Press Release
College releases advice to physicians on preventing diversion and abuse of prescription narcotics
Halifax, March 23, 2004 - In a letter dated March 16, 2004, the College of Physicians and Surgeons of Nova Scotia released specific advice to its members on preventing the diversion and abuse of prescription narcotics.
The full text of the letter and its attachment are provided below:
Tuesday, March 16, 2004
Re. Diversion and Abuse of Prescription Narcotics
To the Members of the College of Physicians and Surgeons of Nova Scotia,
As you are probably aware, there has recently been much public concern about the diversion and abuse of prescription narcotics, particularly Oyxcontin, in Nova Scotia. As a former practicing oncologist, I am well aware of the tremendous clinical value of prescription narcotics. These drugs bring unparalleled pain relief to patients suffering from certain disease processes. Unfortunately, the misuse of these drugs comes at a tremendous human cost that cannot be understated. For example, Chief Edgar MacLeod of the Cape Breton Regional Police recently told the College's Council that since the beginning of 2004 alone, there have been three sudden deaths linked to prescription drugs in Cape Breton and a significant spike in violent crime and theft as a direct result of prescription drug abuse.
At the request of Council, I am taking this opportunity to support College members in their ongoing efforts to prescribe these drugs appropriately and to offer the following advice on minimizing their diversion and abuse:
1. Seriously consider whether your prescribing behaviours may contribute to drug diversion and abuse in your community or beyond. For example, if you answer "yes" to any of the questions below, consider revising your practices accordingly.
• Do you prescribe on demand?
• Do you accept the diagnosis made by a patient?
• Do you comply with drug selection suggested or requested by a patient?
• Do you prescribe small quantities of medication to "get the patient out of the office"?
• Do you prescribe any medication without first performing all necessary examinations to ensure that the patient is in actual medical need of such medication?
• Do you prescribe before making every effort to ensure that the patient is not obtaining medication from other sources while under your care?
• Do you practice in isolation without maintaining a close professional relationship with pharmacists and other practitioners in your area to facilitate the early identification of drug abuse problems?
• Do you react in a negative manner when contacted by a pharmacist to confirm a prescription or to discuss any other matter related to one of your prescriptions?
• Do you permit your nurse/receptionist to authorize prescription renewals or to relay such information to pharmacists on your behalf?
2. Be aware that the Prescription Monitoring Association of Nova Scotia has a medical consultant, Dr. Ken Cooper, who is available by phone at (902) 478-0546 to provide confidential advice on the prescribing of restricted drugs. Dr. Cooper also maintains a list of physicians with a special interest in addiction medicine who may be willing to serve as advisors.
3. Familiarize yourself with the College's Guidelines for the Use of Controlled Substances in the Treatment of Pain, which discuss the treatment of non-cancer pain and the documentation required. This document is available online or upon request from the College.
4. Establish a contract with all patients to whom you prescribe opioids. (See attached example).
5. Review your care of all your patients who are currently prescribed Oxycontin, to determine if this drug or its current dosage is appropriate. Consult with knowledgeable colleagues if necessary.
6. Consider prescribing opioids for non-cancer pain only after all other reasonable attempts at analgesia have failed. Consider switching existing non-cancer pain patients to another analgesic.
7. Consider a history of substance abuse, severe character pathology or chaotic home environment as relative contraindications for prescribing opioids for non-cancer pain.
8. With the exception of methadone in a methadone maintenance program, do not prescribe opioids to patients who you know to be addicted to opioids in the belief that these patients will thereby not commit crimes to support their habits. Unfortunately, it is well recognized that such patients frequently traffic at least some of the prescribed drug to others (diversion).
9. Secure your triplicate prescription pads and drug samples at all times.
10. Educate yourself and your staff about how to identify and respond to drug-seekers.
11. If threatened or coerced by a drug-seeker, call the police without hesitation.
Opioid-related complaints to the College appear to reflect a growing concern about the misuse and diversion of prescription opioids. Of the 40 complaints about controlled substances received in the past 10 years, 19 have been dismissed, 11 have resulted in a Counsel, two have resulted in a Caution, four have resulted in a Counsel and Caution, one has resulted in a Reprimand, one has resulted in the loss of the physician's medical license, and in two cases the physicians involved have retired with an open complaint. Four physicians have surrendered their license to prescribe restricted drugs, and one physician's prescribing rights have been limited. (Descriptions of disciplinary terms are available online or by contacting the College). Complaints regarding opioids have come from the Prescription Monitoring Program, police, pharmacists, patients, patients' relatives, and physicians.
The College recognizes that it has an important role to play in minimizing the abuse of prescription opioids while ensuring that these essential drugs continue to be prescribed appropriately to those who need them. Over the past year, we have met with the chiefs of police of the Halifax Regional Municipality, the Cape Breton Regional Municipality and the town of New Glasgow to better understand the abuse and diversion situation across the province. We also continue to work with the Department of Health, the Nova Scotia Prescription Monitoring Program and the Nova Scotia College of Pharmacists.
I thank you for your careful attention to this issue and offer my assistance in answering any questions you may have about the above information.
Best regards,
Cameron D. Little MD, LLB, FRCPC
Registrar and CEO
College of Physicians and Surgeons of Nova Scotia
Attachment
CONTRACT
MANAGEMENT OF OPIOID THERAPY
FOR CHRONIC NON-MALIGNANT PAIN
1. Opioid maintenance therapy should be considered only after other treatment modalities and analgesia have failed.
2. One physician should be responsible for opioid therapy.
3. Patient should be informed of the risks and benefits of opioid therapy, which could include such side effects as skin rash, constipation, sweating, sexual dysfunction, sleeping abnormalities, and altered mental status. Overuse of opioids can cause decreased respiration and sedation.
4. Patient should realize the possibility of tolerance when using opioid therapy, which means the loss of effect of the current dose and the need to escalate the dose in order to maintain effective treatment. The patient should also be aware that he or she could become dependent on the opioid therapy. This means that if the therapy is withdrawn, an abstinence syndrome can occur. This abstinence syndrome could include: nervousness, sweating, abdominal cramps, diarrhea and alteration in one's mood.
5. Opioid medications can interact with over-the-counter and prescribed medications. Therefore, the doctor should be informed of all medications the patient is taking.
6. The patient will be seen on a regular basis and prescriptions given to last until the next visit.
7. Any evidence of drug hoarding, acquisition of drugs from other physicians (which include emergency rooms), uncontrolled dose escalation, loss of prescriptions or failure to follow the agreed upon contract will result in tapering and a discontinuation of opioid therapy with resulting discontinuation of the doctor/patient relationship.
The above contract has been explained to me by ________________________ so that he/she can provide quality pain management using opioid therapy in my best interest.
WITNESS:____________________ PATIENT:____________________
DATE: ____________________ DATE: ____________________
I, Dr. _____________________, hereby agree to accept ________________________
as my patient under the foregoing conditions.
________________________
PHYSICIAN'S SIGNATURE
_________
DATE
-30-
Contact:
Bruce Thorne
Manager, Policy and Communications
College of Physicians and Surgeons of Nova Scotia
Suite 5005, 7071 Bayers Rd.
Halifax, Nova Scotia
B3L 2C2
Phone: (902) 421-2212
Cell: (902) 499-6403
Toll-free in Nova Scotia: 1-877-282-7767
E-mail: bthorne@cpsns.ns.ca
