Prescribing Opioids Safely: How to Have Difficult Patient Conversations

Roneet Lev, MD, Chief of Scripps Mercy Emergency Department, Chair of Prescription Drug Abuse Medical Task Force, and President of Independent Emergency Physicians Consortium

Updated March 24, 2021: Drug overdose is the leading cause of accidental death in the U.S., and opioids account for over 60% of those deaths.¹ While opioids are effective pain medications when used in the proper setting, concerns arise when the patient’s condition lasts longer than three months, and prescribing more medication does not necessarily result in better pain control.

Building a strong doctor-patient rapport can help facilitate tough conversations with patients about opioid prescriptions and reduce risks that could lead to malpractice suits. The Doctors Company reviewed 782 claims that closed between 2015–2019 in which patient harm involved medication factors. The Doctors Company in which patient harm involved medication factors. In 118 of these claims (15%), the medications were narcotic analgesics. Seventy-four percent of these claims (n=87) were in the outpatient setting, including:

• Physicians' offices and hospital clinics (90%).
• Emergency room (6%).

The admitting diagnoses for these outpatient narcotic-related claims were pain, including chronic pain not otherwise specified (NOS) (66%), spine-related pain (7%), joint/extremity-related pain (3%), mental health issues (6%), and drug abuse/dependence (3%).

Patient allegations for these claims included improper medication management or treatment (80%), other medication-related issues, such as unknown allergies or adverse reactions (10%) and ordering the wrong dose (4%). Final diagnoses in these claims included poisoning by methadone, heroin, and opiates/narcotics NOS (53%), drug dependence (20%) and adverse effects of medications (8%).

Communication problems are among the patient-contributing factors that lead to injury, appearing in 48% of claims. Incomplete or unclear communication can compromise patients’ ability to understand the doctor’s instructions and, especially in the case of pain medications, also make them feel as if the doctor doesn’t care about their issues or concerns.

These tips can help when dealing with opioid requests and prescriptions:

• Don't make the mistake of jumping to conclusions that the patient is a drug seeker because the patient is there repeatedly for the same pain complaint. It could instead be a situation of missed diagnosis. Treat this patient like any other patient. Take a good history, including a very detailed medication history. Do a thorough physical examination. See if something was missed on previous visits.
• Your prescription drug monitoring program (PDMP) is a valuable tool, like checking allergies and old records. Use the PDMP to learn about your patient's prescription patterns, not just to check for doctor shopping.
• Medication refills for chronic conditions should have a medication agreement. ONE doctor and ONE pharmacy should prescribe controlled medication given for three months or more. This is true for dental pain, fractures, fibromyalgia, cancer, anxiety, and ADHD. If you see a patient for the third month of a controlled medication, start a medication agreement if you plan on continuing this therapy.
• Opioid withdrawal is uncomfortable but not life-threatening. New patients who present to a new pain specialist should not immediately be given the pain medications they state they need. A pain specialist typically completes thorough research before making medication recommendations and it could be two weeks before the patient is placed on a regular regimen. You may find it necessary to send a patient home without a pain prescription if that patient has already received one in the past month from a different provider.
• When patients say that their medication is not working, ask the patient, "How are you taking the medication?" You’ll be surprised how many patients used 400mg of ibuprofen twice a day and it was not enough. Taking a detailed medication history and providing patient education about the right dosage, right timing, and side effects to be aware of is essential to medication safety.
• When you hand a patient a prescription for a controlled medication, add a few words to let the patient know that these are serious medications: "I will give you a prescription for Norco. Please realize that this is a medication that can be abused. Keep it secure, take it only as prescribed, and do not drive if not fully alert."
• Be aware of the level of health literacy of the individual patient, and adjust your language appropriately. Ask patients to repeat back the information you gave to ensure they properly understand.
• Communicate the risk of medication theft to patients. Patients who are on a chronic treatment plan should know to watch their medication as closely as they would their money.

Good answers for specific patient questions and situations:

PATIENT	DOCTOR ANSWER
“Can I have something for pain?”	“Yes, let me check your medical record for the best choice.”
“The medicines don’t work.”	“Can you please tell me how you take the prescription?”
“My prescription was stolen.”	“Did you file a police report?”
“I have chronic pain.”	“For your safety, you need your medications coordinated by one doctor and one pharmacy.”
“I received extra pain medications elsewhere.”	“Let’s do a drug specimen today.” “I see you received 20 pills from the emergency department, what happened?” “OK, to stay on the same schedule, this month I will write 100 tablets (120 minus 20).”
A case of clear doctor shopping	“I am concerned because your medications can be addicting. I am going to refer you to someone who can help with this.”
A case of need to stop an opioid prescription	“The medication no longer appears to be as beneficial as it once was. As the benefits of the opioids no longer outweigh the risks, we need to discontinue this approach and together find a safer and more effective means of dealing with your pain.”

Get more safe prescribing resources at www.SanDiegoSafePrescribing.org and learn more about effective doctor-patient communication at www.thedoctors.com/askme3.

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