Solving the narcotics dilemma

Key Points

I need another script for my Vicodin because I accidentally dropped my pills in the toilet." "I'm going out of town for 2 weeks; I need my Oxycontin early." No doubt you have heard these kinds of requests for early refills. As physicians, we roll our eyes and exchange knowing looks with our staff every time we hear them, and groan every time a narcotic refill request crosses our desk.

If you write any narcotic prescriptions at all, it can seem as though everyone is a druggie and that every patient taking them is out to pull a fast one on you. It is even worse if you manage chronic narcotic use. It's hard not to get cynical.

THE EMOTIONAL APPROACH

Here is one approach that may not be the best. "You have pain? Nothing but Vicodin works? You look sincere. Here's your prescription. I put refills on that script as well." Unfortunately, I have seen this approach commonly (though not always to that extreme). The perceived sincerity or desperation of the patient is the primary consideration for determining pain treatment. I call it the emotional approach to narcotics management since feelings, or gut instincts, make the decision. For these doctors, maintaining pleasant feelings by avoiding confrontation or disagreement is important. Often, a narcotics prescription is the least painful means to end an office visit for a pain complaint. While this approach avoids confrontation or disagreement, it will ensure that many narcotic scripts are written.

Perhaps this approach comes naturally to us. We go into medicine because we want to help others. Our training reinforces our listening and empathy skills. After several years of this kind of training, we are ready to believe anything our patients tell us. Usually that's a good idea, but occasionally it is not. While those who actually need narcotics probably will get them from the emotional prescriber, those same patients may misuse them due to the lack of restraint in prescribing.

Narcotic abusers will also find it easy to get prescriptions. Moreover, since the emotional prescriber prefers a narcotic prescription as the path of least resistance, many patients may miss out on potentially more effective, non-narcotic options.

THE CYNICAL APPROACH

Rarely prescribing narcotics is another way of avoiding conflict, but that practice doesn't help the patient with a clinical indication for the drugs. I call it the cynical approach to narcotic management since it seems to be based on universal suspicion. Physicians who deal with narcotics this way probably have been burned before by some clever abusers. Since these physicians have discovered that they can't always trust their own feelings, they prefer to avoid the issue altogether. Commonly, they refer the patient to a specialist, often a pain specialist, who often will put the patient on narcotics anyhow. But at least the referring physician didn't have to try to sort out which person's pain was real.

Of course, the methods presented above are at the extremes, but they illustrate poor ways of managing chronic narcotic use. So what is a better way? The following ideas may help you to navigate the difficult waters of narcotics management.

Be consistent.

If seeing old records is important for you to verify prior narcotic use, always at least try to get them. If checking a controlled substance database is part of how you monitor narcotic use, do it consistently. I could talk about many specific ways to control or monitor narcotic use, but that is not the purpose here. Rather, I wish to emphasize that whatever tools you use, use them consistently.

Think of how you manage other chronic illnesses, such as diabetes. You have a set schedule for labs and office visits. You have pre-determined goals for hemoglobin A_1C, blood pressure, and cholesterol. You may tailor the plan slightly, as appropriate, but you consistently apply the same standard to all of your diabetic patients. Do the same thing for chronic narcotic users.