1. Controlled substance compliance
Patient-provider agreements, urine drug screening, pill counts, prescription monitoring programs

2. Your speaker
Eva Quirion MSN, PhD, FNP-C St. Joseph Internal Medicine Pain and Recovery Care 900 Broadway Bangor, ME

3. Disclosures
I have no disclosures.

4. objectives
Participants will be able to identify key components in patient provider agreements for controlled substances
Participants will be able to state rationale for informed consent related to controlled substances
Participants will be able to assist in interpretation of urine drug screening and pill count data

5. Patient-provider agreements and informed consent
Why do we do this?
Patient-provider agreement
So that each participant understands the responsibilities of controlled substance
Informed consent
To document that the provider has explained to patient the nature of being on a high risk medication and to all the patient the opportunity to “opt out”
Is this a contract?
NO, this is not legally binding and either party can cancel the agreement at ANY time
I encourage people to NOT call this a contract so that the patient does not get the impression that the provider HAS to prescribe

6. Patient-provider agreements – major components
Goals for treatment
What is being treated
State that the goal of treatment is improved function
Safety
Take medications only as prescribed
No buying/selling/pharming
Disposal
Use of other drugs and having other prescribers
Notification of pregnancy or other health changes
Keeping appointments
Use of one pharmacy
Permission to speak with other providers in the care team

7. Patient-provider agreements – major components
Monitoring
Agreement to conduct and be present for random pill counts
Urine screening tests – more on this later
Not replacing lost of stolen medications
Prescription monitoring program – more on this later too!
Management of prescriptions and refills
The 28 day vs 30 day refills
Refills only happen on week days and not weekends or with on call providers
No early refills

8. Informed consent – major components
Uses
Benefits expected
Risks
Alternative treatments

9. Urine drug screening
Should always do UDS prior to starting any controlled substance
There is no such thing as a “clean” or “dirty” urine. The results are “as expected” or “not as expected.”
If a urine is not as expected, discuss with the patient
If you get a “confession” there is no need to confirm
If you get a “denial” send for confirmation – ESPECIALLY if you are basing a clinical decision on the data in a urine screen
There is a high inaccuracy rate for any in-office urine screening
Confirm, confirm, confirm

10. Urine drug screening
Most in office tests check for opioids, oxycodone, methadone, amphetamines, methamphetamines, cocaine, THC, benzodiazepines. There are variants.
An opioid is: Any drug in the opium family (heroin, morphine, hydrocodone, hydromorphone and others – but NOT oxycodone or fentanyl)
Oxycodone is: oxycodone only, no other drug will make this positive
Methadone is: only methadone
Amphetamines are some ADHD medications – but NOT Ritalin
Methamphetamines – illicit substances (Crystal meth, nothing prescribed)
Cocaine – is cocaine
THC – is marijuana
Benzodiazepines – sedatives like valium, Xanax, clonazepam, and many others

11. Urine drug screening
To test for methylphenidate (Ritalin), must be sent to the lab
Fentanyl and Tramadol must be done in the lab
Some dip tests check for buprenorphine and others do not and may need to be sent to the lab
Urine tests range from $8 cost to hundreds of dollars depending on how comprehensive it is
If you don’t know what the test is telling you – call the LAB!! They are usually more than happy to help interpret results

12. Pill counts
This Photo by Unknown Author is licensed under CC BY-NC-ND

13. Pill counts Call to patient in the morning 3 attempts in 2 days
If need to leave a message, “please call the office” and don’t tell them on a message that this is for a pill count
Do not combine with a previously scheduled appointment
3 attempts in 2 days
If patient does not call back, consider the pill count a “fail”
Request to patient to come in that day to bring their medications
Provider discretion if allowed to come in the following morning
Excuses:
I can’t get in to the office while you are open – utilize their retail pharmacy
I am out of town – request that they provide proof of being out of town (receipt)

14. Pill counts
Not being able to accomplish a pill count is “non-reassuring”
Our policy is 2 failed attempts and the CS is stopped
If the patient has signed an agreement, they will know the expectation of doing pill counts from time to time
We do once a year as a minimum
More frequent counts are appropriate, but consider if this patient is appropriate for controlled substances at all (is it a safe environment?)

15. Sample documents

16. CS documents
When policies and documents are similar in the community, it can cut down on patients changing practices for more lenient controlled substance policies
Feel free to use and adopt any of these documents for your own facilities

17. Questions?