When doing a procedure that will expose you to blood or body fluids do you wear gloves? Of course you do. Universal precautions are standard of care and a good idea. If your patient guaranteed you that he did not have any infectious disease would you decide not to wear gloves? Of course not. That’s why we call it universal precautions.
When our patients tell us that they don’t have addiction problems or use drugs do we always trust them? With the amount of diversion of prescription medications that takes place should we trust them? I practice universal precaution when prescribing narcotics and other controlled substances on a chronic basis. I have done so for years. My patients sign a controlled substance agreement and participate in urine drug screening that can be verified by gas chromatography.
When prescribing controlled substances red flags frequently pop up: early prescriptions, lost prescriptions, a report of multiple providers or multiple pharmacies, to name a few. By practicing universal precautions we do not discriminate based on age, sex, religion, or physical appearance. It just makes sense and adds a tool to our ability to safely and responsibly prescribe controlled substances. We can not only verify that a patient is not taking unprescribed medications or street drugs but we can verify that they are compliant with the medications being prescribed. (At least to some degree)
It is important to know the limitations of urine drug screen testing. For example, clonazepam and its metabolites do not always show on urine benzodiazepines. Oxycodone is a synthetic opioid and does not always produce positive results for urine opiates. When discrepancies occur, verification with gas chromatography is vital. When initiating a program of prescription universal precautions be prepared to be surprised at what you will find. Before doing so make sure you are informed and confident in your knowledge of urine drug screening.
Below is a link to a 96 page guide produced by the US Government.
Drug Testing In Primary Care
All primary care providers face the challenge of assisting patients with chronic pain. With the upswing in prescription drug abuse, diversion and overdoses of controlled substances we also face the difficulty of deciding if we can trust what our patients are telling us. It is clear to me that pain scales don’t work in adults. When asked to rate their pain from one to ten, how many patients rate it ten out of ten. Even while sitting quietly in their chair, easily bending over to tie their shoes, and conversing in a calm manner. It makes sense to me that in an acute pain or chronic pain situation that a patient would elevate their numbers. If they say a two, are you going to take them seriously? No test exist to accurately rate pain levels, therefore the sufferers account is taken at face value.
In a perfect world there would be no need for health care providers. There would be no dishonesty and mutual trust would be a given. Unfortunately, we do not live in a perfect world. With all my heart I desire to trust what others tell me to be fact. In 47 years of life, my extension of trust resulted in bruises, heartaches and at times potential patient harm. Let me explain. Twenty years ago, as a budding enthusiastic Physician Assistant I had a pleasant, but odd, noncompliant, uncontrolled diabetic patient. Armed with the latest and greatest medical knowledge and best intentions I treated her with the standard of care. The first time I saw her I performed a monofiliament test. I asked her to close her eyes. I even blocked her view using a piece of paper. No neuropathy identified. I adjusted her diabetic and blood pressure medications and ordered labs and a follow up exam in 4 months. One month later she returned to the clinic. Her complaint, redness and swelling of her right foot, ankle and lower leg. Further exam revealed a fever and advanced cellulitis. I also found a push pin in the bottom of her foot. She faked me out. After we cleared her cellulitis and osteomyelitis I asked her why she cheated on the test. “I didn’t want you to know that my diabetes was that bad.”
So, do patients tell us untruths? Yes. Do they omit things? Yes. Pain management and controlled substance issues open universe of concerns. Some reasons untruths may be told.
1. History of undertreated pain. So called pseudo-addiction.
2. Untreated psychiatric disorders improved with the medication being prescribed.
3. Diversion- The street price for oxycodone can exceed $5.00 per milligram. At this cost, if 120 tablets of 5 mg oxycodone are prescribed a month, the potential income from that prescription is $3000 per month or $36000 per year. It is also not uncommon for people to trade prescription medications for heroin or other illicit drugs.
The question we must ask ourselves. Are we responsibly prescribing controlled substances to our patients? Are we treating pain, anxiety, or are we feeding the monkey on the patient’s back. In my next blog I will discuss universal precautions in prescribing controlled substances.