That's the dog that barks the loudest. The problem of abuse is a lot bigger.
Doctors prescribe for many workers' comp claimants painkillers for the acute phase of their injury or post surgically. Many patients continue on a long-term course of opioids for relief of systems but without the prospect of a cure. For them, the pain doesn't fade away. Because a drug's effect can diminish over time, these patients may be prescribed increasing doses of painkillers.
For instance, a patient might start on 40 milligrams of Oxycontin daily, then obtain an increase in dosage of 200 to 600 milligrams. Except for two observations, I will forsake from reporting on the effectiveness on pain relief of a long-term course of opioids.
First, many doctors prescribing for the long term do not reassess their patients, by requiring periodic counseling, for instance. And researchers have found that long-term users may discover that not using some of their prescription does not increase their symptoms. These patients may well have, each day, hundreds of unconsumed milligrams of opioids on their hands, when each milligram may have a street value of a dollar, for cash or barter.
Many healthy young workers are inured to trafficking in prescription painkillers. A culture of swapping pills thrives throughout the country. You say there is so little we can do about it? Stop whining. Get on with the remedies.
No. 1, according to an experienced medical clinic executive, is for the prescribing doctor to require the patient to sign a treatment agreement that lists the dangers of painkillers. The agreement says that if the patient tries to seek a similar kind of medication elsewhere, or uses illicit drugs, the doctor will stop treating.
"Very few primary care doctors use treatment agreements and even many pain specialists don't use them," this executive says.
Patients can fool their doctors. One study showed that up to half of opioid prescribed patients who divert or use illicit drugs are not caught when their doctors look for telltale behavioral signs of abuse.
No. 2: A remedy is periodic and random drug testing. That's not only good for policing, it also addresses other serious problems with painkillers.
These high-end urine tests collected in doctors' offices are more sophisticated than those used on employees or newly injured workers. The tests provide a detailed drug fingerprint of the patient and reveal the misuse of any prescription drug, whether or not by intent to abuse. The tests also uncover illicit drug use and can check for any abnormality of metabolism which can render a drug ineffective. A doctor not aware of this may be fruitlessly prescribing higher dosages.
North Kingstown, R.I.-based Dominion Diagnostics LLC, a testing lab, estimates that half of ongoing opioid treatments are already flawed, but adjusters and case managers rarely know about it. I don't understand why adjusters can't set as a condition for paying the doctor's invoices evidence of a treatment agreement and urine drug test results.
Insurers, doctors and regulators need to act now. Everyone with influence is still reacting piecemeal.We still are not managing long-term use of painkillers as effectively as we can.
is a Vermont-based columnist for Risk & Insurance«.
April 1, 2008
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