The story which aired recently on CBC alleging inappropriate prescribing and dispensing of OxyContin® serves as a reminder to all physicians about the importance of safe and effective prescribing of controlled substances. See “Pharmacies, doctors fail to stop narcotic shopping spree.”
Public protection begins with the principal precept of medical ethics, primum non nocere – first do no harm. As prescribers, physicians must always consider the possible harm that might result whenever a prescription is issued. Although potent opiates such as morphine, oxycodone, hydromorphone, and fentanyl have tremendous therapeutic effects, their use can also be associated with misuse, abuse and diversion. Current medical literature is full of reports of the harm and death caused by the use of these medications, especially if used in combination with a sedative hypnotic medication.
Previous editions of the College Connector (and its predecessor, the College Quarterly) have highlighted strategies for the safe and effective use of opioids for chronic non-cancer pain. The CBC story identified some patient-specific behaviours, which may be a flag that a patient is misusing controlled substances. Often, it starts with the CareCard. While steps are under way within the Ministry of Health to improve the security of the CareCard, including the addition of photographic identification, physicians should be conducting their own checks already to minimize abuse, such as asking to see a secondary piece of identification for all new patients. Physicians have an obligation to be vigilant with patients they suspect may be “doctor shopping” or attempting to obtain prescriptions for controlled substances from multiple physicians.
The College is quite clear on the standards expected of physicians who provide community-based primary care services. Regardless of the setting, these standards for quality of care must not vary. Even at a walk-in clinic, a thorough evaluation of a patient’s presenting complaints and needs is required, which includes conducting a review of the PharmaNet database when dealing with patients who require prescriptions for controlled substances. In fact, the use of PharmaNet is mandatory for physicians who work in transient care settings, as is the creation of a longitudinal medical record for a patient who attends the clinic on three or more occasions.
Physicians who are not familiar with these expectations should review the following College standards:
Physicians may also be interested in the following resources:
- Prescribing Principles
- Canadian Guideline for the Safe and Effective Use of Opioids for Chronic Non-cancer Pain
- First Do No Harm: Responding to Canada’s Prescription Drug Crisis
This is also a timely opportunity to remind physicians to safeguard their duplicate prescription pad. Lost or stolen duplicate prescription pads should be promptly reported to the College. A stolen duplicate prescription pad used to fraudulently obtain potent opioids is literally worth its weight in gold.
H.M. Oetter, MD
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