White Coat Underground

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Not an opium poppy

I took this picture a couple of days ago. This poppy popped up as a volunteer in my front bed. It’s about four feet tall and the flower is about 5 cm in diameter. It’s not an opium poppy, but it could pass, and I’ve been looking for an excuse to use the picture.

Opium derivatives—and later, synthetic opioids—have probably been used for millennia for the relief of pain. Given human biology, they’ve probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain, but come with a lot of undesired effects, not least among them the potential of developing a substance use disorder. They also have considerable street value, with Vicodin selling for $5-$10 per tablet on the illicit market.

But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective. A multi-modal approach to the treatment of chronic pain can be very helpful, but many patients do not have access to this expensive treatment, and many more simply want instant relief, something which opiates can provide, but with a price.

The abuse of prescription opiates is on the rise. Continuing with Vicodin as an example, 9.3% of American 12th graders reported using Vicodin illicitly in a recent survey. From 1994 to 2002, the mention of hydrocodone—the narcotic in vicodin–in emergency center charts increased 170%. This is a big problem.

So we have two big problems: chronic pain, and narcotic abuse. How can we treat chronic pain and avoid contributing to substance use disorders and drug diversion? One strategy has been the use of so-called narcotic contracts, which we’ve discussed at length. But absent from that discussion was the evidence.

Before we look at this evidence, we must re-examine our reasons for using these contracts. In my own practice, we generally use them to protect ourselves from becoming involuntary drug dealers, and to prevent patients from abusing the narcotics we prescribe. So how are we doing with that?

I can’t answer the first question, but the second was subjected to a systematic review published in the current issue of Annals of Internal Medicine. One of the primary findings of this review was that this question has not been well-studied. The few studies that are out there do not measure some of the most important end-points, such as abuse, dependence, overdose, and death. They also don’t focus on primary care offices, the setting in which these drugs are often prescribed. The limited data available point toward a reduction in narcotic misuse with the use of treatment contracts. They conclude:

Our systematic review reveals that weak evidence supports the use of opioid treatment agreements and urine drug testing to reduce opioid misuse, despite the theoretical benefits of these strategies. This lack of evidence may explain in part why they have not been widely adopted in primary care.

I’m not as optimistic as the authors that it is the lack of evidence driving practice here. Leaving that aside, they make some interesting points regarding plausibility, attitudes, and the use of evidence. With regard to narcotic treatment contracts and urine drug testing they write:

Even in the absence of strong evidence, several compelling reasons for physicians to consider implementing these strategies exist. First, primary care providers who use opioid treatment agreements report improved satisfaction, comfort, and sense of mastery in managing chronic pain. Second, management strategies that include treatment agreements have been associated with reductions in emergency department visits in observational studies. Third, cross-sectional studies and a case series have demonstrated that urine drug testing is a valuable tool to detect use of nonprescribed drugs and confirm adherence to prescribed medications beyond that identified by patient self-report or impression of the treating physician. Finally, implementing routine urine drug testing may improve the provider-patient relationship and clinic morale, as suggested in a letter to the editor.

This is a clearly written and subtle approach to the use of a plausible but not-yet-proved modality, and is a nice example of one way to approach the dark zones of data in science-based medicine. They give a rationale for pursuing further research (the importance and scale of the problem of narcotic misuse, and the dearth of good evidence for current practices). And they give some plausible reasons why we might continue to use this as-yet unproved modality. But they do not overplay the current state of research, or make hyperbolic conclusions.

Science-based medicine does not always give us clear guidelines to care, but often leaves us with more questions to answer. This is one way to approach a difficult problem with incomplete data.

References

Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, & Turner BJ (2010). Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Annals of internal medicine, 152 (11), 712-20 PMID: 20513829

Comments

  1. #1 Alex Besogonov
    June 2, 2010

    “But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective.”

    I’m curious, here in Ukraine ketorolac-containing compounds are used extensively for pain treatment.

    I got it for postoperative pain – it was about as effective as morphine (which I had misfortune to require for pain treatment earlier). However, it seems that it’s not used widely in the US even though it might provide solutions for at least some cases.

  2. #2 PalMD
    June 2, 2010

    in the US, ketoralac is considered unsafe for chronic use.

  3. #3 Regis
    June 2, 2010

    Alternatives are few. My wife has Fibromyalgia and undifferentiated connective tissue disease, has gained 80 pounds on Prednisone. Just started Darvocet. It helps a little. Has an appointment with pain management tomorrow. Sucks.

  4. #4 CanadaGoose
    June 2, 2010

    I don’t know how you know it’s NOT an opium poppy. Looks like one to me. I have one in my front garden and I often see them elsewhere.
    They’re not legal but you are unlikely to get busted for having one.

  5. #5 PalMD
    June 2, 2010

    According to the nursery, they were icelandic poppies…IIRC

  6. #6 Funky Fresh
    June 2, 2010

    We could always try to smoke it and see.

  7. #7 Silver
    June 3, 2010

    I continue to find urine drug testing of value, both to confirm the presence of prescribed medication and to determine whether other substances are present. GC/MS confirmed cocaine metabolite (and an absent prescribed oxycodone) three days after the patient was last seen and the prescription was filled at the pharmacy = relatively few benign explanations.
    When we have had to refer our patients out to specialty PM&R, having a series of congruent tox screens on file has been very helpful for our patients and works for them.

    I’ve been interested in the limited research available on tools such as the SOAPP, DIRE, and other tools. Although patients can certainly lie on instruments such as the SOAPP, and the DIRE is subject to some, um, subjective interpretation on the part of the clinician, I find them of some value, and I would like to implement them on a larger-scale basis on our system. I remember the item re: morning cigarette usage on the SOAPP and the predictive power of that… good teaching point re: impulse control and substance use for staff.
    In any event, I think these have a role as well. When I have been able to trial them clinic-wide or system-wide, they have been well-received.

    As far as the treatment agreements, we use them mainly to have a written record that these things were discussed at some point. It saves a lot of time in a multi-clinician clinic. “But So-and-so never told me…”
    “Yes, she did. Right here. Where you initialed all these paragraphs here and here.”
    “Oh. That.”
    And they do open discussion with the patient.
    They also keep everyone in the clinic on the same path as far as standardizing education, consent, etc.

    But, in large part… I continue to feel that they are mainly there for provider reassurance and to meet documentation standards. And those aren’t bad things, but I don’t think they’re doing anything, really, as far as the actual care concerns.

  8. #8 Stewart Hinsley
    June 3, 2010

    4ft tall is rather big for an Iceland poppy. (But it’s obviously not an opium poppy.) Perhaps one of the seed strains of corn poppy (Papaver rhoeas), but even that doesn’t normally reach 4ft.

    The shape of the fruit is often helpful in identifying poppies.

  9. #9 OleanderTea
    June 3, 2010

    As I’ve mentioned before, I have a narcotic contract with my pain management docs. I’m comfortable with the contract and the treatment I receive even though the pain clinic occasionally wanders down the path of woo – they currently offer the Graston treatment and accupuncture – they don’t make the woo mandatory.

    I do wish my PCP had used a narcotics contract and perhaps had more training WRT chronic pain. It would have been preferable to his thinking that I was an “addict” for my three-and-a-half-Percocet-a-day usage.

    On a side note but related to drug testing and narcotics contracts — My pain management docs don’t care if I drink alcohol (yes, they’ve advised me of the opiate-alcohol caveat), but they test for marijuana. Which is weird, since MJ has been essentially decriminalized in my state. I keep meaning to ask them about it just out of curiosity (no, I don’t want to smoke it; I can’t even jaywalk without getting caught, so I’m sure not going to try to buy weed!). Oh, and my sudafed keeps showing up as amphetamines. But I guess it could be worse in the land of drug testing.

  10. #10 Mu
    June 3, 2010

    I’m wondering how much of the contracts and drug testing are done in the interest of improved care and how much is “cover your behind” from the provider. One of my employees is on chronic pain management, and he takes his time off for mandatory drug testing with three weeks notice. You’d have to be extraordinarily stupid to be caught doing something illicit with that much warning.

  11. #11 Vicki
    June 3, 2010

    Do the authors have any ideas of how or why urine testing might improve the doctor/patient relationship? I suspect that if I needed narcotics long-term, and was told “okay, but the conditions include a regular urine test,” I’d say yes, but I’d also be thinking that my doctor didn’t trust me, and wonder whether they believed me on other medical issues, including symptoms.

    Maybe they were starting from a low level of trust, such that the patients are thinking that those tests are better than being presumed dishonest no matter what?

  12. #12 cicely
    June 3, 2010

    I’ve always wondered—what, if anything, do poppies use the opiates for? Arguably, they’ve caused humans to plant more poppies then might otherwise have grown naturally, but apart from that?

  13. #13 PalMD
    June 3, 2010

    I have no idea whether opium confers a survival benefit for poppies, or whether it is simply a trait that has evolved in conjunction with others.

    Poppies have been cultivated for centuries for their opium, so the anthropogenic component of their evolution is hard to separate out, I’d imagine.

  14. #14 Mu
    June 3, 2010

    Vicki, the low level of trust is based on economic facts. You can live on a narcotic prescription if you resell the pills and are not taking them. So the urine test is to confirm that you actually are taking the narcotic in the dose prescribed. This in turn is supposed to make the doctor feel good about the patient telling the truth, therefore improving the relationship.

  15. #15 CanadianChick
    June 3, 2010

    I’m quite certain that’s papaver orientale. It’s DEFINITELY NOT papaver nudicaule (Icelandic)

    Gorgeous poppy, BTW – don’t you just love volunteers? Especially those that will self-seed with abandon?

  16. #16 Karen
    June 4, 2010

    My limited experience with people on pain meds is that they’re proud of how little they need. My dad, who suffered from a terrible chronic back problem, insisted that he never needed but half the dose of Vicodin prescribed. My nephew, who was in a terrible crash a couple of months ago, proudly announces to the family when he can eliminate a Percocet from his daily drug regimen. When my time comes to need such meds, I hope I can follow in their footsteps.

  17. #17 Vicki
    June 4, 2010

    Mu, From the doctor’s viewpoint, that makes entire sense. What I’m wondering is whether the harm to the relationship, and specifically the therapeutic nature of the relationship, from telling the patient “we don’t trust you” will be greater than the gain of the doctor feeling she can trust the patient more.

    This feels a bit like the stuff I see in advice columns about rebuilding a relationship after one partner has cheated. Many of the things that person is advised to do are things that people who hadn’t cheated would resent being asked for. Maybe it’s necessary, given the current state of the laws, for doctors to make those assumptions, but I think they’ll have a cost.

    On the other hand, if a patient can already see that the doctor doesn’t trust her, there’s probably not much to be lost here.

  18. #18 DuWayne
    June 10, 2010

    I am rather curious what kind of impact providing pharmacies with a copy of the narcotic treatment contracts might have on both the perception of the pharmacist and reducing the occasional problem of getting scripts filled. For all I know, some or even many doctors may do this already. But I have run across a few stories of people on long term pain management having problems getting scripts filled and a lot of stories about people having issues with judgmental pharmacists. Hell, I’ve dealt with judgmental pharmacists when filling my psych meds – though I expect there are different reasons for that.

    I know that it is pretty common for pain contracts to require filling scripts at the same pharmacy anyways. It just seems to me that this might be particularly useful.

    I do have to wonder how UAs improve patient/provider relations though. I mean I can see it improving clinic morale and even the trust of the provider towards the patient. But I am not seeing how this would have a very positive effect on the patient.

    Early studies on drug testing in the work place indicated that non-drug using employees often strongly resent UAs. While in some cases that resentment is targeted at the drug users who make such testing necessary, it was very common for employers to also be the target of resentment. Later studies indicated somewhat lower levels of resentment, but an increase in the employer as a target for resentment – largely correlated with management and executives being perceived as immune.

    The main reason given for the resentment, was the perception that UAs are undignified and insulting. A lot of people who are not illicit drug users seem to feel that being tested is a judgment on their character. I have a hard time imagining that this attitude doesn’t carry over into this discussion.

    references include; Drug Testing in the Workplace, De Cresce (1989); Drug Testing in the Workplace, MacDonald & Roman (1994); Workplace Drug Testing, Karch (2007); Drug Testing in the Workplace: The report of the independent inquiry into drug testing at work Roberts et al (2007) – There are a lot more references that discuss this in great detail, including a report that is about generic drug testing and it’s impact on illicit drug use. There are actually a hell of a lot more books simply entitled “Drug Testing in the Workplace.” I just find the lack fo originality amusing…

  19. #19 DuWayne
    June 10, 2010

    Just to be very clear, I am not arguing that such testing is a bad thing to do – obviously there are important reasons for doing it. I am just questioning the impact on patient/provider relations, or how patients in particular might feel about it. I just wanted to be clear about that, because my comment wasn’t intended to be combative.

  20. #20 D. Lindsay
    June 11, 2010

    I was literally broadsided about a month ago when told I “must” donate a urine specimen at the clinic where my primary care physician is. The advice nurse (?) took my arm (I’m only 73 years of age and KNOW what I’m doing). I’ve spent years working in medicine. I was born into it and married it after getting my degree in total care of cliics. I was stunned enough to just laugh and say “Oh, now the doctor will find the cocaine I did last night!” (NOT!!) I have never touched a street drug in my life! I was not told why the tox test. I sometime take a couple of days off my pain med if I’m not in too much pain and to rest my system. I have severe FMS. The doctor and nurse were quite concerned was “blank”! I couldn’t understand why. Thought that was a good thing as doctor harps on taking less!!!! I NEVER got the contract (I found on line suggested by DEA), but I did sign a simpler form that I would not take more than a specified number of caps per day. No one said I’d better show it on testing! Then I researched online and discovered that little point! So I guess hey suspect me of selling? My pharmacist manager was really puzzled and “annoyed” (for me) as they called and grilled him. This is a very large pharmacy. They all but demand six prescriptions (take original in with five refills) to make their work easier AND stop some patients from repeatedly asking for early refills. I have NEVER abused drugs. I had to pick up the monthly refill last Monday that would definitely be at front desk! NOT! Nurse made me come to back. She said I had to give a “random” sample before I could receive prescription!!! I was late for appointments elsewhere and was “dry” thus had to drink water as they observed. A while later I got out an ounce of urine for them and tore out for appointments! I was late of course. I did tell the nurse I was angry and wanted to know what this was all about as I take no illicit drugs. She “knew nothing” about why. Yeah, right! She said I can refuse and go without (I do have some tolerance built up so I’d have to wean for a bit and then what?). I told her about invasion of privacy and civil rights as I’m a huge supporter of our Constitution (still NOT knowing what doctor was seeking from me). She said the clinic can demand, but I can refuse and have not only some withdrawal BUT a lot more pain off and on. Isn’t that a form of blackmail? My doctor now the police!! I’ll search for a doctor in private practice now! All trust is broken. They have yet to produce the paperwork they say I signed as to picking up prescription as of January (never did until this week!) and all the rest. If I’d seen THAT contract I would have gone “off” on it then, not six months later!! This is full of problems. Making doctors do the work for the DEA is wrong. Doctors should know their patients after over a decade of care IMHO! This was a punch in the gut just from the aspect of trust (no matter what the circumstances). I will gather my “evidence” for them, write up my thoughts and leave it there as soon as I find a non-police state practice. They did NOT need to make an example of me, and the doctor is wrong to do this at least to me. I hate sneak attacks! I hate being thought a liar. I had no drugs in urine this week either as I was off for two or three days again! Sheesh! They will probably now “fire” me as innocent and cost me the care I deserve (post-cancer, post necrosis of colon twice that almost cost me my life, and for sure FMS/IBS). No other doctor will want to take chances with me. Thus, I get to probably live out my life with days of FM flares and severe pain unable to get out or keep promises to others so quality of life that has been so highly prized by my state has been destroyed for the sake of the DEA and their “war on drugs.” Just Google this topic and read all about it. One patient committed suicide because of this stupid “law” due to chronic, intractable pain. NOW this could be a lawsuit against her physicians. Even if doctors think they can prevail in a court of law, they will lose lots of time and money fighting these upcoming cases I am sure will be filed!!!! Shame on the AMA for even allowing this to happen.

    Oh, and now the nurse is calling for me to call them! Why? I can guess. Thus NOT a random situation at all. I’ll wait for my nurse to return from vacation and talk with her. I’m still in total stun!

    BTW, it is very difficult to type more than 10 wpm in this box. It is slow to accept letters, and I have had to hit many of the characters over and over including the space bar. I type about 110 or more wpm/minute!!

  21. #21 OleanderTea
    June 12, 2010

    I am rather curious what kind of impact providing pharmacies with a copy of the narcotic treatment contracts might have on both the perception of the pharmacist and reducing the occasional problem of getting scripts filled. For all I know, some or even many doctors may do this already. But I have run across a few stories of people on long term pain management having problems getting scripts filled and a lot of stories about people having issues with judgmental pharmacists. Hell, I’ve dealt with judgmental pharmacists when filling my psych meds – though I expect there are different reasons for that.

    Ehhh, I think it could be a violation of HIPAA. Pain contacts don’t tell the pharmacist anything they could check on or that they need to know. Mine only says (as you mention) to use the same pharmacy for all RX’s from the pain management docs. The pharmacist won’t know if I use another pharmacy or not.
    [/rant]

    And, yes, you do get judgmental pharmacists. I got one who said, “You take a lot of opiates for a young woman.” I asked him if he was the Percocet Police, then complained to his manager that his commentary was both inappropriate and slightly creepy.

  22. #22 DuWayne
    June 13, 2010

    OT –

    You were one of the people I was thinking about when I mentioned the judgmental pharmacists – though to be sure, I am not the only person I know personally who has had that problem. My sister has rhumatoid arthritis that started in high school and that had become bad enough in college that she was put on disability so she could get medicaid and afford treatment. Having started on a regular regimen of various narcotic pain killers at nineteen – in the mid seventies, she took a lot of shit from pharmacists.

    As for what they can check on, in several states they can find out if you are filling scripts elsewhere, MI included. I had to get my refills written a couple of weeks early, at the end of last semester. I fill my welbutrin at Costco (for less than a third of the cost elsewhere, using their script program), which is an hour away and finals were bearing down on me. I accidentally handed them my ritalin script, instead of my xanax, which I also fill there and was told that it was too early for that to be filled. Only I usually fill my ritalin at Walmart, where it is four bucks and no one has ever given me shit about it.

    Turns out MI has a database for certain controlled substances.

    I am not terribly put out by this either. I have rather funny notions about drugs and the licit/illicit nature, but when it comes to scripts, I am all for a variety of useful tools to prevent doctors from supporting dependence. (though I do have mixed feelings about drug tests). I can see problems with privacy issues, when it comes to pain contracts – I am just not sure if the trade-off might not be preferable. I am mainly thinking about people who have had scripts refused because of busy-body pharmacists who believe they have a right to counter doctor’s decisions.

  23. #23 backsick
    June 15, 2010

    I had a specific question regarding narcotic contracts. I suffer from severe back pain brought on by a herniated disc. I was referred to a pain clinic in January and he put me on Norco’s (hydrocodone 10mg) to treat the pain. I take the 5-6x per day (as prescribed) and had not violated the narcotic contract.

    Last month I had to get several teeth pulled due to an infection and serious pain. The dentist prescribed me an antibiotic and percocet to treat the pain. Since the percocet is stronger than my Norco’s, and I was in increased pain I did fill it at a separate pharmacey, but it was run through insurance. I was only on it one week, and now I am back taking the Norco’s as prescribed.

    My question is, will my Pain Management Doctor be notified or be able to access information that I had filled a prescription for 30 percocets. I do not want to deceive my doctor in any way, however I do not want to be dropped by the pain doctor. I did knowingly violate my contract. Can they access my insurance records or DEA records to see if I have violated and obtained another prescription, or is there only way of knowing through a urine analysis? I do give urine for testing every month I come in to see him. All scripts were filled in Wisconsin…

    I want to decide the best course of action so your advice is much appreciated.

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