All about Opioid Monitoring: Doctor Shopping, Guidelines
Opioid prescription given for chronic pain has increased over last 15 years in USA, so have cases of opioid addiction and ER visit with life threatening side effects.1 The awareness to treat chronic or any pain has been actively marketed to general public for last 25 years. Papers published in scientific journals have discussed the subject regularly.2 Heroin, Dilaudid, methadone and morphine has been sold on street for profit. Opioid addiction resulting in life threatening complication has become a major health issue in USA.
Opioid Monitoring- Who Is Monitoring Who?
- Doctor- Doctor is monitoring patient
- Patient- Patient is monitoring dosage and how many pills are left before end of month supply.
- Insurance Company- Insurance companies are monitoring cost of medications
- Government Authority- Government authorities are monitoring physicians and paramedics.
- Law Enforcement Agencies- Law enforcement agencies are monitoring street drugs.
Need For Opioid Monitoring
- Life Threatening Side Effects- Opioid monitoring is essential to prevent opioid abuse and fatal side effects.
- Lab Studies- Monitoring involves several individuals and lab studies.
- Individuals Consuming Opioids- Monitoring needs to be done by spouse, close family members, physician and friends.
- Opioid Consumption- Opioid monitoring is necessary for patient who are taking opioid medications for pain as well as recreational purpose to prevent respiratory depression and fatal outcome.1
What is The Need For Opioid Prescription?
- Opioids are the best analgesics available for acute and chronic pain.
- Opioids are very effective for nociceptive pain, which is acute in origin.
- Nociceptive pain is observed following trauma or surgery.
- The lower therapeutic dosage of opioids are safe and improves quality of life.
- Opioid prescriptions are given by ER physician, primary care physician and specialist.
- Opioid prescription given in ER has increased several folds between 2004 and 2011.4
- Several opioid products have been aggressively marketed during last 20 years.1
- Prescription of oral opioids has increased nearly 1,448% from 1996 to 2011.3
Escalation of Opioid Dosage-
- Opoids are taken in smaller dosage for pain or pleasure during intial treatment or abuse.
- Prolonged opioid use results in increase of opioid tolerance and resistance for therapeutic effect and also to achieve effect of pleasure.
- Opioid dosage is periodically adjusted to achieve optimum pain relief or pleasure by patient and drug seekers.
Narrowing Of Window Of Opioid Dose Safety-
- Eventually the window of safety between safe and fatal dose decreases.
- Life threatening event occurs when therapeutic dose or recreational dose is very close to fatal dose.5
- In such situation slight increase of dosage or one or two extra pills can cause respiratory depression or apnoea (stop breathing).
- Patients were seen in increased numbers at emergency room with life threatening complications.4
Doctor Shopping For Opioids
- Individuals were caught while doctor shopping, sharing opioid medications and selling prescription opioids at street for profit.
- Physicians are now under pressure to regulate, monitor and report opioid abuse.
Cost Of Providing Service To The Physician
- Cost of providing chronic pain service has rapidly escalated.
- Increased demand by insurance provider for detailed documentation leads to additional expenses to maintain a complicated and expensive electronic medical record (EMR).
- Initial cost and maintenance of EMR is substantial.
- Next, the number of rejections of medical bills for physician services has also increased.
- Physicians are seeing more patients to pay cost of overhead and office expenses.
- Communication between physician and patient is compromized by paperwork, dictation and escalating office expenses.
Challenges For Physician When It Comes To Opioid Monitoring-
- Initial or follow up visits are paid depending on time spent with patients.
- Visit time is restricted between 30 to 45 minutes.
- Monitoring patient may involve multiple phone calls to spouse, pharmacy and other physicians treating patient simultaneously.
- Phone call to pharmacy or physician office can take any where between 5 and 15 minutes. In most cases it would be 15 minutes or more.
- Physicians often prefer to perform urine drug test in office.
- For a facility to have Urine drug test requires a secretary and drug test kit. Cost of urine drug test is often more than insurance payment for the test.
- Physician may prefer to employ a physician assistant or pain coordinator to perform patient monitoring, but these services are not paid by insurance provider.
Opioid Monitoring Guidelines-
Several medical societies have published monitoring guidance. Guidelines include following suggestions-
- Urine drug test
- Pill count
- Detailed patient history
- Frequent interview with family members of patient
- Completion of diagnostic tools of multiple questions to be answered by patients
- Pharmacy call
- Calls to doctor's office.
1. Policies and events affecting prescription opioid use for non-cancer pain among an insured patient population.
Ahmedani BK1, Peterson EL, Wells KE, Lanfear DE, Williams LK.
Pain Physician. 2014 May-Jun;17(3):205-16.
2. The prescription drug epidemic in the United States: a perfect storm.
Drug Alcohol Rev. 2011 May;30(3):264-70. doi: 10.1111/j.1465-3362.2011.00291.x.
3. Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011.
Atluri S, Sudarshan G, Manchikanti L1.
Pain Physician. 2014 Mar-Apr;17(2):E119-28.
4. 4.Epidemiology of emergency department visits for opioid overdose: a population-based study.
Hasegawa K1, Brown DF2, Tsugawa Y3, Camargo CA Jr2.
Mayo Clin Proc. 2014 Apr;89(4):462-71.
5. Risk of adverse health outcomes with increasing duration and regularity of opioid therapy.
Paulozzi LJ1, Zhang K, Jones CM, Mack KA.
J Am Board Fam Med. 2014 May-Jun;27(3):329-38. doi: 10.3122/jabfm.2014.03.130290.