Ask about addiction before prescribing—a standard of care
The Prescription Review Program recently received a letter from a family physician relating the tragic story of a man who had been in long-term, abstinence-based recovery suffering a life-threatening relapse triggered by an inappropriate prescription:
“I was asked to help a young man, an addict in recovery, who was given hydromorphone for pain despite both him and his wife explaining he could not receive narcotics. He had a good job, had achieved a university education and was living with his wife and baby in their new home. He is now on the street, his life is in shambles and he may well die.”
Patients who suffer from the lifelong disease of opioid addiction may require opioids to treat severe acute pain associated with objectively demonstrable pathology like fractures and major surgery, but the medicating must be actively managed and closely monitored. Addiction is a disease characterized by loss of control. People with addiction cannot be relied upon to take their meds safely on a PRN basis, and they must never be sent home with a bottle of pills without supervision. The inevitable struggle to withdraw the opioid when the tissues heal requires explicit advance planning, including a pre-determined end date, consideration of daily dispensing and mobilization of recovery resources such as attendance at a 12-step program, and recruiting a sponsor and other supports. The patient, family or friends, and the physician must all be actively engaged. It is never acceptable to simply issue a prescription in such circumstances and hope for the best.
Similarly, alcoholic patients are too-often provided with opioids, benzodiazepines, and/or sedative hypnotics, and not even asked about that very strong relative contraindication.
History-taking in advance of prescribing a potentially addictive drug must always include consideration of risk. Physicians would never start a beta-blocker without inquiring about asthma! It is equally unacceptable to prescribe an opioid or sedative without asking the high-yield question: have drugs or alcohol ever caused problems in your life? An affirmative response requires very careful consideration of whether the modest potential benefit justifies the significant risk and must often conclude with an empathic, evidence-based, patient-centred “no.”
All physicians struggle with this issue as they inevitably become healers to relieve suffering. In the context of addiction, a physician’s inclination to medicate symptoms has the potential to cause harm.
Protect duplicate prescription abuse
Registrants should be aware that using a sticky-label patient identification on a duplicate prescription can enable misuse and diversion as the labels are easy to remove, and therefore are not appropriate for a prescription—especially for controlled medication.
Take note of the Pharmaceutical Services Act
Registrants are reminded that the Pharmaceutical Services Act states that only “prescribed information management technology” can be used for issuing electronic prescriptions. In British Columbia, the prescribed interface is PharmaNet. The Ministry of Health is currently conducting a pilot test for e-prescribing through PharmaNet. However, until such time as e-prescribing is implemented, pharmacists are obligated to insist on an original or unique signature each time a prescription is authorized. The College is encouraged by the work being done by the ministry to enable e-prescribing in future, and will continue to update registrants as more information becomes available.