages the patient has received, and if the patient has a history of poly-pharmacy.

Regular Urine Drug Screens

• Regular urine drug screens (UDS) must be consistent with the prescription opioid therapy established for the patient. Discovering an absence of prescribed opioids or the presence of non-prescribed opioids during the UDS could be indicative of noncompliance. Additionally, an inconsistent urine drug screen may reveal a patient’s use of illicit drugs, a serious discovery that must trigger a review and modification of the patient’s plan of care (Chou et al., 2009).

When should you disengage a patient from opioids?

Making the decision to disengage a patient from prescription opioid therapy should be conducted on a case-by-case basis and should follow your standard protocol.  One should take all factors of noncompliance into consideration when making a decision. If the patient violates your opioid compliance program, a thorough discussion must occur between the patient and the clinician. The clinical consequences of the violation must be documented in the patient’s record as well as expectations for future patient behavior. Violations that are clear indicators of threat to patient safety and/or place the clinician or practice in a medico-legal risk (e.g., prescription forgery) are grounds for immediate disengagement.

For example:

Patient Jones currently receives opioids for chronic back pain. This patient went to a hospital emergency department and was admitted for a kidney stone. Patient Jones received a short prescription for an opioid. This outside prescription violated the opioid contract. In this case, however, you might determine that issuing the patient a warning, educating that patient about contacting you in advance when receiving an outside prescription, and documenting the exchange in Patient Jones’ medical record is sufficient.

Patient Smith received a warning several months ago for failing to take medications as prescribed. This patient then tests positive for several illicit drugs in a UDS and this result is confirmed in outside testing. This patient is a clear risk to themselves and should be disengaged from opioids.

How do you disengage a patient from opioids?

Once the decision has been made to disengage a patient from opioid therapy, the patient must be informed. The communication can be accomplished through an office visit discussion and/or through a detailed patient letter delivered via certified mail. We like to meet face-to-face with a patient in the office and explain that they have violated our agreement and I can no longer prescribe chronic opioids for their condition.  Usually we explain that we are happy to have the patient continue receiving care in our practice with treatments other than narcotics.

Appropriate referrals to an addictionologist, in-patient treatment center, counselor, and/or psychiatrists are considered at this time. It is also important to notify the patient’s referring physician and/or PCP of this update in their care so that they are aware of the patient’s condition.  As a clinician, we have a responsibility to prevent harm to our patients.  If the patient feels that they must continue opioid medications, a list of clinical providers and their contact information should be provided to the patient to arrange future care. Additionally, providing a final 30 day opioid prescription or a tapering dose to the patient may be appropriate to prevent withdraw symptoms. This should also provide the patient adequate time to locate and establish care with a new provider, so that they cannot make “abandonment claims.” This 30 day continuation of treatment after a patient leaves a practice is considered standard of care in Arizona. Consider the standards in your state in when establishing your disengagement policies.

If your practice uses opioid therapy, it is imperative that your patients are aware of the great risk this therapy holds.  It is also important that your practice has well thought out guidelines for prescribing, monitoring, and withdrawing patients from this therapy. As always, it’s important to follow all DEA recommendations, state guidelines, and society “best practices.” We also recommend you discuss this issue and other common occurrences with a qualified health-care attorney in your area.

 

Dr. Lynch and Dr. McJunkin own and operate Arizona Pain, a comprehensive pain management practice that provides minimally invasive, clinically proven treatments, with five locations in the greater Phoenix area. Dr. Lynch and Dr. McJunkin also provide consulting services to other pain doctors around the country through their partner company, Boost Medical. For more information, visit ArizonaPain.com and BoostMedical.com.

 

 References

Alliance of States with Prescription Monitoring Programs. (2013). About the Alliance. Retrieved July 25, 2013 from: http://www.pmpalliance.org/node/2

Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P.,…Miaskowski, C. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10, 113-130.

Lynch, P. J., McJunkin, T. L., Anderson, J. K., & Swing, E. L. (2012). Responsible use of opioids for chronic pain. Pain Medicine News, 10.

Paulozzi, L. J., Jones, C. M., Mack, K. A., & Rudd, R. A. (2011) Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. Center for Disease Control and Prevention: Morbidity and Mortality Weekly Report, 60, 1487-1492. Retrieved July 25, 2013 from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm