It’s 11 p.m. Do you know where your oxycodone prescription is? Every day I refill prescriptions for various pain medications. These requests raise my concern only if the number of pills is very large, or the patient is requesting an early refill. Because refills are such a frequent task, I don’t analyze them too much, but truthfully there are issues to be apprehensive about.
I saw an 81-year-old man with chronic back pain. Fortunately, he seemed to get some relief using a TENS (transcutaneous electrical nerve stimulator) unit, in combination with tramadol that his family doctor prescribed. I was pleased with this outcome, but his daughter piped up and asked me if I would prescribe hydrocodone for him. I was looking for a polite way to say no, or to at least ask if hydrocodone was really called for, since he was doing well with his current treatment. While I was searching for the right diplomatic formula, his daughter told me that her father’s family doctor used to prescribe hydrocodone, but he had voluntarily given up his DEA license. It wasn’t that big a deal, according to the daughter, but some of his patients had been selling their pills, while other patients had committed suicide.
I was getting ready to deny the daughter’s request with an emphatic "no," but luckily for me, the patient piped up and said he didn’t feel like he needed hydrocodone, so I was spared a potentially unpleasant discussion with his daughter. As far as I know, my patients haven’t sold their medication or committed suicide, but neither category of patient is likely to come to the office and confess their sins.
Doctors are always in a quandary about pain medication. Pain is the "fifth vital sign" and while we have to do a good job of controlling pain, we also have to deal with concerns about patients who are abusing or diverting our prescriptions. In order to balance these demands, urine drug testing has been touted as a necessity.
Many representatives of companies that perform toxicology testing have found their way to my office doorstep, but I’ve dragged my feet for years on this issue. I glibly told one company representative that I have hundreds of patients on chronic pain medication. He got so excited I think he envisioned setting up a bus or a big-top tent in my office parking lot so we could line up all the suspects, I mean patients, for their tests. But I had very mixed emotions about testing. How would I explain this to patients? "Excuse me, Grandma, but I need to make sure that you aren’t taking cocaine or selling your hydrocodone, so you’ll need to give us a urine specimen. The lab tech will watch as you pull up your petticoat and pee in this cup." How often would the testing be repeated? Would all patients be tested, or would there be exceptions? If there were exceptions, what were the criteria?
Even before I resolved these sticky questions, I had an experience in the office that gave me some added insight into the value of testing. A middle-aged man came to see me about his gout. His gout seemed quite well controlled on his current medications, but he was still taking oxycodone a few times a day for pain. After chatting with him, I didn’t have a clear idea of why he was taking so much oxycodone. In a casual way, I told him that the standard of care was to do a urine drug screen. He said that was fine, and he left with his lab order. He never did his drug screen, and he never returned to the office. He probably went to an office that didn’t ask so many questions.