Narcotic prescribing, telehealth, and the rural physician
At a recent educational workshop on methadone presented by the College, physicians heard Dr. Mandy Manak of Kamloops describe the challenges that rural physicians face when delivering opioid agonist therapy. These challenges include: working in a community with a limited number of medical providers; a lack of knowledge of addiction medicine of some health-care providers; the high-risk nature of both the medication and the patient population in question; and difficulties associated with patients accessing treatment centres and services.
Physicians may be inclined to rely on telehealth solutions as a way to address these challenges. However, while telehealth may offer a pragmatic means for treating patients who have difficulty accessing a clinic or service, it is not always appropriate. Physicians should consider the following:
- Arrange a face-to-face assessment every three months where possible. Extra vigilance is required regarding take-home doses and increases in dosing.
- Treat other dependencies such as alcohol. Never prescribe benzodiazepines and opioids together.
- Random urine drug testing is critical. Ensure staff is available to collect results and arrange for random screens.
- Never prescribe narcotics or other controlled medications to new patients who have not been examined or with whom no longitudinal treating relationship exists unless there is direct communication with another licensed health-care practitioner who has examined the patient.
- Ensure patients are familiar with local pharmacies, and that staff support is available to assist with patients.
In some cases there is simply no way to ensure safe narcotic prescribing. A general principle is this: if a patient is unable to attend regular clinic visits, it is unlikely s/he can be treated safely and effectively by telehealth options.
Presentations from the Methadone 101/Hospitalist workshop are available on the College’s website here.