But I know my patient!

When the College speaks to physicians who have challenges related to safe prescribing and who have not practised the precautions that are referred to as “pharmacovigilance,” one of the most common responses is: “But I know my patient!”

What is almost always evident in these conversations is that these physicians highly value the therapeutic relationship they have with their patients. Unfortunately, what is also frequently evident is that they don’t know their patients as well as they think they do. 

For example, physicians may not know:

  • if their patient has ever been diagnosed with, or is at risk of having, a substance use disorder
  • that patients with an active substance use disorder will and must often be dishonest in order to obtain drugs
  • that substance use disorder is often misdiagnosed as chronic pain or anxiety
  • if there is a family history of substance use disorder
  • if their patient smokes (or had trouble quitting)
  • if their patient drinks alcohol (frequently the response is “only socially” but they don't know how much or how often) 
  • if their patient drives, including public transit or a school bus
  • what their patient does for a living or what their job entails (e.g. operating machinery) 
  • if the patient is a caregiver for small children or the elderly

Sometimes physicians claim that the reason they haven’t found out more about their patient’s work or lifestyle in general is because they’re too busy dealing with high patient volumes. Other times physicians are uncomfortable asking pertinent questions or setting treatment boundaries because they worry they may be perceived by their patient as “intrusive.”

The College reminds physicians that providing safe medical care, and specifically safe prescribing, will always involve some difficult conversations. Keeping patients and the public at large safe from the consequences of one’s prescribing requires physicians to put in place a treatment framework that is respectful, non-judgmental and focused on first doing no harm.

Pharmacovigilance includes:

  • a substance use disorder screen documented in the medical record
  • an agreement for long-term opioid treatment
  • having access to and regularly checking PharmaNet
  • providing regular, small dispense volumes
  • including a schedule of random urine drug testing and/or random pill counts for any patient receiving regular dispenses of medications with the potential for diversion