Here's my routine:
At the first visit, I frankly try to obtain as many "leads" to investigate the patient as possible: past doctors, any pharmacies that they *ever* use. I also politely elaborate to them, in detail, about the strict terms of our narcotic agreement form. I do this kindly but firmly, and hopefully encourage drug-seekers to look for easier pickings.
By calling local pharmacies to check on new patients and checking their hospital records on my dial-up connection their hospital records, I am sadly able to catch a number of new patients in deception while they wait in their exam room, and exclude them as patients in utero.
I see my chronic pain patients every month at first, no matter what schedule drug they use, to give us time to receive old notes from past doctors (a *must*), to get feedback from pharmacies, etc. I continue this while their status with my clinic is stabilized, i.e. as I get to understand their problem and their reliability as a patient. We continue monthly for as long as I feel any doubt or suspicion about the nature of their complaint.
As I review their history, I determine whether their pain complaint has really been thoroughly worked up, and we go through the procedure of getting new MRIs if needed, surgical consulation if needed, pain specialist consultation if no surgical consultation is indicated. If there are co-morbid psychiatric problems, I may get a psychiatry consulation (and I usually mail ahead to the psychiatrist about my specific concerns). I specify to the patient that I want to make sure that I am treating all their problems appropriately, and that no stone has been left unturned before we condemn them to potentially harmful medications for the rest of their lives.
Only after I am satisfied that the patient has been properly evaluated and the nature of their pain complaint is understood, and they have demonstrated themselves to be reliable for several months, do I relax the schedule to q 3 months and I never go any longer - EVER.
I sign off all narcotic refills personally.
I never replace lost or stolen medication, and if there are irregularities, I sadly explain the need for a urine drug screen: "it's routine in these cases, I'm very sorry." (make sure and specify to your lab if you're looking for oxycodone or fentanyl as lots of urine drug screens don't catch these drugs: they have to do a special quantitative test for them).
I never, ever prescribe Soma: I have found that this screens out a significant number of abusers, at least in our population. It is popular with abusers, and I think there are equally effective alternatives with significantly less abuse potential. They tell me "it works great for me!" and I say, "I'm sorry -- I just don't like that drug and I don't ever prescribe it."
As a result, I have, at most, a few dozen people with established chronic pain problems who come in every few months, nice as pie, pain well-controlled and we have been going along like this for years. If they de-stabilize, I get a new specialist consult.
Could one of them be fooling me? Possibly, but I think you have to set your paranoia levels to screen out as much debris as you can without harming people with legitimate complaints.
Brian
