Problem Behaviors

Norman Wetterau

Less serious

Ran of out pills three days early

After one year lost pills

Had a headache and a friend gave her a vicodin

Marijuana in urine drug screen after 6 months and the patient told you it would be positive.

More Serious

• Runs out of pills 2 weeks early on several occasions

• Another doctor is also prescribing opioids regularly

• Urine drug screen: no opioid but cocaine is there

• Snorting the medicine• Drinking or using other drugs with the

medication

Illegal or Criminal

• Selling or giving to others

• Prescription forgery

• Stealing or buying drugs from others

What do we do?

• Zero Tolerance: this could drive people into the streets to keep out of withdrawal

• Anything goes: I am a doctor, not a policeman. Aberrant behavior is the patient’s problem, not mine. I just keep prescribing.

• Determine the cause, address it and help the patient

Why deal with problematic behaviors?

• Those who are selling them can stop receiving them

• Those who are addicted can receive treatment

• Those whose pain is not narcotic responsive can stop using narcotics

• Those who are helped by opioids can continue to take them in a proper fashion

What do we do now?

• 35 yo woman with chronic back pain has been on oxycodone 5mg q4 to 6 h for 3 months. She is a low risk patient. With the medication, she has returned to work. She returns for a refill and you obtain a urine drug screen. It comes back 2 days later and is negative for any opioid including oyxcodone, which you specifically asked for. What do you do?

Possible Causes

• Patient is called in for a repeat urine, pill count and consultation with you.

• She had smoked some marijuana so gave you a false urine sample

• She ran out of medication early• She is selling the medication• She was seeing the doctor, so she

skipped her dose that morning

She started taking her pills every 3 to 4 hours and ran out

• Her repeat urine drug screen showed the medication and her pill count showed she was taking 8 pills a day

• She said that the medication helped a lot, but three hours later she became anxious, sweaty, and had mild abdominal cramps

Switched to long acting

• 5 mg oxycodone every 4 hours is 30 mg a day. She is taking 40 mg a day. Switch to oxycotin 20 bid or extended release morphine 20 bid. Would you give her some oxycodone for break through pain?

Could this all be avoided?

• Had we asked on the initial visit if she had taken her medication, if it was working, and how she was doing.

Still having problems

• You gave her 20 5 mg pills for breakthrough pain. She calls 3 weeks later and says she is out of both the short acting and long acting pills.

• She says the pain is getting worse and is spreading up and down her spine and into her shoulders and arms.

What do we do?

• Reevaluate the medical situation. Could she have polymylagia or a spine cord tumor?

• Use other modalities for pain relief, such as PT or mental health counseling

• Educate the patient• More frequent visits, smaller prescriptions.

Make sure she is telling you the truth.

Dose increased and it is still not enough

• Pseudoaddiction: rules out in that the dose was increased and the pain is no better

• Addiction: uncontrolled usage• Hyperalgesia: tolerance can be a form of hyperalgesia, but

some people have pain that spreads over their body. The pain is worse than it has ever been.

• Pain not responsive to opioids– You could try another opioid like methadone or

buprenorphine– You could simply taper and tell the patient that his pain is not

responsive to opioids. Better yet, say that the pain does not seem to be responding to opioids, so you want to taper them off and start some other treatment that will work better

Behaviors that suggest addiction

• Using in unapproved ways: snorting or injecting• Obtaining more opioids from others• Using other illegal drugs or alcohol• Repeated dose increases• Losing prescriptions or getting opioids from others• Positive urine screens for other opiodis or drugs• Deterioration in function in spite of increased

dosage.

What to do

• Addiction: refer to addiction treatment and/or prescribe buprenorphine

• Hyperalgesia or pain unresponsive to opioids: Taper and provide other pain treatments. You might also try methadone or buprenorphine for pain

Patient 2

• 24 yo male with back pain for 2 months. The ER gave him 50 vicodin. He is here to see you and says that the vicodin helps, and he needs a refill. You obtain a urine which is positive for marijuana. He says he smoked this because it helped relieve the pain.

Options

You take a regular hx including hx and family hx of substance use. He has been smoking marijuana for several years. Treat the pain, but not with opioids, because of the risk of addiction and the fact that opioids are not really the answer

Help him see that he also has an addiction problem and offer referral for that

If the pain is more acute and severe, and you feel he needs an opioid, give very small prescriptions, see weekly and have pt agree to stop using marijuana

Another Patient

• On oxycotin 20 mg bid but calls office a few days before her appointment and says that the pharmacist must not have given her the full prescription because she has run out and needs you to call in a refill

Possible Causes

• Did not understand how to take the medicine

• Disorganized, loses pills

• Pain not relieved, so takes extra pills

• Addicted

• Selling the drugs

• Dishonest

Urine drug screen

• Before obtaining the urine, ask if they took their pills that morning and document their answer

• Ask them if any other drugs or marijuana will show up in their urine

• If the prescribed drug is not in the urine? Diversion or they ran our early, or it was not in their urine

Is the patient telling the truth? I may not know but,

• Help correct the problem behaviors

• Stop the medication if it is not working

• Rather than arguing, I may have them come in very frequently. Some become angry and leave, while others comply and end up doing well. Time may determine if they were telling the truth