Published in the March 2008 issue of Today’s Hospitalist
A middle aged patient tells you he has been taking a benzodiazepine for a condition that’s long been resolved, then becomes anxious when you discuss discontinuing the prescription. You suspect that he is abusing the medication, but you’re not sure. Do you withdraw the drug immediately, or continue it while the patient is hospitalized but reduce the dose? Or do you just continue the drug at the same dose to avoid creating problems for the nurses?
If you’re like most hospitalists, the answer is probably a combination of all of the above. Unlike your colleagues in the ED, you probably don’t see many drug-seeking patients who fly into a rage when you withhold a drug or broach the topic of addiction. You’re more likely to see the elderly patient with heart failure who claims she uses narcotics only occasionally “then develops a psychosis that looks a lot like withdrawal.
Because these patients aren’t stereotypical drug addicts, they can easily fall through the cracks. They also pose distinct challenges for hospitalists, who have limited time to not only detect problems related to prescription drug abuse, but to address patients’ dependence before they go home.
Here’s a look at how several hospitalists approach patients they suspect are abusing prescription drugs “and the actions they take to help those patients.
Prescription drugs being abused are the usual suspects: narcotics like Percocet and Lortab and benzodiazepines. But hospitalists say that increasingly, headache medications (the triptans) and muscle relaxants “notably the popular and reportedly overprescribed Soma (carisoprodol) and Flexeril (cyclobenzaprine) “are a growing problem.
But identifying what drugs a patient is abusing is just the beginning. Nikunj Doshi, DO, a hospitalist with Banner Gateway Medical Center in Gilbert, Ariz., recalls a 25-yearold with inflammatory bowel disease admitted for abdominal pain “for the fifth time in as many months, despite negative results on a gamut of tests. As soon as the young man arrived on the floor, he asked Dr. Doshi for dilaudid, stating that he was “allergic to morphine.”
“If the first thing the patient asks for is the high-potency pain medication, that sets off an alarm,” says Dr. Doshi. “But that doesn’t make it easier to deal with.” Given his hospital’s suburban setting, he adds, he’s been surprised by the number of patients, who range in age from their 20s to their 70s, who ask for dilaudid by name.
Or patients come in with pneumonia, heart failure or COPD, “and we’re asked to continue their drugs,” explains James Franko, MD, director of Carilion Clinic Hospitalists in Roanoke, Va. “Maybe we think they really don’t need one of the drugs, so it becomes an ethical issue.”
Particularly with older patients, Dr. Franko adds, polypharmacy can pose as much of a problem as prescription abuse.
“I’ve seen 80-year-old patients taking 20 different medications a day, sometimes two or three drugs for anxiety and a couple of painkillers,” he says. “You know that it’s not right, but you also figure that, with that many medications, the patient can’t possibly be compliant.”
How does he begin sorting out that dilemma? If a patient has taken Xanax for 20 years, Dr. Franko says that he doesn’t necessarily take any action. “It’s not within the realm of what I’m doing,” he says. “You can’t solve these issues with a single hospitalization.”
Following subtle clues
Then there are patients who may be more manipulative, leaving doctors to parse out clues.
Glenn Focht, MD, recalls a recent out-of-state patient who was admitted for issues unrelated to pain. While the patient was taking several narcotics, she made a play to secure some extra pills.
When asked to write down her medications, the patient did so “but listed twice the dosages she was taking, recalls Dr. Focht, who is chief medical officer at Cooley-Dickinson Hospital in Northampton, Mass., and directs three hospitalist programs in that state. He discovered the discrepancy after calling the prescribing physician and the pharmacy.
“One of the first things I do is ask patients what their understanding is of how the medications are to be taken,” Dr. Focht says. “I tell them that I will be calling their physician to make sure I have accurate, up-to-date data.” He concludes the conversation by telling patients that he will use the lowest possible safe doses, but that he will frequently evaluate their pain control.
According to Dr. Focht, most patients “concede to your candor and are conducive to the plan.” For those patients “less than happy” with that arrangement, he adds, he talks about the dangers of abuse and dependence. The key, he says, is to couch the discussion as an attempt to prevent harm. “That sometimes provides an opportunity for patients to talk about a part of their life that they’ve kept secret,” Dr. Focht says.
Testing the waters
Eric Howell, MD, director of the Collaborative Inpatient Medicine Service at Johns Hopkins Bayview Medical Center in Baltimore, agrees that conversations about drug abuse can be productive, as long as patients sense that you’re looking out for their interests.
“I find that people tend to tell you the truth if you have a relationship with them,” he says, “and it doesn’t have to be a long-term relationship.” By connecting with patients even informally “sitting on their bed and talking to them in a nonjudgmental way “patients are more likely to disclose use or abuse patterns that could affect their care.
Dr. Howell makes a point of telling patients that he asks all of them the same question: Have you ever used drugs in a way not prescribed by a doctor?
“You would be shocked at how many patients say, ‘I have used my brother’s benzodiazepines to help me sleep, but only occasionally,’ ” he says. With a little nonjudgmental probing, he adds, the real scoop often comes out. “It turns out that the patient uses three times a day and buys the drug on the street.”
What leads patients to open up? “They’ve tested the waters to indicate socially acceptable use,” Dr. Howell says. “If you don’t judge them, often patients give you more information.”
He also points out that hospitalists need to re-evaluate for drug use, especially in patients with unexplained symptoms. “It’s never closed,” he says, “even if a patient says, ‘No, I never use’ on day 1. Whenever something bizarre happens, I immediately start suspecting that there’s a substance abuse issue and I test the waters again.”
Chronic pain or dependence?
Banner Gateway’s Dr. Doshi points to another common situation: Patients three months out from surgery who still take a post-op dose of narcotics. The natural tendency is to decrease the dose, he says, but that gets challenging when dependence has developed.
“It can be very hard to sift through who actually needs the drug and who is just using or abusing it,” he says. “Sometimes, you just don’t have the time or the resources to delve into their pain “so you just prescribe what they need at the time.”
That dilemma is exacerbated when a patient has a serious illness associated with chronic or frequent pain. Meredith Heller, MD, a hospitalist at University of California, San Francisco (UCSF) who works primarily at the university’s Mount Zion Hospital campus, tries to tackle prescription drug abuse head on. But she says that she struggles with the subset of sickle-cell disease patients who often end up on her service when they’re in vaso-occlusive crisis.
“The hard thing about sickle-cell pain is that there’s no objective measure of pain during a crisis,” Dr. Heller explains. “It’s difficult when the same patient comes in once a month and reports that he’s experiencing the worst pain of his life and stays two weeks at a time. We wonder if there are other factors besides physical pain that can be treated by opiates, contributing to the picture.”
To address those types of patients and reduce unnecessarily long stays, the UCSF hospitalists, working with hematologists, have devised a narcotics-weaning protocol. Intravenous narcotics are cut off after 48 hours, with patients gradually being moved to their home oral narcotics regimen. Each frequent-flyer patient receives an individualized protocol and frequent pain assessment.
From the hospitalists’ perspective, says Dr. Heller, the approach works for the most part. “Stays are shorter now.” She admits, however, that occasionally from the patients’ perspective, their pain control is suboptimal.”
Management and acquiescence
When a pain or addiction medicine consult isn’t available, deciding how to taper a narcotics dose without setting off withdrawal becomes a time-consuming balancing act. “I start with long-acting medications and I try to titrate slowly,” Dr. Doshi says, “but inevitably the patients with dependence will constantly harass the nurse,” who in turn pages him.
At that point, Dr. Doshi tries to talk with patients about dependence and the risks of overdose. But if that’s unproductive, he may end up just titrating the dose until things calm down.
“Sometimes, you need to make everyone’s life easier while the patient is in the hospital,” he says. “But I make it clear that I won’t prescribe the medication to the patient when he leaves.”
Dr. Franko enlists Carilion’s substance abuse counseling service, whether dependence involves licit or illicit sub-stances. But he acknowledges that his daily time crunch “and the pressure to not keep patients hospitalized any longer than necessary “makes it hard to sort out these problems. “Sometimes we acquiesce and just deal with the immediate issue,” he says. “It’s a dilemma for all of us.”
What to do at discharge
The key to helping patients with prescription drug problems, hospitalists agree, is getting the outpatient physicians directly involved.
For sickle-cell patients, the UCSF hospitalist service has implemented a no-narcotics-on-discharge policy as one way to ensure that patients see their primary physician soon after discharge. “This can provide additional incentive for these patients to see their regular doctor,” Dr. Heller points out.
Often, however, “patients come in, and they don’t realize the trap they’re in until you talk about it,” explains Dr. Franko from Carilion Clinic. “At discharge, I try to communicate that in a skillful way to the referring doctor, asking why the patient is on a particular medication or dose.”
When he sees elderly patients taking multiple antianxiety medications and an antidepressant “a situation that is increasingly common “he makes a point to talk to the primary care physician. He is also candid with patients, telling them that he plans to talk to their primary care physician about their medications. When patients ask him to continue a drug, Dr. Franko agrees “but reiterates that he wants to ensure the patient isn’t being harmed.
Dr. Focht from Cooley-Dickinson notes in the discharge summary any open issue identified during hospitalization related to a patient’s use of prescriptions.
He also informs referring physicians that he has asked the patient to follow up after discharge. Dr. Focht prescribes the smallest quantity of the medication he can and he lists on the discharge summary the exact number of pills he’s prescribed. “It varies by patient,” he says, “but I spend a lot of time to make certain that the patient has a safe and effective plan.”
In the best-case scenario, Dr. Focht says, those efforts may spawn a “heightened awareness” on the part of the primary care physician that a regimen may not be in a patient’s best interest. “Sometimes just having someone else’s perspective,”
he says, “benefits everyone involved.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.
The pros and cons of narcotics contracts
WHEN IT COMES TO PRESCRIPTION DRUG ABUSE, hospitalists can unwittingly wade into another morass if patients have a narcotics contract with their primary physician.
Such contracts typically spell out how much of a medication doctors will prescribe and under what conditions. Often, hospitalists say, hospitalized patients don’t divulge that they have a contract in place “one that the hospitalist inadvertently violates by prescribing a narcotic or sending a patient home with a few doses.
That can give office-based physicians a long-hoped-for opportunity to fire the patient. “Unfortunately, it’s something that some people use to get patients out of their practice, because they know these patients will fail on compliance,”
says James Franko, MD, director of Carilion Clinic Hospitalists in Roanoke, Va. “I personally try to avoid using contracts that way. I’m inclined to be more lenient because I want to help the patient who has the problem.”
Michael Strong, MD, however, says that initiating such a contract with patients can be helpful. His group has done so with patients who say they’re in a lot of pain and who have been hospitalized enough times for him to realize that there’s a problem.
“I’ll say straight out to the patient that I suspect there’s a dependency issue and that I’ll treat the pain, but only on the schedule I set,” says Dr. Strong, director of the hospitalist program at University of Utah. When he puts a contract in place or hears that a patient has a contract with a primary care physician, his group “always gets the primary physician involved on admission.”
He’ll also check a state-run database of all controlled-substance prescriptions issued over the past three years. That way, he points out, when a patient says she hasn’t had her Percocet filled in a long time, “I can say, ‘You know what? I see in this report that you had your prescription filled a week ago.’ "