Controlled substance compliance Patient-provider agreements, urine drug screening, pill counts, prescription monitoring programs

Your speaker Eva Quirion MSN, PhD, FNP-C St. Joseph Internal Medicine Pain and Recovery Care 900 Broadway Bangor, ME 04401 Eva.Quirion@SJHhealth.com 207-907-3300

Disclosures I have no disclosures.

objectives Participants will be able to identify key components in patient provider agreements for controlled substances Participants will be able to state rationale for informed consent related to controlled substances Participants will be able to assist in interpretation of urine drug screening and pill count data

Patient-provider agreements and informed consent Why do we do this? Patient-provider agreement So that each participant understands the responsibilities of controlled substance Informed consent To document that the provider has explained to patient the nature of being on a high risk medication and to all the patient the opportunity to “opt out” Is this a contract? NO, this is not legally binding and either party can cancel the agreement at ANY time I encourage people to NOT call this a contract so that the patient does not get the impression that the provider HAS to prescribe

Patient-provider agreements – major components Goals for treatment What is being treated State that the goal of treatment is improved function Safety Take medications only as prescribed No buying/selling/pharming Disposal Use of other drugs and having other prescribers Notification of pregnancy or other health changes Keeping appointments Use of one pharmacy Permission to speak with other providers in the care team

Patient-provider agreements – major components Monitoring Agreement to conduct and be present for random pill counts Urine screening tests – more on this later Not replacing lost of stolen medications Prescription monitoring program – more on this later too! Management of prescriptions and refills The 28 day vs 30 day refills Refills only happen on week days and not weekends or with on call providers No early refills

Informed consent – major components Uses Benefits expected Risks Alternative treatments

Urine drug screening Should always do UDS prior to starting any controlled substance There is no such thing as a “clean” or “dirty” urine. The results are “as expected” or “not as expected.” If a urine is not as expected, discuss with the patient If you get a “confession” there is no need to confirm If you get a “denial” send for confirmation – ESPECIALLY if you are basing a clinical decision on the data in a urine screen There is a high inaccuracy rate for any in-office urine screening Confirm, confirm, confirm

Urine drug screening Most in office tests check for opioids, oxycodone, methadone, amphetamines, methamphetamines, cocaine, THC, benzodiazepines. There are variants. An opioid is: Any drug in the opium family (heroin, morphine, hydrocodone, hydromorphone and others – but NOT oxycodone or fentanyl) Oxycodone is: oxycodone only, no other drug will make this positive Methadone is: only methadone Amphetamines are some ADHD medications – but NOT Ritalin Methamphetamines – illicit substances (Crystal meth, nothing prescribed) Cocaine – is cocaine THC – is marijuana Benzodiazepines – sedatives like valium, Xanax, clonazepam, and many others

Urine drug screening To test for methylphenidate (Ritalin), must be sent to the lab Fentanyl and Tramadol must be done in the lab Some dip tests check for buprenorphine and others do not and may need to be sent to the lab Urine tests range from $8 cost to hundreds of dollars depending on how comprehensive it is If you don’t know what the test is telling you – call the LAB!! They are usually more than happy to help interpret results

Pill counts This Photo by Unknown Author is licensed under CC BY-NC-ND

Pill counts Call to patient in the morning 3 attempts in 2 days If need to leave a message, “please call the office” and don’t tell them on a message that this is for a pill count Do not combine with a previously scheduled appointment 3 attempts in 2 days If patient does not call back, consider the pill count a “fail” Request to patient to come in that day to bring their medications Provider discretion if allowed to come in the following morning Excuses: I can’t get in to the office while you are open – utilize their retail pharmacy I am out of town – request that they provide proof of being out of town (receipt)

Pill counts Not being able to accomplish a pill count is “non-reassuring” Our policy is 2 failed attempts and the CS is stopped If the patient has signed an agreement, they will know the expectation of doing pill counts from time to time We do once a year as a minimum More frequent counts are appropriate, but consider if this patient is appropriate for controlled substances at all (is it a safe environment?)

Sample documents

CS documents When policies and documents are similar in the community, it can cut down on patients changing practices for more lenient controlled substance policies Feel free to use and adopt any of these documents for your own facilities

Questions?