Tuesday 16 May, 2006

Don’t prescribe opiates and benzodiazepines to new patients

Posted in Drugs & Alcohol, Emergency Dept., General Practice, Michael Tam at 13:03 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Slow release oxycodone (OxyContin) is
now the opiate seeker’s choice.
They can be boiled up to remove
the wax and then injected.

It is a sad state of affairs, but you will not have to work in the emergency department or in general practice for very long before you see a stream of patients coming through asking for opiates and/or benzodiazepines. Your best policy (which often will be the practice and ED policy) is not to prescribe either of these agents to new patients.

No matter how clever you think you are, where will be patients who are smarter. They will have honed the practice of getting opiates and benzos out of doctors to a fine art. I certainly have been duped more than once; and it is going to be the patients who you don’t think of who will get the better of you.

“Primum non nocere”

You are not helping your patients by feeding their opiate and benzodiazepine dependence.

For example, my most recent case of being duped was a 65 year old Greek lady who spoke poor English. She hobbled in with two single-point sticks, her infirmity the result of a right total knee replacement which was complicated by a post-operative infection. Apparently, her usual doctor at a medical centre had retired and she wanted a new regular GP. As part of her initial consultation, she needed some scripts, including her prophylactic antibiotics and pain medication (oxycodone SR – OxyContin). She brought in an empty box of her OxyContin tablets where the prescriber details were unclear/smudged. On examination, she had also a severe hypertension (systolic of over 200 mmHg!) and much of my consultation was focussed on that issue, and the fact I need some old medical notes.

She seemed genuine and bona fide. Needless to say, after I gave her a script for OxyContin, she never came back, and nor could I find the details of the practice she attended previously.

Now, I am certain that she has had (and might still have) some degree of chronic pain and she does have severe poorly treated medical conditions. However, the prescription was still a mistake on my part. If I hadn’t given her the OxyContin, she may well have returned to have some of her other medical conditions sorted out – and we could have addressed her dependence on strong opiates. This cannot be done at a first meeting and certainly not in the ED.

Moral of the story? Be firm and be very very suspicious of anyone who asks you specifically for pain medication or benzos.

Updated: Michael Tam (19 June 2006)

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25 Comments

  1. Michael Tam said,

    Where the patient has a valid medical complaint and either strong opiates or benzodiazepines are indicated, then the Prescription Shopping Information Service can be of great help. Patients who are not "shoppers" generally don't have any issue of you calling the service during the consultation.

    Another useful tip is to "ration" out the medications. That is, until they can prove that they are in fact seeing a pain specialist or their regular doctor does in fact use benzodiazepines for their anxiety disorder, you can write a script where the patient must go to the pharmacy to pick up medications for only the next three days (or even daily pick ups).

  2. Denise said,

    You know I find it disgraceful in this country that the DEA has literally scared doctors into not prescribing necessary pain medications for people who truly need them. This country has gone to hell in a hand bag. Also, doctors have no right to give their so called moral and ethical opinion in practicing medicine. If a patient is truly in pain, give them pain medications. What the hell is wrong with you people? I can guarantee you if a doctor or nurse had chronic pain, you can bet your ass they would be popping them. I have seen in my career doctors and nurses by the droves who were actually stealing pain medication or prescribing them from other doctors for themselves. Boy, they will prescribe the medication that can give you heart attacks or kill your liver and they are so quick to give children anti psychotics and ritalin.. Unless you are an absolute moron, you can see the drug seekers. And about the old lady, did you test her blood? Did you actually do your job and get her records from her past hospital. I know you mentioned that her doctor was no longer in service. Did you ask what hospitals she had been to prior? I bet you didn’t.. That’s your fault. Aren’t you educated? Did you check her insurance card? Also, pharmacies are required by law to see if a patient has abused their system. The DEA would be automatically notified if she were abusing her medication. That is the Law.. or do you know the Law… There are so many people out there with horrible chronic pain and are refused opiates. That makes me sick. do you know how many people kill themselves every year because of chronic pain? You doctors better get on the band wagon here. You could easily have gotten her past medical history, with pain meds even through her insurance. Give me a break… You know in my business, I have seen so many doctors and nurses who are addicted to opiates, it makes me sick… They have clear access to them. I’ve also seen in hospitals where the nurses have stolen the patients meds… And not only that, not trying to get off the medication subject, but, I’ve seen the nurses who sit there at their nurses station scarfing down donuts galore.. and standing outside, even the surgeons smoking away.. cigarettes.. so lady, look into your own backyard in the hospitals and tell me what you truly see. People in glasses shouldn’t through stones, ok. maybe you don’t take them, but you should look in the hospital that you work at and tell me what you really see….

  3. Michael Tam said,

    Thank you for your US-centric and interesting (if irrelevant) point of view.

    Firstly, I don’t live or work in the United States where your health system is an aberration in the developed world. There is no “DEA” or equivalent militarised agency in Australia so certainly doctors here are in no way “fearful” of some sort of external agency. My concerns are much more pedestrian. Secondly, if there was a simple method of preventing abuse and diversion of medications of addiction, then there wouldn’t be a problem. There clearly is since there is a brisk trade of benzodiazepines and prescription opiates on the streets. Thirdly, that there are “bad” doctors and nurses doesn’t mean we give out medications to addiction to everyone who asks for it which is what you are suggesting. Fourthly, the suggestion that “you will have to be a moron” not to be able to pick the drug seekers is wrong. Sometimes it is pretty obvious, but many times it is not and it seems pretty self-evident to me that it is the “clever” actors who are successful.

    The patient in the narrative in my article was one of these “clever” actors. She had a good reason to have chronic pain and her story seemed credible According to your view in your comment, I’m sure that not only would you have recommended giving her a prescription but probably scream and rant at any doctor who refused. My suspicions were raised when she didn’t come back for follow up for her other serious medical conditions and a bit of investigative work revealed that little old grandma had filled over 90 scripts of OxyContin in the past 3 months from over 35 different prescribers. With these quantities, she MUST had been selling them (and at a good profit considering that the “street” price is several hundred dollars per box). “Moron”? You are only a moron if you believe that you are always smarter than someone trying to swindle you.

    The entire point of the article is that people who actually have a chronic pain disorder (in Australia anyway, and much of the developed world where there is access to universal health care) will have their medications prescribed by a single prescriber and will have documentation to support their need for medication. People who come out of the blue asking for medications who are unable to immediately and coherently provide independently verifiable past history should not be prescribed medications of addiction as a matter as protocol as you are either, (i) supporting their abuse of prescription medications or (ii) increasing the amount of diversion of these medications to be sold on the street.

    It is frankly a matter of common sense.

    The problem Denise in the United States has nothing to do with doctors refusing to prescribe strong opiates. The Unites States consumes more strong opiates per head of population than any other Westernised country. It would be laughable to suggest that management of chronic pain in the US is better than in other developed nations. People with chronic pain don’t just need pain medications; they need a multidisciplinary management plan as the pain medications are only a small component in the treatment of their condition and frequently become unhelpful with escalating doses. On the same note, people with drug (prescription or otherwise) dependence or abuse do not need more pain medications, they need rehabilitation to help them manage their addiction. The problem is that your health system denies ready and affordable access to primary health care (i.e., General Practice) for a large proportion of your population, especially to the poor or sick. You are barking up the wrong tree; go spend your energy making real changes to your health system rather than automatically bashing the provisioners of health care.

  4. Denise said,

    You are correct on that one.. And yes, I was quite angry when I wrote that. I’ve just seen so many people who truly need the pain medication and the doctors are way too sheepish to prescribe them anything. I’ve also seen lots of Vietnam Vets who have serious PTSD/panic and anxiety disorders and are turned away by the doctor in the VA hospitals and refused anti anxiety medications… This country is horrible in health care and some of the doctors are also.. They have no right to give their so called moral and ethical opinions on prescribing especially the veterans who truly need the medication. Instead they choose drugs, anti psychotics, that really aren’t indicated… And also drugs that are so old and outdated, just to pacify these poor guys.. I see it everyday.. And it makes me sick to my stomach. And the part about the nurses that I have seen that take the medications themselves, I know for a fact with some of them.. Like I said, my sister in law is a nurse and tells me horrifying stories about the nurses who abuse the drugs all of the time.. I was in the hospital one time in the cardio unit.. Yes, I had a heart attack and a poor old guy got sick and was crying and one of the nurses said, (I could hear this clearly)… Give him the haldol and shut him up.. It made me sick to my stomach.. Hospitals in this country seriously suck..And the Health Care System in this country is the worst… And go to a Veteran’s Hospital in this country and you would want to throw up…. It is disgusting, the way that they treat their patients.. There filthy as hell and they do nothing for these poor veterans that have served their country… And another thing, if that’s the case that a doctor or medical professional can’t see a drug seeker, then they should go to some kind of training… And if they suspect that someone is a drug seeker, then give them a few days of a medication and that’s all. You know we have computerized pharmacies that have social security numbers and can track everything… So, if some little old lady comes in and gets prescription upon prescription, then someone is not doing their job… I just get upset when I see people that truly need the pain or anxiety medication and are treated like they may be drug seekers or the docs are just to chicken because they worry about the DEA… I’ve been told this by actual medical people and pharmacists.. Because the drug laws are now so strict on prescribing anything that they deem addictive…. Now people have to suffer.. Yes, the dippy legislators have made the laws so strict, it is pathetic.. for people who actually need the proper medication and the proper care. And they should also get rid of the pill doctors, the ones who know they are over prescribing, yes, there are those in this country also, who ruin it for the good doctors.. and for the honest, law abiding patients who are in need of proper care… Health care in the United States is one of the worst in the world… The hospitals get huge money and kick backs from the pharmaceuticals and the insurance companies are ridiculous.. We should really have more of a socialized approach in health care..

  5. joeyanonymous said,

    Hi,

    I’m a chronic pain patient in australia of 24. And yes these is an issue in australia regarding lack of use of pain medication and yes prescription of pain medication is policed by the health inspectors and the drugs of dependance unit who enforce laws that often make it difficult for ‘pedestrian’ doctors who hold the same predjudice as everyday citizens regarding ‘narcotics’ (meaning stupor inducing in my case woulf be better described as liberating and suffering alleviating.)

    Yes i have always seen the same doctor. But based on australian laws without direction from a pain clinic i am only allowed 10 days worth at a time (my doctor gives me another script dated ten days in advance).
    At the RBH (royal brisbane hospital) pain clinic i was accepted into a gabapentin program which was pushed beyond an objective desire on to relieve my pain (on behalf of my anaesthetist.)

    When he kept trying to increase gabapentin (a medication i was desperately hoping to help but proved to be ineffective for me) and decrease the opioids (oxycontin) i had to refuse treatment as he basically said take it or leave it regarding gabapentin and my treatment at the clinic this was a hard decision to make. He then tried to make me admit i was addicted to oxycontin and that i wasn’t using it for pain (i was run over by a truck about 5 years ago have had over 20 operations and haven’t been painfree since.)
    He obviously held a bias against opioids not based on modern science and unwarranted (also known as discrimination) I am not a junky. I have been on the same dose for years.

    My GP admits that i probably need a higher dose but he cannot give it to me without authority from a pain clinic. I am now booked in at PAIN LOGIC a private clinic which i will have to pay big money for somehow (on disability pension). I have been fast tracked and will probably get in in a few months as i have been fast tracked based on need (otherwise it would have taken a year).

    I am still a member of the RBH pain clinic where the anaesthetist reluctantly gave the go ahead to prescription of oxycontin at the dose of 30mg tid. He hasn’t seen me since i refused the gabapentin program and refused to admit (falsely) i am a junky (sardonic laugh).

    I am proof of issues in the australian system. Yes drugs are diverted. No legitimate patients should not suffer as a result.

    Whoever you are, above doctor i consider suicide regularly comtemplating the possibility of over one thousand visits over my lifetime to obtain medication i have a legitimate need for where legally my doctor has to question me to make sure i’m not abusing/diverting medication.

    I am being punished for something that happened to me (being run over by a truck) and the consequential pain. I have no choice but to take the medication.

    P.S. many doctors still don’t accept the new science that opioids are effective for chronic pain as definite (and know like most medical science it is not) and due to their predjudice against narcotics they hold as ‘pedestrians’ they don’t prescribe for chronic pain or are very reluctant and insult their patients.

    I hope you respond because my struggles to find relief from my near constant chronic pain are making life hell for me.

    I had to quit my dream job (after my accident) as a library assistant (note before my accident i enjoyed travelling fruitpicking skateboarding and the outdoor active lifestyle). All of that i had to change and after i had managed to adjust i had to quit my job due to pain which couldn’t be addressed due to insensitivity and apathy on behalf of my employers and the inability of my GP to change my dose to help me through the last 6 months of my traineeship.

    Since i have developed disabling anxiety due to the hopeless situation i find myself in and have had to use valium due to extreme anxiety.

    PEOPLE LIKE ME NEED DOCTORS (I.E.) YOU TO BE COMPASSIONATE. WE HAVE NO CHOICE BUT TO ASK YOU FOR PAIN MEDICATION. TO GROUP US IN WITH AND INADVERTENTLY SUBJECT US TO THE SAME SCRUTINY AS DRUG SEEKING PATIENTS IS UNNACCEPTABLE !!)

    The number of times i have been insulted due to my medical need is absolutely dreadful and makes me dread the next 50 or so years of life (i fear my fears will get the best of me before then though)

    I HOPE YOU HEAR ME FOR MY SAKE AND ANY OTHERS LIKE ME (there aren’t that many i have no friends in the same position i.e. chronic pain)

    note my e-mail address is real you can respond directly if you like

  6. Michael Tam said,

    I have no idea of the specifics of your case or history but there are clearly some facts that need to be corrected.

    Firstly, for people with severe and disabling pain, the maximum quantity of most strong opiates that can be given on a single script by a GP is one month’s supply by a telephone PBS authority or three months supply (one month with two repeats) through a written PBS authority, though for pragmatic reasons, most doctors don’t give larger quantities than a month. “Authorisation” from a pain clinic is not required legally. The story of your doctor giving you a forward dated script is illogical.

    Nevertheless, if a new patient presents to a random doctor asking for large quantities of strong opiates without independently verifiable documentation, prudence would clearly suggest that medications of addiction should not be prescribed.

    Secondly, as I am sure that the doctors at the pain clinic will have told you, medications are only a small component for the treatment of chronic pain disorders and escalating doses of strong opiates are rarely helpful. Furthermore in the specific case of oxycodone, it has a ceiling effect; above a certain dose it does not give any additional analgesia.

    Thirdly, if you had a regular GP and a single prescriber of your analgesics, the problems that you described (small quantities, authorisation from a pain clinic, “discrimination”) clearly would not have occurred. Despite what you have initially stated in your post, you have clearly seen multiple medical practitioners for opiates.

    Fourthly, the majority of doctors accept that opioid analgesics have their use in chronic pain and there is no new science to it at all. It is old science. The new science is with adjunctive therapies like gabapentin or medications to reduce opioid tolerance (e.g., ketamine). However, almost all doctors recognise that medications in themselves are not helpful for chronic pain behaviours.

  7. Michael Tam said,

    Firstly, DO NOT SPAM. I consider 5 posts in 12 minutes to be spam.

    Secondly, I have no interest in debating you. I am not your physician and am not involved in your care. Take you concerns to your regular doctor.

    Thirdly, quantities of strong opiates that can be prescribed is public information. You can find it on any number of resources released by the PBS including their website. And yes, I know exactly how much you can and cannot prescribe since I do this regularly as my job. This is hardly secret information and all GPs would know the maximum quantities allowable for prescription.

    Fourthly, unless it is your own GP that is “discriminating” against you, then clearly you must have seen other practitioners to be “discriminated” against.

    Fifthly, do not post scripture on this website.

  8. Zach said,

    Hello everyone… I am no doctor or physician of any flavor, yet understanding people with anxiety, pain, and the prescriptions that follow comes very natural to me.

    joeanonymous – Just by your statement “PEOPLE LIKE ME” shows that you are the person that gets defensive in the event that you are confronted.

    This is all too common in prescription pill related problems. What you fail to realize is that when you rely on a substance to maintain “normal function” you are dependent on said substance. You “need” it to get by (prescription or not).

    Life is a beautiful thing, but it will drag you down just the same.

    If you stop looking at life’s gray spectrum and choose undisputed happiness, i.e Look at all the good things in your life, surround your self with positivity, and banish all negative influence, you just might “see the light” so to speak.

    It is to my understanding that the “art of medicine” (It is not a science but I won’t discuss that just yet.) is meant to treat an issue, not medicate it. Meaning that medicating is how I describe when doctors prescribe just to maintain “‘normal’ everyday function”.

    Pain should definitely be treated, as should anxiety, but for your own sake and those around you, please realize that you are strong enough to live without medications for pain and anxiety that take away so much from one’s personality and true potential.

    Even if you don’t want to, just know that you can.

    Zach

  9. Craig said,

    I’m sorry to say this, but I think it is doctors like you that cause me (and I’m sure many other men) to avoid going to the doctor, even when chronically ill. I suffer from panic attacks, and in particular have a serious phobia of needles. This becomes a particular problem whenever I’m told I need a blood test. The last three times that I tried to have a blood test the same things occurred: I tell the doctor that I have a problem with panic attacks, and especially with blood tests, the doctor either laughs or minimises or ignores the issue. I go to the blood test centre, ask for a time when there isn’t likely to be many people around for me to embarass myself in front of and (again) warn them that I have had serious difficulties getting blood tests done in the past. Again, they laugh or ignore/minimise the issue. On EACH of the last three occasions I have attempted to have the blood test done, but then had a severe panic attack AND BEEN KICKED OUT OF THE CENTRE with the nurses saying that they can’t do the blood test with me in such a frantic state. The thing that really gets my nerve is that they blame ME for having the panic attack, even though I have asked for help at every step of the process and been humiliated.

    I think it largely is because I am a large, muscular male – my wife doesn’t understand why they don’t just give me a sedative or an anti-anxiety drug on those occasions – they do regularly for a friend of hers who suffers a similar condition. The thing is, if a man has problems with anxiety or panic attacks, he is treated like a drug addict (even though I don’t touch illicit drugs, nor am I addicted to any other medication), and it is this attitude – propogated by doctors like yourself – that is responsible for men avoiding medical care and dying in droves as a consequence. What on earth am I supposed to do when I can’t get a blood test done, and when I ask GPs directly for help they do NOTHING. And then they get annoyed at ME for not having had the blood test done.

    For a profession who claims that their aim is to save lives and improve help, you sure can be a callous bunch.

  10. stranger said,

    HA,
    knew i wasn`t the only one in australia. i suffer from serious anxiety panic attacks and have rapid cycling bipolar. I dont go to the doctors anymore and would rather be manic than to be treated like a drug addict. Dr Tam shame on you and all doctors like you. In 10 to 20 years time there will be a breakthrough in this area and it will be shown that using controlled dosing of benzodiazapines can greatly improve quality of life for sufferers of mental conditions. The crappy placebo based medication will also be found to be addictive more so than benzos.I quess all your medical training and experience shows you havent really opened your eyes.But i guess your asain like every other doctor in australia.Racist? your the racist treat me and others like drug addicts…..SHAMEEEEEEE.

  11. Michael Tam said,

    It is interesting that this article like no other seems to bring out the worst in the public. This is exactly the point of this article.

    @ Craig:

    I cannot comment on how you have been treated by your health practitioners since I wasn’t there. However, the most appropriate treatment for anxiety and panic disorders and particularly, phobias, has clearly been shown to be a structured course of psychotherapy. Cognitive-behavioural therapy is the modality that has the strongest evidence.

    The current best evidence insofar as a comprehensive and independent review of good quality studies is provided by the Cochrane Library of Systematic Reviews and its recommendation for anxiety/panic disorders is the same. The first line treatment is cognitive behavioural therapy. When medications are needed to augment therapy, the newer class of antidepressants (particularly, SSRIs) are recommended.

    Benzodiazepines are NOT recommended as they have limited benefit and there is a high risk of dependence. In essence, there is little difference in prescribing a benzodiazepine for someone with anxiety to telling them to take regular amounts of alcohol. Both are inappropriate and unlikely to be helpful in the longer term.

    If you believe that you have a serious problem with anxiety and panic attacks, then I would strongly recommend that you discuss this problem with your regular practitioner and consider a referral to a competent local clinical psychologist.

    @ stranger:

    Controlled dosing of benzodiazepines can make a big difference. The problem for its use in the community is the “controlled dosing” part. Benzodiazepines are commonly and often used in hospitals.

    Benzodiazepines are addictive and it is not uncommon for people to find themselves using progressively larger doses for the same effect.

    The rest of your post is largely nonsense and frankly offensive. I don’t treat my patients like drug addicts but I don’t intend on making any of them “addicts”.

    Furthermore, the context of this article is the prescribing of medications of addiction to patients unknown to a doctor. Any patient who has a genuine need for strong opiates or benzodiazepines must have a regular doctor and regular prescriber. In the event that they will be separated from their regular prescriber (e.g., move, doctor going on leave, etc.) there needs to be a clear plan to handover management to a new / temporary practitioner. Patients who show up asking for scripts for opiates or benzodiazepines, especially without immediate and independent confirmation of their regular medications should definitely not be prescribed these medications. If there is an issue of substance dependence, that will not be treated or addressed by the continuing supply of the medications of addiction, not to mention that it is illegal to prescribe a medication of addiction to a drug-addicted person.

    And yes, your last comment is intensely offensive and racist. Unless “you and drug addicts” form a “race”, it makes no sense at all. As per this article, I intend on treating my patients who have drug addiction like any of my other patients; that they are responsible adults.

    Shame on you.

    Regards.

  12. tabt said,

    If your patients were truly being treated like responsible adults, they would not require written permission (a prescription from you), to have legal access to whatever they chose to use for pain, anxiety or anything else.

    It is a mistake to allow doctors, in any country, to be gatekeepers. They should be used as advisers only. Give patients your advice and let them make up their own minds. Doctors, like all other human beings on the planet, bring their own biases, inadequacies and misinformation to any situation. Why should other adults be legally bound and/or restricted by doctors decisions?

    Finally, SSRIs and other anti-depressants are just that.
    Anti-depressants. While pharmaceutical companies seek to market them as anti-anxiety drugs, pain medications and everything else they can possible imagine, they really do not, for most people, fulfill these functions.

    Terry Bank

  13. Michael Tam said,

    Interesting points Terry.

    However, I have a differing view of what it is to be a responsible adult in society. A responsible adult understands the necessity of rules and restrictions for a functional society, not only for other people but for themselves as well. The fact is that if there were no laws for seat belts, people would not use them. If there were no age limits to the serving of alcohol, alcohol WILL be served to minors.

    Medications of addiction like opiates and benzodiazepines are highly addictive. Moreover, they can lead to severe harm for the addicted individual. I am sure that there are many individuals who CAN self control their use of these medications but there are many who cannot. I would argue that most cannot. The problem is that you do not know this until “after the fact”.

    If people can use self control for the use of these medications, then frankly, this article wouldn’t exist as there would not be the common situation of random patients asking someone other than their regular prescriber for drugs of addiction.

    With regards to SSRIs, please actually look at the evidence. There is no conspiracy theory. SSRIs are effective for anxiety. However, as I have clearly written further up this thread, the best validated therapy for anxiety is not medication at all, rather, it is a course of structured cognitive-behavioural therapy. SSRIs or other medications should preferably only be used as an adjunct or in treatment resistant cases. In any case, there is no place for the routine use of benzodiazepines as the first line treatment for anxiety. It has been clearly shown that this is harmful. As per previous analogy; it is just the same as using alcohol in the form of a pill.

  14. Ash said,

    After reading this article which is both informative and articulate I was shocked at the comments it provoked. Most of these are very emotional and make the (invalid) assumption that in being cautious about supplying medications to potential ‘doctor shoppers’, to feed either the black market or their own drug dependence, doctors are not denying that there are patients with valid pain syndromes who require pain management.

    I am a SRMO working in a regional hospital in NSW and I have encountered both of the above types of patients in my rotations in ED. In my experience doctors, especially JMOs, tend to overprescribe opiates rather than underprescribe as we are loathe to leave a patient suffering and err on the side of providing short-term treatment while we sort out past history and form a management plan. Even more cynical MOs who have seen more than their fair share of drug seekers will still attempt to provide a limited number of pain meds after assessing a patient. We have a blanket policy of not prescribing benzos unless the patient requires sedation as they are highly addictive and only effective in the short term.

    I want to thank you Michael for this article as it highlights an issue that is a complicated one and encourages us to be vigilant of misuse of the health system. This thread has become such a tangle of issues that I think the key point that you made has been missed. The emergency department is not the appropriate setting to be prescribing opiates or benzodiazepines as patients who genuinely require these medications in the context of other therapies need to be managed by a GP who is able to take a full history over several appointments, aware of their history and has the opportunity to follow up the continuity of their care.

    Your suggestions and advice come from evidence-based recommendations and studies that show that both chronic pain syndromes and mood and anxiety disorders require a multidisciplinary approach with medications as an adjunct. Where chronic pain and anxiety disorders are being appropriately managed with clear communication between the patient and their GP there should always be a plan in place for exacerbations of pain/anxiety and this should not involve coming to ED for prescriptions. Part of being a responsible adult is forming a good rapport with your GP and being responsible for your scripts as well as not misusing your medication.

    I have not found GPs to be unreasonable or lacking compassion when they know their patients well and understand the context of their health problems, including issues with pain and anxiety. On the other hand I have heard about GPs who are happy to endorse opiate and benzo dependence in their patients as it results in repeat business with their patients/clients for scripts. This results in an unhealthy relationship that feeds an addiction and is indicative of a GP who is more interested in business than their patients. A cautious GP is more likely to be one who cares about what is happening to their patient as well as their responsibility to the community.

    As Michael says, there will always be people who abuse the system and this includes doctors, nurses and other allied health practitioners. However, the system is in place to safeguard the people who do the right thing. The problem is that as pain is a subjective experience there is no way to guarantee when people are in pain and when they are not. MOs are more than happy to trial analgesia in patients but become suspicious when pain is inappropriate to injury, persistent or unchanged in level despite other forms of analgesia. In the case of chronic pain patients should approach the appropriate people (ie, their GP) for an appropriate long-term management plan and have documentation of their health problems.

    Essentially, this is an issue of responsibility on the part of patients as well as doctors. A patient with chronic pain syndrome or anxiety needs to educate themselves on their respective illnesses. This includes recognising that both of these illnesses are multidimensional and need to be approached from perspectives other than simply medicating and certainly not blindly medicating with highly addictive medications. The patient also needs to seek medical attention through the appropriate channels as well as recognise that in order to be effectively managed by their non-primary health care provider they need to provide evidence of their condition.

    On the same note doctors need to approach patients with compassion as well as caution but recognise that there are times when they may misjudge one way or the other. Patients who have become dependent on medications often don’t have insight into their problem and therefore do not have the appropriate responsibility required to make decisions for themselves, which is where we come in. This is why there are laws and regulations and why Terry’s argument is flawed as it doesn’t recognise that the biases and inadequacies that he accuses doctors of exists in patients as well and is magnified in those who abuse drugs.

    It is easy to become emotional about this issue as both drug seekers and chronic pain and anxiety sufferers have highly subjective viewpoints. And doctors who see more of the former than the latter may come across callous when they are simply trying to be discerning. This article is not about telling doctors not to ever prescribe pain relief or anti-anxiolytics to patients. It is about being aware of people who trespass on our compassion and who misuse the health system. In order to help doctors as well as patients recognise the people who genuinely require opiates in the intermediate term it will require improved communication between parties, including here on this forum.

  15. Michael Tam said,

    Ash, thank you for your eloquent and insightful comments!

    The management of medication dependence and its associated behaviours is a challenging area. It is an area, unfortunately, that many doctors choose to avoid.

    Perhaps a useful framework that junior doctors can apply in managing the new patient seeking/dependent on medications of addiction is, “I am happy to be your doctor, but I am not willing to be your prescriber“. All patients who are on long term regular strong opiates or benzodiazepines should have one doctor who is their regular prescriber who manages their chronic pain / anxiety disorder. That doctor will often be a general practitoner, but not necessarily. Some patients prefer their prescriber to be a pain physician or a psychiatrist.

    The nature of the multidisciplinary team can be quite flexible. I have many patients with chronic pain disorders who are on strong opiates; some with marked issues of opiate tolerance. Some of my patients have their pain medications managed and prescribed by myself. Other patients have their chronic pain primarily managed and prescribed by their specialist (e.g., rheumatologist, pain physician) while I see them for their other health issues. Some patients have their chronic pain and medications managed by their specialist, but see me as their GP and prescriber. For my patients in this category, the agreement is that although I will prescribe and keep track of their medications, the actual doses must be negotiated between the patient and their specialist.

    I believe that doctors must be willing to engage with and treat patients with medication dependence. However, this cannot be achieved by giving the patient a lecture and then giving a script for a small quantity of the requested medication, “just in case”. Being a responsible and caring doctor means that you should not perpetuate the cause of their psychosocial dysfunction.

    As an aside, with regards to Terry’s rejection of “doctor’s being gatekeepers”, this has in fact an example in Sydney itself. Dr Steven Goodman of the Redfern Street Medical Centre had an ultra-liberal ideology on the treatment of drug dependence. He and his colleagues would prescribe whatever the patient asked in return for promising to attend Narcotics Anonymous and counselling. The result was predictable. The practice became a hotspot for drug addicted persons, many patients receiving almost daily massive prescriptions of drugs of addiction, multiple overdose related deaths, and, the complete failure of effecting any cures. I am sure that the majority of the drugs were diverted to the street trade. The details of this travesty can be found in the NSW Medical Board’s list of deregistered medical practitions in the Orders and Reasons of Determination between the HCCC and Dr Steven Goodman.

    Best regard.

  16. Jonas Mendleson said,

    Your point, Michael Tam, is well taken. However, I have just as much sympathy for opiate-dependent patients as I have for the doctors whose backs are up against the examining room wall. This is all so wrong!

    Had you considered that this drug seeker posing as a cripple was actually a patient who was legitimately in pain? Have you given any thought to the possibility that while you were sizing up this patient she was feeling “criminalized?” There’s a concept for you. Drs. feel victimized and deceived by drug-shopping patients while patients feel victimized, deceived, scrutinized and criticized. Guess who ends up with the better hand? At least the doctor is the one left holding the prescription pad and he is the one who makes the final determination as to whether his patient passes his covert inspection.

    A gross unfairness exists when a patient’s credibility is evaluated according to what medication he requests. If the patient who is a newcomer to the doctor’s ER or office practice asks for pain medication or anxiety medication, he or she is immediately determined to be a “shopper.”

    Lest Dr. Tam and others forget, you are all health care providers, paid to deliver a service. You are not being paid to be law enforcement officers and perhaps it is doctors who need to stand up to the DEA and help champion for the rights of their patients.

    Also, Dr. Tam, it is not a bad idea to consider the plausibility of someone coming to your office for the first time and seeking anxiety medication or pain medication, especially if the patient’s previous doctor was a suspicious doctor of your ilk.

  17. Michael Tam said,

    Yes, it is unfair. However, we are not mind readers and not every patient is honest. In fact, the majority of patients in this category; unknown to the doctor and specifically asking for a medication of addiction without immediate verification are rarely genuine.

    Furthermore, you are missing the point entirely. Patients who present with anxiety, should NOT be prescribed benzodiazepines as they are clearly harmful. Patients who present with pain should clearly not be automatically prescribed strong opiates. There are many other analgesics to use first. There is the assumption that the refusal to prescribe these medications somehow constitutes the unwillingness to treat anxiety or pain. Nothing can be further from the truth.

    Moveover, I repeat the comments I made up this thread. I do not work in the United States. We don’t have a DEA and we don’t have the draconian drug enforcement laws you have. Patients in Australia who have severe and chronic pain have generally good access to necessary medications. Part of the agreement, however, is that you must see one prescriber as the management of chronic pain is much more than medications. These medications are addictive and have a brisk illicit trade, and the easiest method of obtaining them is by presenting yourself to the “sympathetic” medical system.

    Yes, we are paid to deliver a service. The service is to provide ethical and competent healthcare. Delivering the agent of addition to a drug addicted individual is neither ethical or competent practice.

    Yes, people what are drug-seeking/doctor-shopping can often have real pain as well. Unfortunately, if they engage in antisocial (and what is in most countries, illegal) activities, there are limitations on what we as doctors can do. An analogy; someone who is violent and abusive in the waiting room may well have a real medical disorder but we can’t help them if they act in an inappropriate manner.

    I am not at all suggesting that we shouldn’t treat pain and anxiety. We do and I consider myself doing this well. However, there is a big difference in doing that and acquiescing to demands for drugs of addiction. Rather than “assessing the patient’s credibility” as you describe, the best way is simply to have a policy that one does not prescribe these medications to new patients and for this to be clear and upfront.

    Regards.

  18. dave said,

    Hello.

    I suffer from chronic pain and see the addiction all too well to pain meds. Although there was a time I got a real kick out of taking them, it’s no joke when your body has a diagnosed condition. I have epidural nerve degeneration. It took four years of horrible suffering and back forth to doctors, specialists, and finally, pain management, which still, under another doctor’s written ticket is the only way through the door, you still don’t get pain meds on the first visit. It dosen’t matter how much pain you’re in, the only reason is that there is no reason. it’s policy.

  19. Michael Tam said,

    There is a reason for the “policy”. It is a matter of safety.

    The diversion of prescription opiate medications street use is a massive problem and the medical profession is doing no favours to the community at large by being a “soft touch” to the prescription of these medications. The world would be a better place if were found analgesics with the potency of opioid analgesics without the problem of dependence. Such medications, however, do not currently exist.

  20. dave said,

    yes, I agree and from the patient side of the problem, being part of the community as well as in need of medical treatment gets you both ways, if that makes any sense. My point I fear lost was simply this, … you’re transfered to a pain management clinic by a GP, you in effect have a script for opiates already, but in need of stronger medication, not a month vacation to think things out, or in most cases, suffer one more month before starting to get some relief. I put it that way because people in genuine pain have been there foe a long time before achieving the level of care that will be effective and the clinic is going to start you out at a low dose and build you up so you just as if you’ve never taken any thing stronger than what’s in your pocket. Pain is a vicious circle. The world would be a better place if doctor and patient could take each other at their word and not worry about what the other will think of them or worse, not getting the meds they need.

  21. Michael Tam said,

    Yes, the world would be a better place if doctors could trust every person who comes in their door asking for strong opiates. The reality is that we cannot. The majority of patients unknown to the practice asking for strong opiates have problems with opiate dependence, not chronic pain. Unrestricted prescribing of opiate analgesics perpetuates opiate dependence.

    I have personally seen several patients with chronic pain where I had thought we had reached a formal agreement on prescribing as well as a strategy for improving functioning. It was not until weeks or months later that it becomes revealed that the patient has been seeing multiple practitioners and getting quantities of medications that cannot be all personally consumed (i.e., they must have been sold on the street).

    In Australia, bona fide patients with acute or chronic pain have good access to both GPs and pain specialists. However, the cost of access is that they must attend to one regular prescriber and explore pain treatment modalities apart from strong analgesics; both of which are considered best practice in pain management. The regulatory control is required as these medications have a high demand and resale value in the black market. This is not a theoretical problem. Diversion of prescription opiates represents a substantial proportion of the total illicit use of opiates. In my experience, patients who abide with their treatment regimens have much better control of their chronic pain. Patients who develop a long lasting and trusting relationship with their doctors have much better access to medications if necessary for an acute flair.

    So yes, it would be fantastic if some sections of the population didn’t view doctors as a potential source of opiates for illicit use. However, we must live in the real world. Not including my regular chronic pain patients, 9 out of 10 patients who come in demanding specific strong opiates are easily provable to be not genuine.

  22. darawk said,

    The only problem with benzodiazepine or opioid dependence is the fact that they aren’t both over the counter. Sure, but the vast majority of the problems associated with dependence on either of these two substances comes from the difficulty and expense associated with consistently obtaining them. I’ve been addicted to OxyContin and heroin before and am clean now, and looking back on it – the only thing I really regret is all the money I spent and time I wasted trying to get the stuff. The health risks are very minimal, and would be even more so if these drugs and dependence on them was not a taboo subject.

    You might say “but they would be abused”…so what? These drugs don’t cause harm unless they’re pushed underground. By prescribing that lady OxyContin you didn’t make her life worse, you made it easier and better, and if she knew you were willing to consistently write that same prescription, she would undoubtedly have returned and treated her other conditions. The only reason she didn’t is likely because she knew you would investigate the lies she was forced to tell and cut her off.

    It’s not like modern medicine isn’t capable of safely and painlessly eliminating dependence on either opioids or benzos. Ultra-rapid opioid detox under general anaesthesia can be done in 24 hours. Benzodiazepines are a little bit more difficult if the person is taking enough, but it’s certainly not impossible, and it doesn’t need to be expensive.

    Literally the only health risks associated with these drugs are overdose and addiction – and if access to them were less regulated, the public would be more educated about them. And if chemical dependence wasn’t so taboo, dependents who needed help would be much more likely to seek it, and those who didn’t want help wouldn’t have to commit crimes or trick doctors to get their otherwise harmless chemicals.

  23. Michael Tam said,

    Unfortunately, your viewpoint on opiates and benzodiazepines is incorrect. Arguably, most people who use regular opiates for the treatment of pain will not become dependent on them. However, their recreational use (i.e., use of opiates for their euphoric effect) is very addictive for many people; and by addictive, it means they need progressively higher and higher doses for the same effect and will modify their behaviour to get higher and higher doses.

    The obvious analogy is alcohol which is an addictive substance for some people, freely available and legal. Alcohol is not as addictive as opiates so most people can use it without serious health issues. However, there are those that cannot and you only need to go to your local AA meeting to know the profound effects that alcoholism (i.e., alcohol dependence/addiction) has on a person.

    If opiates were available like alcohol, the problems would be greater given its higher toxicity and higher propensity for dependence.

    The belief that a lot of harm from these medications are due to it “being pushed underground” is true to some extent which is why there are free and legal drug and alcohol programs in most Western nations. However, ignoring the psychopathology of addiction is denying reality.

    You said that “by prescribing that lady OxyContin you didn’t make her life worse”. I disagree. I did in fact prescribe the script in that anecdote because I believed her story. It was that she didn’t come back that made me suspicious and on further investigation, it became obvious that she was probably selling OxyContin for a (huge) profit.

    Regards.

  24. S. D. Reiter, M.D., FAAEM said,

    “Don’t prescribe opiates and benzodiazepines to new patients”

    As an emergency physician, most of my patients are “new patients”. I appreciate your concern with enabling Rx drug abuse, but it is often difficult to tell real pain from scammers. I admit that I tend to overtreat, unless the patient is an obvious faker, but I don’t agree with your advice. (Maybe it is good advice for primary care providers that provide continuity of care.)
    I practice in Los Angeles where the worst that happens is a notice from the Dept. of Justice displaying the recent narcotic Rxs that a patient has received, which I find useful.
    Practitioners here have been doing a better job of pain management these last few decades

  25. tim D., PharmD. said,

    Admin: moved comment to article

    Dear Mr. Tam,
    I just wanted to clarify a fact for you, so that you, nor your patients, nor your readers get misinformation. In your article called “medicine box”, where you discuss being careful not to prescribe opiates to ED patients without a written history when they specifically request large amounts of opiates (which is quite a prudent suggest, to agree with you).

    You replied to a reader, saying “unlike some other opioids, oxycodone has a ceiling effect, meaning that larger and larger doses will not reduce pain”.

    I want to inform you that that statement is INCORRECT. Oxycontin(R)(Oxycodone), like morphine and some other opioids HAS NO ceiling effect. You can keep giving it in larger doses, which WILL reduce pain at the proper dose. You only have to be aware of reduced respirations and airway maintainance.
    This is unlike codeine. Perhaps you were thinking of codeine, which DOES have a ceiling effect. Please post this correction, so that your readers will be aware of the right information: OXYCODONE does NOT have a ceiling effect.

    Quote from source: “Oxycontin does NOT have a ceiling effect and the dose CAN be increased gradually, provided that any adverse effects are monitored.”

    sources: Clinical Drug Investigation. Vol 28(7) 2008, p. 399


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