Algos Substance Abuse Tips and UDS
1. Incidence of substance abuse in chronic pain populations is very high, up to 34% in well conducted
studies.
2. Substance abuse in your pain population can lead to patient death or injury to others by patients
operating machinery under the influence, overdose, scrutiny of police, reduction in referrals, medical
licensing board scrutiny, and DEA scrutiny.
3. Diversion of prescription narcotics WILL lead to DEA scrutiny in cooperation with the state medical
licensing boards if this becomes a pervasive problem. These agencies view a physician as misdiagnosing
patients and inadequately monitoring patients when there are many patients from the physician's practice
diverting narcotics for sale on the street or for trading for illicit drugs. When the physician knows the
patient is diverting drugs and has been informed of such, continued prescribing of narcotics to these
patients may lead to action being taken by the DEA, State Medical Licensure Boards, and other
governmental agencies. Therefore, physicians should become extremely proactive in averting diversion in
such cases that the physician was notified. While such actions are not spelled out by the DEA, appropriate
actions include documentation in the chart that the patient was questioned about the information, received a
random drug screen, had a pill count mid month, and the police department in the patient's home town was
contacted to query about possible drug diversion. The DEA is interested in preventing diversion especially
if a physician should have know diversion was occurring such as when there are high doses of medications
being prescribed with several dose escalations during a time in which the patient consistently rates their
pain relief as low, but are extremely functional. If there is a legitimate purpose for prescribing, the DEA
does not interfere with the practice of medicine. The state medical licensure board on the other hand is
concerned about the appropriateness of narcotic prescribing for the selected patients. Diversion of
narcotics (trading these for money or illicit drugs, altering prescriptions, sale of narcotics by patients) is a
felony, and is not protected by patient-doctor confidentiality. These felonies, as all other felonies, should
be reported to the DEA and the local police drug diversion unit.
4. Many states do not permit pharmacists or doctors to have access to information (when collected)
regarding patient prescriptions. Therefore, it is easy for some patients to go to 5 different doctors in 5
days and fill narcotics scripts from each at separate unlinked pharmacies without the knowledge of the
physicians or pharmacists. Many states do not have laws making this practice illegal, therefore substance
abuse is encouraged by the states irresponsibility in lack of legislation. These glaring legal oversights
permit substance abuse to continue for very lengthy time periods.
5. Not all who enter your office and complain of pain are legitimate chronic pain patients. Some are posing
as patients to obtain narcotics for sale. Some are state agents with hidden miniature cameras to assess
the degree to which a legitimate diagnosis is obtained. Therefore, ALWAYS perform a history and physical
exam. If the patient appears fishy, it is perfectly acceptable to tell the patient you cannot help them, and
send them on their way (without charge) before establishing a doctor patient relationship.
6. Some physicians are guilty of lying to patients about their capabilities to prescribe narcotics or regarding
state and federal laws. These physicians will tell patients "I cannot give Percocet since my license will not
permit it" or "I cannot prescribe methadone to treat chronic pain because a special license is needed".
Both of these are false for any physician with Schedule II privileges. Some doctors tell patients because of
the DEA, I cannot prescribe any narcotics any longer. Fear of the DEA is unfounded unless the physicians
practice is engaging in prescribing narcotics for non-legitimate medical purposes, is trading drugs for sex,
or is receiving kickbacks for narcotic prescribing.
7. Tips for prescribing narcotics to patients in follow-up visits: DOCUMENT, DOCUMENT, DOCUMENT!
On every visit revisit the reason for prescribing, attempt to obtain a VAS/%decrease in pain with opiates
assessment along with a functional assessment. Periodically it is prudent to review psychiatric attributes of
pain with a SF-36 or BBHI. Make sure there is a patient plan including narcotic prescribing by dose and
name. Do not use slang names in your medical record.
8. Use duplicate scripts, photocopies of scripts, or electronic printing of scripts for all narcotics. This
prevents unrecognized diversion if a pharmacist calls you questioning the script. Require a lock box for all
patients and tell the patients to have the pharmacist give a large container and small container for each
narcotic so the daily dose can be transported without the possibility of losing the main supply.
9. Absolutely no refills on nights, weekends, or holidays, even if the patient goes into withdrawal from lack
of narcotics. It is the sole responsibility of the patient to make the scheduled appointment, which should
always be made a few days prior to the patient's calculated time to run out of medications. If there is a
legitimate reason the patient could not make the appointment (hospitalized, etc) then appropriate latitude
may be rendered.
10. Do not mail scripts to patients or pharmacies. The lack of these locations receiving the scripts will
cause you to write duplicate scripts without having any way to track the original script.
11. If a patient threatens the staff or the physician with legal action or violence in order to obtain narcotics,
call the police at once and report an attempted extortion is taking place in your clinic.
12. Do not discharge patients unless guilty of threats of violence or diversion. Discharging a patient in
many states requires the physician give the patient a reasonable (usually 30 day) supply of narcotics until
the patient can find another physician to prescribe narcotics. If a person is guilty of substance abuse, the
last thing in the world a physician should do is give the patient more narcotics to abuse. Therefore, don't
discharge substance abusers, simply change their therapy to a non-narcotic therapy. In that manner there
are no patient abandonment issues since you are continuing to treat them with other therapies. You are
under no legal obligation to refer a patient to a physician who will prescribe narcotics, although in some
states such as California, you must tell the patient there are other physicians who will prescribe narcotics.
13. Monthly visits are optimal, especially in situations where high does opiates (>100mg/day oxycodone
equivalent) is being prescribed. Some patients have 3 month mail in pharmacies requiring a single
presciption for all 3 months on one script. This is legal according to the DEA. It is NOT LEGAL to write
more than one prescription on the same day for the same Schedule II drug. Therefore a 3 month supply
must be written on one script. If there are patients who are unreliable or questionable as to their ability to
take opiates in a manner prescribed, then you may consider telling the patient they are not candidates for 3
months of Schedule II medications, regardless of the cost savings.
14. Whereas a physician may not write more than one script for a schedule II drug on a given day, it is
permissible for the physician to write a script on a later date which may be picked up by the patient at the
clinic or mailed to the patient (ill-advised). Our suggestion is that appropriate patient monitoring for use of
Schedule II medications in high doses (see above) does mandate monitoring of the patient at monthly
intervals due to increasing potential for substance abuse and iatrogenic overdose (kidney or liver function
decreasing unknown by the patient). Therefore monitoring in such high dose situations should be done by
at least a nursing visit and patient questionnaire completion (level one charge) if not by a NP or physician.
It IS legal for a physician to write one script for a given schedule II drug with the same days date listed on
the sig line, but with instructions to fill on or after a given date. This is used when patients are seen in
follow-i[ prior to their supply of drug running out and the physician does not want the patient to have access
to large supplies of such drug. This practice has been cleared by the DEA in Washington March 2005.
15. For all narcotic medications, it is useful to write "MAXIMUM __ per day" filling in the maximum number
of tablets per day. In this way, the patients who have prn schedules written on their script cannot overuse
the amount allotted per month without engaging in substance abuse.
16. If patient's run out of medications early, do not refill them until the refill date is due. It is imperative the
physician retain control of the use of these potent narcotics. Withdrawal from narcotics will not kill a
person unless they have severe cardiovascular disease. If a patient during the withdrawal interval receives
narcotics from any other physician, then it is appropriate to tell the patient all future narcotic prescriptions
must come from the physician who was used to violate your clinic's opiate agreement. It is unfortunate that
some well meaning but gullible family physicians will continue to enable the patient's substance abuse by
giving narcotics during the patient's self induced opiate withdrawal.
17. If a patient is discovered to have received narcotics from one other prescriber in small quantities (eg. a
dentist for a dental procedure), warn the patient they must call you when they receive any narcotics from
any other physician. If the patient is discovered to be doctor shopping and is chronically receiving
narcotics from multiple prescribers, immediately cease prescribing all narcotics, notify all the other
prescribing physicians the patient is engaging in substance abuse, and consider contacting the police on
suspicion of possible drug diversion or sale if there are signs of such.
18. Urine drug screening is a mandatory part of any practice in which high dose narcotics are being
prescribed. Katz found 50% of patients suspected of abusing narcotics were doing so based on UDS while
25% of those he did not suspect were engaging in substance abuse. Substance abuse is the lack of a
prescribed +-drug in the urine, the presence of non-prescribed narcotics (or benzodiazepines) in the urine,
or illicit drugs in the urine. However the UDS must be performed properly to assure there are no interfering
substances and that the test will detect the narcotics prescribed. Most urine dipstick methods will not
consistently detect oxycodone, hydrocodone, oxymorphone, hydromorphone, meperidine, methadone,
fentanyl, or propoxyphene since these are semisynthetics and synthetics. Often UDS dipstick tests will be
negative for these substances even if you know positively the patient is taking them. This is due to the
insensitivity of the tests which are designed to test at limits set much too high for pain management or due
to the insensitivity of the measuring enzyme which is designed to pick up morphine and codeine, but not the
synthetics or semisynthetics. Therefore, a negative UDS for prescribed drugs is meaningless unless a
secondary test GC/MS is used. The GC/MS is used in all cases where there are positive findings for THC,
cocaine, benzodiazepines, etc, but must be specifically requested to be run on all patients you want to test
for compliance in taking the narcotics the physician is prescribing. There are many interfering substances
that will trigger a positive UDS for marijuana such as Advil or Motrin, therefore a confirmatory test is run
using GC/MS technologies. A positive test on GC/MS for any drug is deemed a true positive. Opiates will
be detected 24-72 hours after the last dose, benzodiazepines up to a week, and marijuana up to 30 days
or more after the last use.
19. Finally, do not be afraid to contact the narcotic division of the local police and chat every so often to
look for trends in drug use. There are times where certain illicit drugs and prescribed drugs are linked such
as the link between Oxycontin and methamphetamine. The meth users will pose as pain patients, sell most
of the narcotic on the street to buy the methamphetamine. The local police and DEA can be helpful with
trends, although due to ongoing investigations may not be able to give specifics about a particular patient
who is selling the prescribed drugs. The police and the DEA are involved in control of diversion, as should
physicians when diversion is known or suspected. Diverted prescription drugs find their way onto our
schoolyards and are a plague to our society. We as physicians are not policemen, but we should not hide
behind the white coat of patient confidentiality when we strongly suspect or know we have been deceived
by those who would commit felonies with the narcotics we prescribe.