I wrote this for my clinic when I was trying to figure out how to monitor my opiate chronic pain patients and buprenorphine opiate dependence with or without chronic pain patients.

Why do I monitor? Big Brother?

Not really. I think of addiction as the person having failed in their boundaries and the addiction taking over. My job is to assist with external boundaries until they get control and resurrect their own boundaries. The length of time this takes depends on how much of a mess their life is. Legal trouble, family trouble, job trouble, depression, etc.

If the addiction takes back over, the person lies. The active addict and the compliant well behaved patient TELL ME THE SAME THING. "I'm not using." Right. Ok, so I have to maintain a level of cheerful skepticism and pay attention. And bust the liars. Because, honey, that's my job. Remember, overdose can kill so it really matters.

Why am I including chronic pain patients? Opiates are addictive. The idea that "taking them as directed" protects from addiction is currently thought to be a myth.

Opioid/Buprenorphine Monitoring Guidelines

Four general categories of narcotic use/abuse

(These are my categories. I made them up. This is purely practical based on observation. It's not science. There have been no clinical trials.)

1. Patient in control, urine drug screen matches story, regular visits, no aberrant behavior.

2. Patient in mild relapse/questionable*: lost medicine, missed visit, cancelled visit, one questionable urine or patient states that is in relapse and urine drug screen matches the story. Patient not in denial and/or rare or mild aberrant behavior. Resists behavioral treatment requirements mildly.

3. Serious relapse or markers for addiction/opiate dependence outweigh chronic pain complaints. Patient denies that there is a problem, urine drug screen does not match story, tampered urine, other substances, repeated lost meds/attempts at early refills/missed visits/does not do behavioral requirement despite repeated reminders/warnings/ cancelled visits/requests phone refills/ repeated boundary testing.

4. Severe relapse. Patient denies problem. Illegal substances in urine (cocaine, methamphetamine) or continued use of outside narcotics or benzos with buprenorphine. Or prescribed medicine not showing up in urine, concern of selling medicine. Or pharmacy records indicate multiple prescribers.

Monitoring plan for each category:

1. Urine drug screens can go to random.

Over time behavioral treatment can be reduced. (Time in years, not weeks or months.)
Chemical dependency counseling vastly preferred over non-chemical dependency counseling for opiate dependent patients.
Interval for visits may be increased.
Minimum length for visits:
Buprenorphine monthly visits
Methadone monthly visits
Other chronic opiates (chronic pain patients) maximum interval 3 months.

2. First offense: warning and documented.

Repeat if long interval/low concern: repeat warning.
Short interval/high concern: shortens visit interval
And/or requires contact with behavioral component/attendance proof
And/or send out urine

3. First offense: warning and documented.

Continue to document warning and number of drug contract violations.
By second or third, interval must be shortened
Repeat send out urine
Repeat proof of behavioral attendance/contact.
By fourth offense within 3-6 months, consult with University of Washington Roam Echo/referral to pain clinic/referral to addiction specialist/transfer to inpatient rehab or methadone clinic/ or discharge patient.

4. First offense: warning, documentation/immediate shortened interval of visits.

With sales of drugs or illegal drugs, stop prescribing immediately.
Benzos difficult because diazepam may stay in urine for 6-24 days, do multiple visits and keep discussing.
Discuss other options (consult with Roam Echo/referral to pain clinic/referral to addiction specialist/transfer to inpatient rehab or methadone clinic/ or discharge patient) at first serious offense.
Multiple prescribers of potentially lethal meds or narcotics or benzos from two providers, stop prescribing controlled substances immediately. Contact the other prescribers. Since the patient can potentially die of overdose, that outweighs HIPAA. Offer help going to inpatient rehab or medications to help mitigate withdrawal or address of nearest methadone replacement program.

*I asked Dr. Merrill at UW how many "dog ate my homework" stories he tolerates. He said, "Four." That was the number I'd reached through trial and error. Creative patients manage to have all four in one visit.


University of Washington Project Roam: http://depts.washington.edu/fammed/roam

University of Washington TelePain: http://depts.washington.edu/anesth/care/pain/telepain/

Washington State Department of Health: Pain Management http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPatients.aspx

CDC Grand Rounds: Prescription Drug Overdoses -- a U. S. Epidemic: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

Opioids for chronic pain: Addiction is NOT rare https://www.youtube.com/watch?v=DgyuBWN9D4w

Oxycontin Poster Children: 15 years later https://www.youtube.com/watch?v=hwtSvHb_PRk

Effectiveness of Opioids for Chronic Pain https://www.youtube.com/watch?v=l4Y3TQUsH4k

COWS: Clinical Opiate Withdrawal Scale https://depts.washington.edu/fammed/files/Screening_Orcas_COWS_71.pdf

Opioids for Chronic Pain: Understanding Physical Dependence https://www.youtube.com/watch?v=pILIJ9VyWAU

....if opiates don't work for chronic pain, what does? Jon Kabot-Zinn's work....

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