It doesn’t matter what specialty you are in: most of us prescribe controlled substances, including opioids. However, the culture for prescribing these agents has certainly changed. I can remember a time when treating a patient’s pain was one of the most important things that we could do. Now, prescribing a controlled substance is done with reservation.
In my practice of sleep medicine, opioids generally are not prescribed; however, we prescribe other controlled substances such as sleep aids and stimulants. Where I work, before writing a prescription for a controlled substance, we must access the state prescriber’s database to make sure that the patient is not abusing or diverting controlled substances. I recently had an experience involving a prescription for an 84-year-old patient. Normally, we are of the mindset that an individual of an advanced age would not be misusing controlled substances. However, I discovered that the patient was receiving the same stimulant from both me and his primary health care provider. When I confronted him about this situation, he had little to say in response. He then returned to my office 2 weeks later demanding his prescription.
How should we handle these situations? In the aforementioned case, I requested that the patient obtain a letter from his primary provider stating that he no longer was receiving the prescription. This request alerted the provider that the patient was receiving the same stimulant from another clinician, and it was good documentation practice to show that I had acted responsibly.
It is important to note that sometimes patients might not be aware that they are receiving the same medication from multiple providers. I remember a situation when a patient of mine was receiving Klonopin® from his primary care provider as well as generic clonazepam from a mental health provider. It wasn’t until the patient could barely keep his eyes open during the day and was sent to me for severe hypersomnolence that I discovered he was taking the medication in excess. The patient had no idea that the 2 drugs were the same.
Having patients bring in all the medications they are taking is important as a list doesn’t always reflect this information accurately. They may forget to list everything or forget to remove a medication they no longer take. In this case, one of the treating clinicians noticed both clonazepam and Klonopin® on the list but thought the patient was simply listing the generic and brand names and never questioned it. Had the patient brought in all of his pill bottles, someone would have noticed the duplication error.
Other times, unfortunately, family members may use or abuse a patient’s medication. Therefore, ensuring that the patient is the person filling the prescription is important. Patients also may self-medicate without the permission of their provider, which can lead to hospitalization and/or addiction. They may feel that if 1 tablet is good, 2 are better. We must remind our patients to call us if they feel that their medication is not strong enough.
The way we practice medicine is constantly evolving. What was once an accepted practice has now become taboo. We must be willing to change our practice and inform our patients why it is important for us to make these adjustments. Individuals who have been taking opioids for years may not be happy when they learn their medication is being taken away or substituted with another drug. However, taking a moment to educate them about why it is happening can make a significant difference for both your patients and you.