Narcotics risk assessments?

[cara susanna]

As you all know, I work in the VA and we keep getting requests for additional services from community care pain management for "narcotics risk assessments." As the name implies, basically, they want the patient to have a psychological assessment (they say neuropsychology, but they say neuropsychology for everything) before getting prescribed narcotics.

Is this a thing?

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[WisNeuro]

Never heard of it, would certainly never do one unless I had a training in this and felt comfortable with the literature and liability aspect.

 

[PsyDr]

Yeah, I just learned about this.

Pain medicine knows that the number of exposure days to opioids is correlated with opioid use disorder, and that opioids are only indicated in the treatment of acute pain and/or cancer pain. Some jurisdictions have created this weird pathway where pain medicine can send someone to a psychologist, the psychologist says, "yeah, this person is somehow immune to getting dependent on (insert opioids and benzos), so you can totally use the fun drugs for nonindicated purposes", and then the pain medicine is allowed to prescribe max dose demerol+max dose xanax+max dose other sedative for a nonindicated purpose. And if someone gets addicted, the pain medicine guy can point his finger at the psychologist.

 

[WisNeuro]

Yeah, this seems like it's more liability than risk assessments for firearms. Pass.

 

[cara susanna]

That's what I figured, thanks. They also keep calling then pre-surgical evals, which makes it sound like they're spinal cord stim evaluations (which we do offer).

 

[AcronymAllergy]

Yeah, I haven't heard of these until just now, either. If I were going to do them, I'd definitely reach out to someone who has and see if they'd be willing to provide some peer-to-peer consultation.

I imagine the best you could do would be to say something like, "this person has X protective factors and Y risk factors. Treat based on your own medical judgment"; or, "this person acknowledges a history of misuse of multiple illegal and prescribed substances, has not undergone any treatment related to such, and may have been intoxicated at the time of their appointment with me. There appears to be increased risk for misuse."

 

[Ollie123]

Predicting who will go on to develop dependence is an interesting scientific question, but also one we presently suck at answering. I'm not aware of any established protocols for doing something like this. If backed into a corner and forced, I would just do something like what AA wrote above and assess presence/absence of risk factors and just be very explicit the liability is back on them in the report. There are some ways to predict use, but we're generally talking about extremely complicated experimental methods. Nothing I've seen has anywhere the sensitivity/specificity to be clinically useful.

I love that people think we have ways to magically answer any question with "assessment." Wondering how the clinics would handle it if we just started sending them therapy instructions with vague "Please prescribe medications to increase engagement in psychotherapy" or something like that.

 

[psych.meout]

Yeah, I just learned about this.

Pain medicine knows that the number of exposure days to opioids is correlated with opioid use disorder, and that opioids are only indicated in the treatment of acute pain and/or cancer pain. Some jurisdictions have created this weird pathway where pain medicine can send someone to a psychologist, the psychologist says, "yeah, this person is somehow immune to getting dependent on (insert opioids and benzos), so you can totally use the fun drugs for nonindicated purposes", and then the pain medicine is allowed to prescribe max dose demerol+max dose xanax+max dose other sedative for a nonindicated purpose. And if someone gets addicted, the pain medicine guy can point his finger at the psychologist.

There's definitely an element of CYA and defensive medicine and I wonder if another part may be a way of deflecting when they aren't going to prescribe opioids or other controlled substances but don't want the patient to be angry with them. They can push off the responsibility and blame onto the psychologist for not giving the patient what they want.

 

[PsyDr]

There's definitely an element of CYA and defensive medicine and I wonder if another part may be a way of deflecting when they aren't going to prescribe opioids or other controlled substances but don't want the patient to be angry with them. They can push off the responsibility and blame onto the psychologist for not giving the patient what they want.

That is not consistent with my understanding. It seemed like the physicians wanted a “go ahead”, and an easy way for a psychologist to get cash paying clientele. I did not get an impression that anyone was being told “no”.

Then again, I don’t live in the state where this happened. It was just a conversation at a conference. So what do I know?