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Old 12-19-2006, 11:49 AM   #1
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Question Monitoring Prescribed Painkillers Question, Please Help

Hello,

My husband and I live in Long Island, NY. He has been in treatment with a pain management specialist for about 4 years because of his back. And is on a lot of heavy prescribed narcotics.

I searched online and found alot of guidelines and other articles that suggest to monitor patient to prevent addiction and toxicity. They state things like 'monitoring is crucial to prevent the risk to kidneys and liver posed by long-term therapy' and 'Opioids 4 treatment of chronic pain periodically assess functional status, opioids effects, and medication misuse' or 'As noted in the Supreme Court (Gonzales v. Oregon) ensures patients use controlled substances under the Supervision of a doctor so as to prevent addiction and recreational abuse'

BUT...

The guidelines and/or articles, don't discuss 'HOW' the physician should monitor, example: by performing xyz steps to patient, like check his blood pressure, take his pulse. How can you monitor for addiction?

The Question: What are some required steps or guidelines, a physician could perform to monitor their patient for adversely affected signs of addiction? Also, is a physician required to routinely monitor medication levels, either by blood, urine, pill counts? Or run a diagnostic test and drug screening, if prescribing a controlled substance?

I hope I don't sound a little rude or nasty, its just becoming extremely frustrating not being able to find the answer. Its almost like this is a big secret. Shouldn't this be public knowledge. Why is it, that no one wants to answer this.

I apologies for taking up any of your time and tried to find the correct words to express my concern, with the fewest words possible. I will be extremely grateful for any help.



Thank you so much,

Lisa S

 
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Old 12-19-2006, 12:37 PM   #2
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Re: Monitoring Prescribed Painkillers Question, Please Help

Hey Lisa-
Welcome to the boards. Different doctors do different things as far as monitoring a patients medications & health.

My PM doctor orders certain blood tests at certain intervals, for me will e every 6-8 months to check my liver function and also does a fasting glucouse with it because of some of the medications I'm on. There may be other tests other doctors do as well.

As far as monitoring the actual medications themselves, different states have different laws requiring doctors to keep detailed records. Some doctors have random pill counts, or pill counts at every appointment, some have random urinalysis tests in their office to make sure you have the medications they are prescribing to you in your system, and some have really no rules so to speak.

My PM doctor, at the first appointment had me sign some kind of release which allowed him to get some kind of records from the state that told him exactly what medications I have been prescribed and purchase prior to my seeing him. I'm glad I was honest on my patient forms about the meds I'd taken in the time before ever seeing him.

As far as monitoring for addiction, most PM doctors are keenly aware of behaviors that would indicate whether a patient is becoming addicted. Having said this, I must also state that they are also just as keenly aware of the difference between addiction and dependance. Part of trying to insure against addiction is the pill counts, and the urynalisis. If too much of the med is in your system, it might indicate you are taking more than he prescribed. If a doctor feels you are showing signs of addiction, I would think they would be forthcoming with their suspicions and tell you they feel there may be a problem. If my PM doctor feels a problem is beginning, it states in our contract that he can refer me to a psychologist for further evaluation.

You asked a very good question and will be getting some great information from others who post here. Are you concerned about your husband? Is this why you ask, or are you just wanting to know for personal information? I ask because you specifically mentioned addiction in your post. Please, just know that there is a huge difference between addiction and dependance.

Take care! Keep checking back.

OH- P.S.- Many states do have monitoring programs as well. Someone here can tell you where to go to find that information. I know the state my PM doctor is in has a statewide monitoring program.

Last edited by ozzybug; 12-19-2006 at 12:39 PM.

 
Old 12-19-2006, 04:15 PM   #3
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Re: Monitoring Prescribed Painkillers Question, Please Help

Hello!
Those of us in chronic pain make a huge distinction between dependence and addiction, You might not read about this anywhere else on the net, I know I havent.
Everyone who takes something on a daily basis may become dependent on it to feel 'normal'. If someone drinks 4 espressos a day, and then quit, they will have withdrawals, get terrible headaches, ect.
Likewise people who take narcotic pain medicine daily become dependent. If it is withdrawn, they will become sick. But that is not the same as addicted.
Addiction is behavior driven. Addicts lie about how much meds they are taking, and they lie to get more than prescribed, either saying they were lost, stolen, dropped in the toilet, or by going to more than one doctor and not telling them about each other.
People on successful opiate therapy have a vastly improved quality of life. most of them do not even feel the dopiness drugged feeling from the meds anymore, just the pain relief.
Addicts are miserable. They have NO quality of life and niether does anyone around them.
Some huge red flags of addiction are using street drugs, forging or altering of prescriptions, doctor shopping, ect.
We all have our ups and downs in pain management, and sometimes people assume we are addicts, but very very few of us will ever show any of the behaviors listed above.
I hope this helps you find the best care for your husband.
Your Friend, Fabby
PS, forgot to say that PM docs are trained to watch for these signs of abuse and more, and besides that they monitor when and how often meds can be picked up, and some do pill counts and urine tests as well, Like Ozzy said. :::waving at Qzzy

Last edited by Fabrashamx; 12-19-2006 at 04:18 PM.

 
Old 12-21-2006, 01:56 PM   #4
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Unhappy Re: Monitoring Prescribed Painkillers Question, Please Help

Hello,

First want to thank everyone for taking the time out to help. Fabrashamx, thanks for taking the time and I do appreciate your info. But my question was about physicians monitoring. Most people who have answered my question, also start to explain how addiction works and all, but that is not my concern. My husband and I have learned alot about addiction and etc from reading all the guidelines and articles.

ozzybug, you mentioned 'doctors do different things' and that was one of the concerns I have been trying to get a handle on. I would have thought all pain management specialists have to follow a certain method of monitoring. So if dr's do different things, then does it mean that they also dont HAVE TO monitor the patient at all? I've asked lots of people, even some doctors online and they dont have an answer, which I think is strange being they are dr's and should know this.

You also mentioned 'different states have different laws requiring doctors' This is information that I have been searching for and cannot find anywhere. I have tried to findout what the 'laws require' from doctors in my state. I live in Long Island, NY. And again I still cannot get a striaght answer. You also noted, that some may have no rules so to speak....can that really be true, because I would have thought if they didnt have rules, then one they open themselfs to big lawsuits and second, doesnt the state or board demand they have rules?

As for if I ask this because of my husband, no. Our concern is not of how he feels on the meds. We know the process, and how they can effect the body. Our main problem was not being able to find the info on the set rules, guidelines, whatever you want to call them, for physicians who prescribe narcotics. When it comes to monitoring, everything states to monitor your patient but does not say HOW. And he other best part is, are the doctors, mainly pain management specialists, required to monitor their paitent. Is there some big secret, that we should not know...I dont get it?


Thanks for all the help, maybe you will be able to locate some info or maybe some one else might have some helpfull info. I just dont understand whats the big deal for certain people not to tell me.


God bless,

Lisa S

 
Old 12-21-2006, 02:52 PM   #5
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Re: Monitoring Prescribed Painkillers Question, Please Help

Hey Lisa, Physicans are monitoring by doing all these thinngs, perioiodic drug testing, psychological evals, pill counting. They also bill for differentlevels of carfre. Every 3 months I have an apt with the actualdoc alled a follow up, the apts in between are simply med checks where pills are counted and the next script is given. On the more extensive follow up apts when the doc is there, He has the ability to make and note physical observations, Talk to the patient about what's goiong on in their life, and how they spend their days, what are their plans for the furure.

The idea of the questions and questionaires, psych evals and seeing the doc and not just picking up a script is to see if the patient is actually benefitiing from this treatment plan. Some docs take it seriously and some docs are lax in the way they document and treat. Say, patient X says his pain is reduced from an averagwe of 7 to an average of 3, sounds great. The docs job is to find out how he's doing dealing with chronic pain severe enough to require these meds. Since starting long acting opiates 2 years ago, patient X has gotten 2 DUI's, been fired from his job, his wife left him, he lost his home and went BK. Now he lives in his car but states the meds are working great and would have no quality of life without them. The DEA may have a little problem justifying continued use of meds on Patient X and so should the doc.

I think part of what they are asking or suggesting is for the doc to look at the big picture. They want the doc to know these basic life details and when they start adding up on the minus side, pain relief doesn't appear to outweigh what it might have cost or be costing patient X to be comfortable and fine. Is he really fine? Did he hide these facts, did you learn from a concerned family memeber? Everything matters as CP effects every part of someones life.

Investigate means to gather information to support the benefit and continued use or information to discontuinue treatment if the negatives outweigh the positives. There are many ways for a doc to gather information and that's what they are asking.


That's my take on it
Welcome, Dave

 
Old 12-21-2006, 09:10 PM   #6
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Re: Monitoring Prescribed Painkillers Question, Please Help

Monitoring of patient progress, status and compliance is relatively the same for pain mgt docs as it is for other specialists. For the most part there's no mandated process or checklist that physicians must follow. Doctors are responsible to the DEA, the state medical boards and their own conscience about patient treatment. Not all GPs, Psychiatrists and other docs go about patient treatment and management according to mandated rules, but rather known good practices. And their interpretation of the "recommended guidelines" is usually highly individual.

Some will take regular urine screens, some won't. Others will perform blood tests for toxicity, others may not. Some have very strict rules regarding pill counting and replacement of lost or stolen meds, others not so strict.

It usually depends how much they know about the risks and benefits of prescribing controlled substances, and how much concern they have for DEA oversight and medical board sanctions if complaints are made.

I have searched and found state policies on the practice of pain management which covers rules on how one can and cannot prescribe controlled substances - for this there are also laws. But I've never found laws regarding blood testing and such, just suggested guidelines.

As already mentioned, most pain management docs are intimately familiar with the kinds of behavior that indicates addictive disease. The signs are pretty clear and most of these docs have strict rules prohibiting such behavior and for the suspension of treatment if/when it occurs.

As in all disciplines, there are good and bad pain docs, informed and uninformed practitioners, experienced and unexperienced, etc. They get to decide how to practice their speciality. The mandates are usually related to prescribing controlled substances.

Last edited by forginon; 12-21-2006 at 09:14 PM.

 
Old 12-22-2006, 04:20 AM   #7
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Re: Monitoring Prescribed Painkillers Question, Please Help

Hey Lisa-
[removed]

I know you really just want to know what the true rules are and understand what you are asking as well as why you are asking. Being in pain management is a huge responsibility and one that shouldn't be taken lightly.

It really is true that different PM doctors monitor their patients medication use in different ways. Those doctors who are really concerned about keeping the DEA happy tend to have more "rules" about monitoring programs. The other doctors who want to keep the DEA happy, but maybe aren't so worried about being investigated or whatever may just have more "lax" rules.

I will tell you that my PM doctor has a Patient/Physician pain management contract which clearly states each of his rules and monitoring practices. These things include all the things mentioned in previous posts such as pill counts, periodic in-office urinalysis tests, blood tests, and also getting my signature on the controlled substance sheet each time I am given a refill.

Most states also have statewide prescription monitoring databases. These databases are linked to the pharmacies, insurance companies and also to the doctors offices via computer. Anyone can access this information and see what meds a patient has been taking, the prescribing doctor, the pharmacy at which the scrip. was filled, how many pills were prescribed and if there are any refills left on the prescription. As a matter of fact, most states have these databases, and many of the ones that don't have them are trying to get legislation and funding to start one. I don't think Florida has one, and I know NC is trying to get the ball rolling to start one. Virginia does have one, Kentucky has one too. I'm not sure about New York.

I know I basically repeated myself and the other posters, but I really am trying to help. Sorry if I haven't. You do ask a truly valid question. Try and do a search on State Prescription Monitoring Programs too. Maybe you can get information that way.

I hope you are able to get the answers you are looking for sweetie.

Last edited by HBMod07; 12-22-2006 at 01:17 PM.

 
Old 12-23-2006, 06:58 AM   #8
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Re: Monitoring Prescribed Painkillers Question, Please Help

Thank you HBMod07 for clearing that up. I didn't want to break any rules. I think the link I have is one that is within the rules, but will check with you guys before I post it. Happy Holidays to all!

 
Old 12-23-2006, 01:06 PM   #9
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Question Re: Monitoring Prescribed Painkillers Question, Please Help

Hello,

I want to thank everyone again for taking the time out of your life and trying to help me understand how this should all work. It means alot to me and my family. From what I read, it all makes sense and its kind of what I thought to be the truth.

So, if the physicians know that there are certain rules or guidelines and still make the decision not to perform them, is this because they know they will not get in trouble either by medical board or lawsuits?

I mean, after reading some of what you all said, and knowing there are certain guidelines for prescribing controlled substances but still don't perform them and then the patient becomes either addicted or even dies...is the physician responsible?

Also, I'm not sure how the rules work for this forum but if anyone knows where I can look or ask about the guidelines/laws for prescribing in New York, please let me know either by posting here or PM me.


Thanks again for all the help,

Lisa

 
Old 12-24-2006, 10:17 AM   #10
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Re: Monitoring Prescribed Painkillers Question, Please Help

ACC-
I was able to contact HBMod07 via email, and was approved to post the following link which describes/details each states laws regarding monitoring prescription of narcotic medications. The link is as follows:

[url]http://www.medsch.wisc.edu/painpolicy/matrix.htm[/url]

Again, this link was approved by HBMod07. (Thank You!)

I hope you are able to get more answers from this site. Have a great day!

Ozzybug

 
Old 12-24-2006, 01:22 PM   #11
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Re: Monitoring Prescribed Painkillers Question, Please Help

Quote:
Originally Posted by ACCTEAM2006
...So, if the physicians know that there are certain rules or guidelines and still make the decision not to perform them, is this because they know they will not get in trouble either by medical board or lawsuits?
This is not the case from my experience. I believe most pain management physicians have the patient's best interest at heart. And many have a great deal of experience in the field. (of course there are exceptions) It wasn't that long ago that agressive pain management with opiates for non cancer pain was taboo, and brought down serious scrutiny by the DEA, etc (it can still happen). I believe the '90s was the Decade of Pain Management? And the emphasis on pain management continues today at some pace. Before this newer approach, those doctors that cared enough about their patients were "out of bounds" when treating non-malignant pain with opiates. But if they felt it was in the best interest of their patients, they might risk practice-ending scrutiny to prescribe something more effective than ibuprofen.

Many of today's doctors may skirt suggested guidelines for equally honorable reasons, rather than just thinking they won't get caught.

What scares me more are those doctors who hide behind misconceptions about opiates (some from older guidelines) to avoid effective and appropriate management of patient pain.

Quote:
I mean, after reading some of what you all said, and knowing there are certain guidelines for prescribing controlled substances but still don't perform them and then the patient becomes either addicted or even dies...is the physician responsible?
Neglect is up to the courts to decide. And it goes both ways. Neglect that can result in patient harm, and neglect that results in undue patient suffering. In fact, there are some high-profile cases where doctors have been found guilty in a court of law for under-prescribing opiates to dying patients in terrible pain.

So I guess the idea is to locate a PM doctor that practices pain management according to your preferences. I believe it's possible to search for malpractice suits against doctors. I don't remember just how to do that though. Maybe the State Medical Board?

Last edited by forginon; 12-24-2006 at 01:23 PM.

 
Old 12-25-2006, 10:27 AM   #12
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Question Re: Monitoring Prescribed Painkillers Question, Please Help

Hello,

Again, I want to thank everyone for taking out the time. I guess from what I'm getting from all this and that physicians really dont have to follow their state guidelines...they may suffer jail time or lawsuits but that is their choice.

The only other thing I would like to be able to find out is, what are the set rules, steps, etc for my state New York, when it comes to monioring a patient. I'm not sure if there is a list of what to perform first or what to perform in a order process...do 1 then 2 then 3, etc. But if all these guidelines suggest to monitor, I would guess there should also be a break down on how to perform this.

Thank you all for not passing my post over and making a stand to help. I truly, truly do appreciate it.


Lisa S

 
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