The standard of care

It’s 11 p.m. Do you know where your oxycodone prescription is? Every day I refill prescriptions for various pain medications. These requests raise my concern only if the number of pills is very large, or the patient is requesting an early refill. Because refills are such a frequent task, I don’t analyze them too much, but truthfully there are issues to be apprehensive about.

I saw an 81-year-old man with chronic back pain. Fortunately, he seemed to get some relief using a TENS (transcutaneous electrical nerve stimulator) unit, in combination with tramadol that his family doctor prescribed. I was pleased with this outcome, but his daughter piped up and asked me if I would prescribe hydrocodone for him. I was looking for a polite way to say no, or to at least ask if hydrocodone was really called for, since he was doing well with his current treatment. While I was searching for the right diplomatic formula, his daughter told me that her father’s family doctor used to prescribe hydrocodone, but he had voluntarily given up his DEA license. It wasn’t that big a deal, according to the daughter, but some of his patients had been selling their pills, while other patients had committed suicide.

I was getting ready to deny the daughter’s request with an emphatic "no," but luckily for me, the patient piped up and said he didn’t feel like he needed hydrocodone, so I was spared a potentially unpleasant discussion with his daughter. As far as I know, my patients haven’t sold their medication or committed suicide, but neither category of patient is likely to come to the office and confess their sins.

Doctors are always in a quandary about pain medication. Pain is the "fifth vital sign" and while we have to do a good job of controlling pain, we also have to deal with concerns about patients who are abusing or diverting our prescriptions. In order to balance these demands, urine drug testing has been touted as a necessity.

Many representatives of companies that perform toxicology testing have found their way to my office doorstep, but I’ve dragged my feet for years on this issue. I glibly told one company representative that I have hundreds of patients on chronic pain medication. He got so excited I think he envisioned setting up a bus or a big-top tent in my office parking lot so we could line up all the suspects, I mean patients, for their tests. But I had very mixed emotions about testing. How would I explain this to patients? "Excuse me, Grandma, but I need to make sure that you aren’t taking cocaine or selling your hydrocodone, so you’ll need to give us a urine specimen. The lab tech will watch as you pull up your petticoat and pee in this cup." How often would the testing be repeated? Would all patients be tested, or would there be exceptions? If there were exceptions, what were the criteria?

Even before I resolved these sticky questions, I had an experience in the office that gave me some added insight into the value of testing. A middle-aged man came to see me about his gout. His gout seemed quite well controlled on his current medications, but he was still taking oxycodone a few times a day for pain. After chatting with him, I didn’t have a clear idea of why he was taking so much oxycodone. In a casual way, I told him that the standard of care was to do a urine drug screen. He said that was fine, and he left with his lab order. He never did his drug screen, and he never returned to the office. He probably went to an office that didn’t ask so many questions.

I gradually reached a comfort level discussing testing with patients, but many delicate areas of medicine require some practice. "Roll over, it’s time for your annual rectal exam," is tough to say when you’re a shy medical student, but after a while it becomes second nature. Asking patients for a urine drug screen should be relatively easy by comparison, but there are many issues involved. Psychologically it is much easier for me to tell a new patient, "Okay, if I am going to prescribe opioids for you, this is one of the prerequisites." I’m much more squeamish explaining this change of protocol to patients that I have been seeing for years.

My practice finally seemed to iron out many of the small details that had previously hampered me from testing. The lab shipped us a box that was so large, and so heavy, I thought that perhaps FedEx had delivered a toilet, but in fact the box was crammed with specimen cups, plastic bags, and lab requisitions as a sign of the lab’s optimism about the amount of business they expected me to generate for them.

One of my long-term patients with chronic back pain came in. I’m on chummy terms with him, and over the course of many years I learned many details about his divorces, his kids, and their college plans. He’s been on a hefty dose of oxycodone for many years, and over the last 10-15 years I let him talk me into increasing the dose a few times, against my better judgment.

I gave him a nice little speech, and I explained that I had been prescribing his pain medication for many years, but I felt that my practice needed to incorporate urine drug testing to be consistent with the current standard of care. He agreed readily, and I dispatched him to the restroom with his specimen cup. I heaved a sigh of relief, and congratulated myself on my suave little speech.

Unfortunately, I wasn’t so suave or well prepared when I got his test results back a few days later. After a few more days of intense deliberation, I mailed him a note which read as follows: "I regret to inform you that you failed your urine drug screen. There was no evidence of oxycodone in your urine, even though I have been prescribing a large dose of this medication for you. Therefore, I will be unable to prescribe further pain medication for you."

I felt like a fool for prescribing so much pain medication without ever confirming that he was actually using it. I’m suspicious that he was selling his pills, and my prescriptions probably put his kids through college, but I’ll never know for sure. It was a tough pill for me to swallow, but it’s better late than never.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

It’s 11 p.m. Do you know where your oxycodone prescription is? Every day I refill prescriptions for various pain medications. These requests raise my concern only if the number of pills is very large, or the patient is requesting an early refill. Because refills are such a frequent task, I don’t analyze them too much, but truthfully there are issues to be apprehensive about.

I saw an 81-year-old man with chronic back pain. Fortunately, he seemed to get some relief using a TENS (transcutaneous electrical nerve stimulator) unit, in combination with tramadol that his family doctor prescribed. I was pleased with this outcome, but his daughter piped up and asked me if I would prescribe hydrocodone for him. I was looking for a polite way to say no, or to at least ask if hydrocodone was really called for, since he was doing well with his current treatment. While I was searching for the right diplomatic formula, his daughter told me that her father’s family doctor used to prescribe hydrocodone, but he had voluntarily given up his DEA license. It wasn’t that big a deal, according to the daughter, but some of his patients had been selling their pills, while other patients had committed suicide.

I was getting ready to deny the daughter’s request with an emphatic "no," but luckily for me, the patient piped up and said he didn’t feel like he needed hydrocodone, so I was spared a potentially unpleasant discussion with his daughter. As far as I know, my patients haven’t sold their medication or committed suicide, but neither category of patient is likely to come to the office and confess their sins.

Doctors are always in a quandary about pain medication. Pain is the "fifth vital sign" and while we have to do a good job of controlling pain, we also have to deal with concerns about patients who are abusing or diverting our prescriptions. In order to balance these demands, urine drug testing has been touted as a necessity.

Many representatives of companies that perform toxicology testing have found their way to my office doorstep, but I’ve dragged my feet for years on this issue. I glibly told one company representative that I have hundreds of patients on chronic pain medication. He got so excited I think he envisioned setting up a bus or a big-top tent in my office parking lot so we could line up all the suspects, I mean patients, for their tests. But I had very mixed emotions about testing. How would I explain this to patients? "Excuse me, Grandma, but I need to make sure that you aren’t taking cocaine or selling your hydrocodone, so you’ll need to give us a urine specimen. The lab tech will watch as you pull up your petticoat and pee in this cup." How often would the testing be repeated? Would all patients be tested, or would there be exceptions? If there were exceptions, what were the criteria?

Even before I resolved these sticky questions, I had an experience in the office that gave me some added insight into the value of testing. A middle-aged man came to see me about his gout. His gout seemed quite well controlled on his current medications, but he was still taking oxycodone a few times a day for pain. After chatting with him, I didn’t have a clear idea of why he was taking so much oxycodone. In a casual way, I told him that the standard of care was to do a urine drug screen. He said that was fine, and he left with his lab order. He never did his drug screen, and he never returned to the office. He probably went to an office that didn’t ask so many questions.

I gradually reached a comfort level discussing testing with patients, but many delicate areas of medicine require some practice. "Roll over, it’s time for your annual rectal exam," is tough to say when you’re a shy medical student, but after a while it becomes second nature. Asking patients for a urine drug screen should be relatively easy by comparison, but there are many issues involved. Psychologically it is much easier for me to tell a new patient, "Okay, if I am going to prescribe opioids for you, this is one of the prerequisites." I’m much more squeamish explaining this change of protocol to patients that I have been seeing for years.

My practice finally seemed to iron out many of the small details that had previously hampered me from testing. The lab shipped us a box that was so large, and so heavy, I thought that perhaps FedEx had delivered a toilet, but in fact the box was crammed with specimen cups, plastic bags, and lab requisitions as a sign of the lab’s optimism about the amount of business they expected me to generate for them.

One of my long-term patients with chronic back pain came in. I’m on chummy terms with him, and over the course of many years I learned many details about his divorces, his kids, and their college plans. He’s been on a hefty dose of oxycodone for many years, and over the last 10-15 years I let him talk me into increasing the dose a few times, against my better judgment.

I gave him a nice little speech, and I explained that I had been prescribing his pain medication for many years, but I felt that my practice needed to incorporate urine drug testing to be consistent with the current standard of care. He agreed readily, and I dispatched him to the restroom with his specimen cup. I heaved a sigh of relief, and congratulated myself on my suave little speech.

Unfortunately, I wasn’t so suave or well prepared when I got his test results back a few days later. After a few more days of intense deliberation, I mailed him a note which read as follows: "I regret to inform you that you failed your urine drug screen. There was no evidence of oxycodone in your urine, even though I have been prescribing a large dose of this medication for you. Therefore, I will be unable to prescribe further pain medication for you."

I felt like a fool for prescribing so much pain medication without ever confirming that he was actually using it. I’m suspicious that he was selling his pills, and my prescriptions probably put his kids through college, but I’ll never know for sure. It was a tough pill for me to swallow, but it’s better late than never.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

It’s 11 p.m. Do you know where your oxycodone prescription is? Every day I refill prescriptions for various pain medications. These requests raise my concern only if the number of pills is very large, or the patient is requesting an early refill. Because refills are such a frequent task, I don’t analyze them too much, but truthfully there are issues to be apprehensive about.

I saw an 81-year-old man with chronic back pain. Fortunately, he seemed to get some relief using a TENS (transcutaneous electrical nerve stimulator) unit, in combination with tramadol that his family doctor prescribed. I was pleased with this outcome, but his daughter piped up and asked me if I would prescribe hydrocodone for him. I was looking for a polite way to say no, or to at least ask if hydrocodone was really called for, since he was doing well with his current treatment. While I was searching for the right diplomatic formula, his daughter told me that her father’s family doctor used to prescribe hydrocodone, but he had voluntarily given up his DEA license. It wasn’t that big a deal, according to the daughter, but some of his patients had been selling their pills, while other patients had committed suicide.

I was getting ready to deny the daughter’s request with an emphatic "no," but luckily for me, the patient piped up and said he didn’t feel like he needed hydrocodone, so I was spared a potentially unpleasant discussion with his daughter. As far as I know, my patients haven’t sold their medication or committed suicide, but neither category of patient is likely to come to the office and confess their sins.

Doctors are always in a quandary about pain medication. Pain is the "fifth vital sign" and while we have to do a good job of controlling pain, we also have to deal with concerns about patients who are abusing or diverting our prescriptions. In order to balance these demands, urine drug testing has been touted as a necessity.

Many representatives of companies that perform toxicology testing have found their way to my office doorstep, but I’ve dragged my feet for years on this issue. I glibly told one company representative that I have hundreds of patients on chronic pain medication. He got so excited I think he envisioned setting up a bus or a big-top tent in my office parking lot so we could line up all the suspects, I mean patients, for their tests. But I had very mixed emotions about testing. How would I explain this to patients? "Excuse me, Grandma, but I need to make sure that you aren’t taking cocaine or selling your hydrocodone, so you’ll need to give us a urine specimen. The lab tech will watch as you pull up your petticoat and pee in this cup." How often would the testing be repeated? Would all patients be tested, or would there be exceptions? If there were exceptions, what were the criteria?

Even before I resolved these sticky questions, I had an experience in the office that gave me some added insight into the value of testing. A middle-aged man came to see me about his gout. His gout seemed quite well controlled on his current medications, but he was still taking oxycodone a few times a day for pain. After chatting with him, I didn’t have a clear idea of why he was taking so much oxycodone. In a casual way, I told him that the standard of care was to do a urine drug screen. He said that was fine, and he left with his lab order. He never did his drug screen, and he never returned to the office. He probably went to an office that didn’t ask so many questions.

I gradually reached a comfort level discussing testing with patients, but many delicate areas of medicine require some practice. "Roll over, it’s time for your annual rectal exam," is tough to say when you’re a shy medical student, but after a while it becomes second nature. Asking patients for a urine drug screen should be relatively easy by comparison, but there are many issues involved. Psychologically it is much easier for me to tell a new patient, "Okay, if I am going to prescribe opioids for you, this is one of the prerequisites." I’m much more squeamish explaining this change of protocol to patients that I have been seeing for years.

My practice finally seemed to iron out many of the small details that had previously hampered me from testing. The lab shipped us a box that was so large, and so heavy, I thought that perhaps FedEx had delivered a toilet, but in fact the box was crammed with specimen cups, plastic bags, and lab requisitions as a sign of the lab’s optimism about the amount of business they expected me to generate for them.

One of my long-term patients with chronic back pain came in. I’m on chummy terms with him, and over the course of many years I learned many details about his divorces, his kids, and their college plans. He’s been on a hefty dose of oxycodone for many years, and over the last 10-15 years I let him talk me into increasing the dose a few times, against my better judgment.

I gave him a nice little speech, and I explained that I had been prescribing his pain medication for many years, but I felt that my practice needed to incorporate urine drug testing to be consistent with the current standard of care. He agreed readily, and I dispatched him to the restroom with his specimen cup. I heaved a sigh of relief, and congratulated myself on my suave little speech.

Unfortunately, I wasn’t so suave or well prepared when I got his test results back a few days later. After a few more days of intense deliberation, I mailed him a note which read as follows: "I regret to inform you that you failed your urine drug screen. There was no evidence of oxycodone in your urine, even though I have been prescribing a large dose of this medication for you. Therefore, I will be unable to prescribe further pain medication for you."

I felt like a fool for prescribing so much pain medication without ever confirming that he was actually using it. I’m suspicious that he was selling his pills, and my prescriptions probably put his kids through college, but I’ll never know for sure. It was a tough pill for me to swallow, but it’s better late than never.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.