In an effort to address the epidemic of pain killer abuse, Minnesota is the 34th state to mandate monitoring of prescribed controlled substances through a national database.
Starting in January, 2010, pharmacies in Minnesota are required to submit to the database the name and address of the patient, the name of the prescriber, and the name of the pharmacy that filled the prescription.
If a prescribing doctor suspects abuse and wants to check on a particular patient’s use of controlled substances, he or she will be able to go to the Minnesota Prescription Monitoring Program Database. The Minnesota Board of Pharmacy will manage this database. It is anticipated the program will not be fully functioning until March of this year.
According to a survey by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, more than 10.5 million Americans are affected by substance abuse, which includes the use of alcohol, drugs, and prescribed medications. Dentists may unintentionally become involved by responding to patients’ requests for pain medications. Whether the patient’s intent is for personal use or re-sell, the dental team must be able to identify drug seekers.
Common drug seeking characteristics include:
• Unusual behavior in the reception room
• Refusal to see another practitioner for consultation
• Any indication the patient is receiving the same drugs from other doctors
• Assertive personality, often demanding immediate action
• May show unusual knowledge of controlled substances, as well as requests for specific drugs by name, dose, and quantity
• Reluctant or unwilling to provide former provider information
• Generally has no interest in diagnosis or treating the problem and only comes in for emergency care
• May exaggerate pain or simulate symptoms
Train staff to recognize and alert you to questionable patient demeanor. The first person to address a patient is usually the receptionist. By knowing the drug seeking characteristics, he or she should be able to identify a patient who exhibits drug-seeking behavior.
Do not provide pain medication to anyone who is not a patient of record. For example, an individual may arrive near closing time claiming severe pain and requesting a pain prescription until he or she can return for an appointment the next day. If the patient resists an examination, consider a referral to the emergency room for assistance. A drug-seeking individual could also be a person who claims to be from out of town and has lost his or her prescription. Offer a pain medication other than a narcotic, when appropriate. If the patient claims to have forgotten or lost a prescription on a trip, check with his or her home pharmacy and contact the dentist he or she claims provided the lost prescription. Be sure to have the patient fill out the same paperwork as any other new patient, especially a health history form. Document your conversation with the patient’s treating dentist or pharmacist in the patient’s chart along with any prescription provided.
In the event you have a request for pain medications from an established patient, perform an examination, diagnose the problem, and determine the appropriate treatment. Prescribe pain medication once you determine clinical support for the pain. If you prescribed the patient painkillers on several occasions in a short span of time, or if he or she continues putting off treatment, do not give another prescription. Explain why you cannot provide additional prescriptions. Established patients may also contact the office when they know you may be busy or over the weekend. They rely upon the likelihood that you will not have the chart available to take advantage of the situation. Document your interaction with the patient in his or her chart in an objective and factual manner. Consider withdrawing from care if the patient refuses to complete treatment.
Follow the suggestions below to avoid becoming a target of drug seekers:
• Review the patient’s chart prior to prescribing medications, and pay attention to the amount and frequency of past prescriptions given to the patient. Providers might not recall the amounts and frequency of prior prescriptions.
• Do not prescribe over the phone, especially if you have not seen the patient previously.
• Do not prescribe a pain medication for a non-dental pain complaint (e.g., back pain, knee pain, and so forth).
• Establish a plan so you know where to refer a non-patient who claims to have a dental emergency, such as a hospital emergency room, the patient’s regular treating dentist, or a local clinic.
• Review medical histories carefully, and note suspicious findings. Consult other health care providers involved with the patient’s care.
• Do not keep prescription pads in treatment areas or controlled substances in unlocked cabinets.
• Do not call in a prescription within the hearing of others, including the patient for whom you are calling.
• Stay informed about what is going on in your community, and discuss suspicions with your pharmacists and colleagues.
Stay in control of the dentist-patient relationship and do not prescribe, dispense, or administer controlled substances to anyone you suspect of being a drug seeker. Misprescribing, over-prescribing, or failure to monitor patients who have a high potential for abuse could result in investigations by the federal, state, or local regulatory agencies. In some cases, patients have sued the prescribing doctor for giving too much medication and creating an addiction.
If you have any questions about the advice presented in this article or are unsure how to handle a potential situation in your practice, please call TDIC’s Risk Management Advice Line at (800) 733-0634.
*Taiba Solaiman is a Risk Management Analyst, TDIC, Sacramento, California.