When it comes to prescribing controlled substances to patients, it’s always best to identify a problem a patient is having with a prescription before it spirals out of control. But that’s easier said than done. Many patients are adept at hiding a problem from their physicians — and even from themselves.
To help gauge whether there’s more you could be doing to identify prescription-abusing problems at your practice, Physicians Practice asked Cleveland-based internal and addiction medicine physician Theodore Parran, who is also a professor at Case Western University School of Medicine in Cleveland, what every prescription drug monitoring program should include.
Here are six items he said are essential:
1. Proper screening:
Before prescribing any patient-controlled substances, thoroughly screen the patient for a history of abuse or addiction, said Parran. That way you can determine if the patient is “high-risk,” meaning he may be more prone to developing problems and/or he may already have a problem with prescriptions; or if the patient is “low-risk,” meaning it is safe to begin prescribing him the medication.
It’s likely that about 15 percent to 20 percent of the patients you screen will be characterized as “high-risk,” said Parran. “Even if they desperately try to convince you that they really need the controlled drug prescription in order to function, most physicians just don’t have the clinical tools and skills in order to safely prescribe controlled drugs to high-risk patients,” he said.
2. Close monitoring:
If you have screened the patient and determined that he is not a “high-risk,” it is appropriate to begin prescribing him controlled substances, said Parran. But you must have a strong monitoring strategy in place, he cautioned, noting, “This is much like monitoring diabetes or high blood pressure.”
The monitoring program should include:
• Occasional urine toxicology screenings;
• Routine reviews of your state’s pharmacy board website — if your state has one — to ensure the patient is not obtaining controlled drug prescriptions from other physicians;
• Regular assessments to determine how the prescription is affecting the patient.
3. Occasional reference checks:
Routinely contact the patient’s close friends and/or family members to ask how they think the patient is interacting with his medication. These individuals can help you identify when/if a problem crops up, said Parran. “Have the patient sign a release of information form so that the office staff, anywhere from two to four times a year, can call two or three of the patients’ significant others and ask how the patient is functioning,” he said.
4. Adherence Reviews:
Frequently relay your expectation (and requirement) to the patient that he must adhere to his whole treatment plan while being prescribed the controlled substances, said Parran. That includes his plan for physical therapy, occupational therapy, pain psychology, exercise, and so on.
5. Smart Policies:
You need to have a strict policy in place refusing or severely discouraging early prescription refills, said Parran. “That reinforces the fact that these medications, which can be so useful when taken appropriately, can also be very dangerous when overtaken or taken inappropriately,” he said.
6. Informed Consent Forms:
A proper informed consent form will help you reinforce boundaries when it comes to prescribing controlled drugs to patients, said Parran. Physicians Practice recently spoke to him about the four items necessary to include in these forms that many practices overlook.
Keep in mind that many of the above tasks can be completed by your office staff, said Parran, noting that “it doesn’t require face-to-face physician time to do it.” But, he said, all of these policies can make a big difference patient care. “If a patient begins to have troubles with his prescription, the office figures it out early,” he said.
Do you have a strong prescription drug monitoring program and policy in place at your practice? Share your tips and ideas for what other practices should consider including in their programs.