chronic pain medication and driving

[hello1234!]

I have seen other docs tell patients to see how pain meds affect them, and that it is ok for non-opioid naïve patients to start driving if they are tolerating chronic pain meds well. I just wanted to see if this is the universally accepted approach or if anyone out there has a different opinion on how to approach patients on chronic narcotics and driving.

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[Ducttape]

"11. Do not use alcohol or marijuana. Please refrain from driving while on these medications."

 

[unchockey21]

Just like how we tell patients to turn their stim off when driving. We know they probably won't but we say it anyway. CYA

 

[NJPAIN]

I have seen other docs tell patients to see how pain meds affect them, and that it is ok for non-opioid naïve patients to start driving if they are tolerating chronic pain meds well. I just wanted to see if this is the universally accepted approach or if anyone out there has a different opinion on how to approach patients on chronic narcotics and driving.

Very foolish advice. Tell patient that you advise them not to drive. Anything they do contrary to your instructions is at their own risk.


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[hello1234!]

I agree that it is foolish advise.

I always advise pts not to drive. I've seen so many patients driving on chronic opioids, it seems to be culturally accepted. The pain people in my area tell patients it's ok for them to drive if they are on a stable dose. I'm encouraged to hear some differing opinions.

 

[clubdeac]

Aren't there several studies out there saying that psychomotor skills are not impaired to preclude driving once on a stable dose?

 

[lobelsteve]

Aren't there several studies out there saying that psychomotor skills are not impaired to preclude driving once on a stable dose?

Yes.

 

[Ducttape]

good luck relying on them in front of a jury of your "peers"

 

[bronchospasm]

I have seen other docs tell patients to see how pain meds affect them, and that it is ok for non-opioid naïve patients to start driving if they are tolerating chronic pain meds well. I just wanted to see if this is the universally accepted approach or if anyone out there has a different opinion on how to approach patients on chronic narcotics and driving.

Document that they have been warned not to drive or operate machinery.

Know a physician in Indiana who was sued for not warning the patient.

 

[clubdeac]

You guys honestly tell all patients you prescribe opiates to (including tramadol) to not drive?? Is that reasonable? You really think they're gonna follow that suggestion? No.... what about gabapentin, lyrica, flexeril, TCAs? They cause just as much psychomotor ******ation

My template says something like this. "Risks, benefits, alternatives and expected outcomes were discussed in length. The patient was advised to not drink while taking medication and to avoid driving or operating complex or heavy machinery until aware of response to medication"

That seems a lot more realistic than just saying you can't drive. I think a lawyer could argue the same in court stating your instructions were so far fetched that no patient would be able to reasonably follow them.

 

[lobelsteve]

You guys honestly tell all patients you prescribe opiates to (including tramadol) to not drive?? Is that reasonable? You really think they're gonna follow that suggestion? No.... what about gabapentin, lyrica, flexeril, TCAs? They cause just as much psychomotor ******ation

My template says something like this. "Risks, benefits, alternatives and expected outcomes were discussed in length. The patient was advised to not drink while taking medication and to avoid driving or operating complex or heavy machinery until aware of response to medication"

That seems a lot more realistic than just saying you can't drive. I think a lawyer could argue the same in court stating your instructions were so far fetched that no patient would be able to reasonably follow them.

And my informed consent and agreement for treatment which was shared in another thread, the patients are explicitly told not to drive while taking any medication. When I discuss with them in the office what this really means is that I am not going to be responsible if they get an accident by driving while on the medicine. I point them to two or three articles that shows they will have no impairment when I'm chronic stable doses of the medicine and that they may be better drivers when their pain is controlled when they are not. I can share those articles with you but the ultimate responsibility is on the patient not to drive while taking the medicine to reduce the liability of the prescribing physician.

 

[lord_jeebus]

My opioid contract says no driving, no heavy machinery, no use of firearms. Of course, my ability to verify compliance with these requirements is very limited.

 

[clubdeac]

And my informed consent and agreement for treatment which was shared in another thread, the patients are explicitly told not to drive while taking any medication. When I discuss with them in the office what this really means is that I am not going to be responsible if they get an accident by driving while on the medicine. I point them to two or three articles that shows they will have no impairment when I'm chronic stable doses of the medicine and that they may be better drivers when their pain is controlled when they are not. I can share those articles with you but the ultimate responsibility is on the patient not to drive while taking the medicine to reduce the liability of the prescribing physician.

Steve, I'd love to have the articles on driving if you have them

 

[Ducttape]

on the other hand...

one of the main articles that suggest that opioids do not affect driving is from one of the "tainted" proponents for opioids - ie fishbain.


this article was very apropos, and it was discussed in the USA Today this weekend:

Trends in Prescription Opioids Detected in Fatally Injured Drivers in 6 US States: 1995-2015. - PubMed - NCBI

Am J Public Health. 2017 Jul 20:e1-e6. doi: 10.2105/AJPH.2017.303902. [Epub ahead of print]
Trends in Prescription Opioids Detected in Fatally Injured Drivers in 6 US States: 1995-2015.
Chihuri S1, Li G1.
Author information
Abstract
OBJECTIVES:
To assess the time trends in prescription opioids detected in fatally injured drivers.

METHODS:
We analyzed 1995 to 2015 Fatality Analysis Reporting System data from California, Hawaii, Illinois, New Hampshire, Rhode Island, and West Virginia of toxicological tests for drivers fatally injured within 1 hour of a crash (n = 36 729). We used the Cochran-Armitage test for trend to assess the statistical significance of changes in the prevalence of prescription opioids detected in these drivers over time.

RESULTS:
The prevalence of prescription opioids detected in fatally injured drivers increased from 1.0% (95% confidence interval [CI] = 0.5, 1.4) in 1995 to 7.2% (95% CI = 5.7, 8.8) in 2015 (Z = -9.04; P < .001). Prescription opioid prevalence was higher in female than in male drivers (4.4% vs 2.9%; P < .001). Of the drivers testing positive for prescription opioids, 30.0% had elevated blood alcohol concentrations (≥ 0.01 g/dL), and 66.9% tested positive for other drugs.

CONCLUSIONS:
The prevalence of prescription opioids detected in fatally injured drivers has increased in the past 2 decades. The need to assess the effect of increased prescription opioid use on traffic safety is urgent. (Am J Public Health. Published online ahead of print July 20, 2017: e1-e6. doi:10.2105/AJPH.2017.303902).

most concerning, i think is that 70% of those fatalities testing positive for opioids also were + for something else, and 30% had alcohol.

 

[lobelsteve]

Not endorsing, just sharing info.

 

[Ducttape]

thanks.

the middle article is the one i mentioned and is most debatable because of the clear preference of opioid use by its primary author.


of note, for those who are having trouble with patients requesting opioids, i inform patients that the clinic does not allow people to drive while on opioids.

to a person, noone who has been willing to give up their driver's license.

 

[Timeoutofmind]

thanks.

the middle article is the one i mentioned and is most debatable because of the clear preference of opioid use by its primary author.


of note, for those who are having trouble with patients requesting opioids, i inform patients that the clinic does not allow people to drive while on opioids.

to a person, noone who has been willing to give up their driver's license.

thanks.

the middle article is the one i mentioned and is most debatable because of the clear preference of opioid use by its primary author.


of note, for those who are having trouble with patients requesting opioids, i inform patients that the clinic does not allow people to drive while on opioids.

to a person, noone who has been willing to give up their driver's license.

U mandate they guve up their lisence?

What does that mean...u call the dmv to confirm? Otherwise...I'm sure many would just say yeah ok I will do it and then and not do it.

 

[knoxdoc]

OTOH, I've seen WC patients try to use this to their advantage. They try to get on any med that can affect cognition (particularly opioids), then tell the doc they can't do their construction job or drive. Its a PIA to deal with such folks.

 

[Ducttape]

i do not mandate patients give up license, but for someone insisting on opioids particularly co-administered with others, on high doses, i use the policy that they cant drive.

if you have someone resistant, check your state DMV, but this website is very helpful for me to show patients.


Report a medical condition

What does DMV do when it receives a report from a doctor?

If a physician reports that an individual has a condition that can affect his or her driving skills, DMV can suspend his or her driver license until a physician certifies that the condition is treated or controlled and the individual can drive safely. DMV can require that the physician recertify at a later time that the condition does not affect the individual's ability to drive. If DMV does not receive the required certification, DMV can suspend the driver license.

i also tell WC patients who drive for work or work in factories that they cannot be on opioid medications because of what knoxdoc noted. for some reason, i have quite a few school bus drivers...

 

[lobelsteve]

OTOH, I've seen WC patients try to use this to their advantage. They try to get on any med that can affect cognition (particularly opioids), then tell the doc they can't do their construction job or drive. Its a PIA to deal with such folks.

I would offer them that if a medication is causing a cognitive side effect severe enough to effect work, it must be discontinued. And as the MD, I have the power of the pen.

 

[hello1234!]

thanks for all the responses, it's much appreciated