An excerpt from the next book you may or may not like

This is from a primer that I am including in my second book to train new providers on how to manage controlled medication patients. Remember that my advice to them is given in the same way I give advice to you. You really may not like some of my advice to them, but I need to help them stay in practice. Read carefully.

Everyone Else (The Protocol Patient) 

First off, what is a protocol patient. If you are going to manage pain, you really must have defined guidelines. These guidelines need to be clearly defined in a controlled medication agreement.  I will include a basic controlled medication agreement at the end of this chapter, and it is not meant to be the template you use personally for your protocol but do feel free to use it as a starting point for your own.   

Here are some basic components of a controlled medication protocol.  Again, this is not meant to be a comprehensive list: 

1. Set expectations for:  

2. Follow-up frequency. 

3. Exclusivity – patients should not be allowed to receive meds in the same class from other providers. 

4. Random pill counts 

5. Urine or serum toxicology and/or point of care urine drug monitoring. 

6. Bringing pill bottles to every visit.   

7. Using a particular pharmacy 

8. Only receiving refills at a face-to-face encounter. 

9. Participation in adjunct treatments 

2. Detail rules for: 

• Prohibition against sharing or selling medications 

• Not replacing lost or stolen medications 

• Maintaining a working and current phone number  

• Taking medication as prescribed 

• Consequences for not following the rules (dismissal circumstances) 

Going through these points in greater detail should give you a basic idea of how to structure your management of controlled medication patients. But before I do, let me say that 90% of controlled medication patients, for the most part, take their medications as prescribed and are adherent to the plan of care.  I am going to make some comments about aberrant behavior, but just because you have to be on alert doesn’t mean you will constantly be placing patients on corrective action or dismissing them.  With this said, let’s resume. 

Follow up Frequency:  Simply put, increased visit frequency saves lives.  At our clinic, we see all class 2 medication patients monthly.  This includes ADHD medications. It can be argued that it is overkill compared to some clinics but for us, it is more important to hold all patients to the same standard than to try and create different rules for different patient populations.  When you consider your rules in this area, remember that it will be your non-licensed clinical staff that will be enforcing the rules so making the rules as simple to interpret as possible is important.  

One of the reasons I feel so strongly about increased visits creating increased safety is because the shorter the duration between visits, the less time the patient is able to break the rules without you being able to detect that something is wrong.  I said that we see our class 2 medication patients every month but because of 31 days months and pharmacy limitations, we actually see them every 4 weeks.  If a particular patient is always showing up with empty bottles on day 28, you can know that their adherence is less than 100%.  If they are out of medication on day 28 AND they are in visible extreme pain in your office, you can begin to question just HOW LONG they have been out of medication.   

Exclusivity: It makes perfect sense that if a patient is getting opioids from you, they should not be receiving them from another provider. However, your protocol should still expressly state it. Are there exceptions to this rule? Yes, but only with discussion ahead of time.  The main exception is when a chronic pain patient has surgery, it is reasonable for the surgeon to be allowed to dispense a single short-term prescription of additional short acting opioids for acute-on-chronic pain.  However, you should tell the patient that any further changes to your normal plan of care after this initial script should be handled through the office.  

Random Pill Counts: Random pill counts are not especially useful about 80% of the time, but if you are going to manage chronic controlled medications, you want to be seen doing them.  Plus, when a patient knows they might be called in for a random count, it is easier to bring them in when you have a clinical concern they may be overconsuming or diverting their medications.  Also, the random drug screens done at random pill counts can often show patients who may be non-adherent but “straighten up” a week before their office visits.  Cocaine and methamphetamine abuse is often caught at random drug screens.  

Urine Toxicology/Point of Care drug tests: the different variations of practices between clinics are vast, but you absolutely should be testing and should not be relying SOLEY on point of care testing.  These point of care tests are notoriously easy to fool and are only useful as an adjunct to forensic testing that should be performed at a minimum of twice a year.  The norm at my clinic is forensic testing every 90 days and when there is a concern.     

Life Hack: It is a simple difference in verbiage but so much more therapeutic to substitute the word “suspicion” with “concern”. What I would tell my students is, “The DEA does not expect you to be a cop, it expects you to be aware.” The purpose of a controlled medication protocol is to keep folks safe, not “weed out the bad apples.” The word suspicion implies that you believe them to be engaged in wrong doing, but the word concern simply means you are worried they are being unsafe.  Are they synonymous?  Fairly close, but one word will keep the conversation moving forward, and the other will likely cause defensive behavior that will shut the process down. Also, when you say in your heart you have suspicions, you subconsciously paint that patient in a less positive light.  And when you feel like you are ALWAYS having to be suspicious, you will get burnt out real fast. 

Bring Pill bottles to every visit: the one thing even an adherent patient has to worry about is medication security.  Bringing their medications in the original dispensing bottles is to help assure accurate counts, but it is also to remind the patients that keeping up with these bottles is part of the responsibility to keep them secure.  (You need the bottles to have the dispensing date to help assure an accurate count.) 

Using a particular pharmacy: While we have not yet removed this identifier from our controlled medication agreement, I will say that this was a lot more plausible before the 2016 guidelines, and before the DEA cut production of opioids so drastically.  Now it is normal to have to call around and find pharmacies that have an adequate supply of a patient's medications.  Using a particular pharmacy should still be the GOAL, but it may now be a teaching point rather than a hard fast rule.  

Only receiving refills at a face-to-face encounter: This really needs to be a hard fast rule if you don’t want to constantly be policing patient requests for refills outside of a visit.  Even when you grow more comfortable with your patients and their specific needs, and even though there WILL be some exceptions, the more exceptions you make, the more you will be pushed to stretch the rule. I have been doing this job for twelve years and have only recently had to ratchet this down hard because folks would push their visit out and ask for a bridge to the new appointment at the same time.  It is amazing how quickly you will look down and realize it has been over two months since this patient actually darkened the doors.  

Participation in adjunct therapies: the expectation that participation in non-invasive therapies will be part of their treatment should be established.  No one should be forced to receive invasive therapies as a condition of medical pain management. This is simply a call to exercise as one is able, use heat/cool therapy, soaks, stretching and all of the other things that keep a patient as functional as they are capable of being. 

It is medical exploitation to require a patient to accept invasive treatments that pays the provider hundreds and thousands of dollars in order to receive an opioid prescription. It is also not ethical to require them to use your personally owned lab company and demand they provide forensic urine drug screens every month.  

Prohibition against selling or sharing medication: If you think this rule should be so obvious that it should not require its own line in your agreement, I would be inclined to agree.  However, I strongly encourage you to have it in there in the same way that shampoo bottles still tell you “Not to be taken internally.”  

Not replacing lost or stolen prescriptions: Yes, this includes the infamous bottles that fall off the back of the toilet into the bowl. Seriously, bad things DO happen to good people. But we must answer for all the prescriptions we write, and by not having a policy expressly stating the above, you will be asked quite frequently to do exactly this. 

Taking medication as prescribed: This is another rule you may feel shouldn’t have to be written down, but the number four reason you will have to dismiss a patient from controlled medications is overconsumption. When a patient consistently overconsumes their medication, they are setting the plan of care, not you. While I don’t believe a patient should be dismissed for the first or even second time they fall into this trap, eventually you have to remember the entire purpose of the rules is to keep folks safe. When you allow your patient to consistently dictate how they will take their meds, you are not keeping them safe, you are enabling bad behavior. 

But what if the pain plan is simply not working? You must mentor your patients that the proper way to handle the situation where the pain plan is not working is to either A) make an earlier appointment to discuss the problem, or B) follow the plan until the next meeting and discuss it then.  Have I ever changed a plan of care when the patient took extra medication the month before? Yes, rarely.  But the normal answer I give to the patient is, “I’m not going to make a bigger promise to you when you are not keeping the smaller one. Follow the plan for the next month, stay in adherence, and we will discuss a change then.”  

What I am trying to teach you at this moment is that just because I want you to be a kind and loving provider, does not mean I am not asking you to be a timid or weak provider. When it comes to medications that are scrutinized to the level that opioids are, being overly permissive to deviations from your protocol will get you labeled as irresponsible. You cannot afford this type of label. So, even here, be kind when you enforce the rules but enforce them.  

Also, you might be wondering what reasons number one through three for dismissing patients from controlled medications. The number one reason to dismiss a patient from controlled medications is an overly adversarial relationship with the patient.  I want you to be comfortable prescribing these medications, and to feel competent with this guidance. But you do not deserve to be mistreated any more than those in your care do. A patient that you are in conflict with at every meeting will make you miserable.  Warn the patient when you are feeling this way and give them a chance to change. But the purpose of the book is to help you love your job, and at some point, you are allowed to protect your peace. 

At my office, there is a slight variation on this theme.  I can take a lot, and I have dismissed less than 5 of my own patients in 12 years for an overly adversarial relationship, but I have dismissed MANY more who mistreated my staff and my fellow providers.  I have also dismissed OTHER providers patients based on how I witnessed them treating that provider. 

The number two reason for dismissal is inconsistent findings on urine toxicology. Again, I often don’t dismiss a patient the first time I get an inconsistent drug screen. I will put someone in corrective action first.  Remembering that the rules are designed to keep folks safe, I teach my students to ask themselves the following question when considering what to do with an inconsistent drug screen: Are they safer in my care or left to their own devices? If they can be brought into compliance, they are often safer in your care. But when the drug screens come back multiple times with inconsistent results – yep, you guessed it, you are enabling bad behavior. 

The number three reason for dismissal from controlled medications is an unusual one – and will often result in immediate dismissal. When the urine toxicology comes back “inconsistent with human urine” - it means the patient bought internet pee. If you can’t trust a patient to even give you a real urine sample (never mind when they bring in someone else’s urine), there is very little that you can do to make them worthy of continued trust. 

Consequences for not following the rules: Here I want you to forget all the second changes I sometimes give. Your protocol should state explicitly that they can be dismissed for the first offense however minor the infraction.  No matter how much I am trying to help you be different than a lot of the care I see delivered today, it is absolutely still your prerogative who stays on service and who does not.