July 2017 President’s Message

Carefully monitoring opiates

by Denis Knight, DO

A January New York Times article documented why Americans need to take the opiate crisis seriously, noting 33,000 people died in 2015. Overdose deaths kill as many people as car crashes, and deaths from heroin alone exceed those of gun homicides.

The lives lost are not simply the homeless, nameless and faceless persons in the forgotten quarters of society but our children, our brothers and sisters, our mothers and fathers. With a problem so widespread, hardly anyone can look at their own family and not see this scourge. Even more alarming is that what little public funds are available for detoxification and treatment could be cut further by our legislators on Capitol Hill.

At the recent AMA Annual Convention in Chicago, I heard much discussion of proposals to address the opiate epidemic. Nevertheless, as physicians we still are responsible for prescribing opiates for those patients needing them. Treatment of pain related to cancer and end of life care seems to be without much debate. Likewise, it isn’t controversial for nurses in licensed facilities to dispense opiate analgesics for rehabilitation and long-term care. Most agree that patients receiving acute care in a hospital can safely receive opiates for pain.The dilemma we face in the outpatient setting is how to properly treat the chronic non-cancer pain of patients for whom no surgery or definitive treatment exists to ease their pain and improve their quality of life. The simple response by many physicians is that they simply will not prescribe opiates. While every provider has the right to practice as they see fit, this response does not address how to deal with chronic non-cancer pain.

In my practice, the vast majority of patients needing opiates have chronic back pain. They usually have well-documented degenerative disc disease and/or have undergone surgery that did not relieve their pain. I am not suggesting my approach is the best or the only way to prescribe opiates, but these are recommendations that physicians in Sedgwick County can follow to protect their patients from injury or diversion of the drugs to others.

• When opiate analgesics become part of the chronic non-cancer pain care plan, it’s important to craft a medication use agreement – a contract, if you will – with the patient receiving these dangerous drugs. The agreement specifies an agreed upon amount of pills per month and establishes that only one physician and one pharmacy, in most cases, will be used.
• A screening tool of questions that can help identify overuse, abuse or diversion should be prepared and used at the start of treatment and at regular intervals thereafter.
• KTRACS is an excellent online prescription-monitoring program that verifies the patient’s access to opiates in Kansas and posts the names of all providers and pharmacies involved with controlled substances.
• Any use of opiates should be monitored with drug screens, urine usually but frequently serum sampling as well, to ensure patients are not using illicit drugs or non-prescribed controlled substances or diverting the opiates to others.
• Make clear that you, the physician, have responsibility for treating the chronic pain and that an urgent care center or emergency department is not the place to seek relief.
• Urge patients to secure the medications in a locked location, ideally a safe that is heavy enough it cannot be carried off, with a key or combination only possessed by the patients themselves. We expect loaded guns to be secured in such a manner and opiate analgesics are just as dangerous.
• Finally, when these policies are violated, the physician must have the courage to say the medication is being used improperly and then withhold the opiates.

We cannot protect the citizens in Sedgwick County from themselves and their poor decisions, but we can treat chronic non-cancer pain within reasonable parameters while abiding by the dictum, “First do no harm.”