Question/scenario....patient taking Schedule 3 meds without a Rx

[Doctodd]

As the title says, im wondering about a scenario which we may all have come across or will come across. Im asking for comments and/or opinions on what other physicians would do in such a case.

A patient comes to your office and states he/she is taking a schedule 3 medication without a prescription and wants your help in managing it, dealing with the side effects, etc etc.

I have left it open ended on purpose. Id like to know comments, opinions, on what the doctor should do, what is required by law, is the doctor liable for managing this patient's issues, anything else you feel would be a good teaching topic, etc etc.

T

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[Aether2000]

1. The patient is committing a federal felony and probably violating several state statutes also.
2. Clearly the patient has no intention of following your clinic rules for prescribing when he will not follow the laws of the land
3. If you did decide to take on the patient, psychiatric screening or preferably the aid of an addictionologist would be necessary
4. Very very short leash on pain meds prescribed for the purpose of treating pain...2 week followup max for at least 3 months until you have assurances the patient is reliable.
5. If the patient comes to you with a chief complaint of being addicted to drugs, as a pain physician you cannot treat the patient unless you are trained in addiction medicine. You can not prescribe methadone for this purpose since it requires a special DEA license, although with the appropriate specialized training, you can treat with Subutex or Suboxone in an office setting.

 

[paz5559]

As the title says, im wondering about a scenario which we may all have come across or will come across. Im asking for comments and/or opinions on what other physicians would do in such a case.

A patient comes to your office and states he/she is taking a schedule 3 medication without a prescription and wants your help in managing it, dealing with the side effects, etc etc.

I have left it open ended on purpose. Id like to know comments, opinions, on what the doctor should do, what is required by law, is the doctor liable for managing this patient's issues, anything else you feel would be a good teaching topic, etc etc.

The question is, do you have an obligation to report him, either to your local authorities, or to the feds, regarding his diversion of controlled substances. My knee-jerk response was of course not, but I have been told by Jennifer Bolen (www.legalsideofpain.com) and others far more knowledgeable that I that that obligation may well exist, and that doctor-patient confidentiality is not an adequate defense.

For those who wish to just dismiss this as the ravings of one crazy, Jeri Hassman, a Tucson physiatrist, pled guilty in federal court last year to four counts of failing to notify authorities that patients had admitted using other family members' prescription drugs. She lost her DEA license, was sentenced to 2 years of probation, plus 100 hours of community service, 50 in a substance abuse center & 50 serving nonpaying patients in her office. She also must publish a letter in the Archives of PM&R, recounting the above details without blaming the government, to inform others of her financial devastation, the loss of much of her practice, her humiliation, and what changes she planned to make.

Still think it is worth the risk?

 

[Aether2000]

Excellent points!
The November 2004 response by the DEA published in the Federal Register makes it clear it is expected action will be taken by the physician in the case of drug diversion, but unfortunately the DEA does not specify what action. We report patients to the local police where the patient resides in cases of
1. Selling the drugs we are prescribing (does not have to be substantiated)
2. Altering scripts
3. Stolen scripts
4. Reports from others that an individual stole our patient's opiates
5. Use of subversion to obtain narcotics (eg. failing to report they are receiving narcotics from other physicians simultaneously with our prescribing...there is a state law that makes this a crime in my jurisdiction)

But should we as pain physicians draw the line? Should we be reporting patients who have positive drug screens for cocaine? For THC? Should we report sharing of drugs as a criminal offense if the patient did not know it was a crime? Hmmmm....these are interesting times as we increasingly are having to police the use of both opiates we are prescribing and drugs we are not....

 

[Doctodd]

I was hoping for more comments. I want to add to the scenario, but only after i think more people have chimed in.

T

 

[lobelsteve]

I was hoping for more comments. I want to add to the scenario, but only after i think more people have chimed in.

T

I'm scheduling a lunch with my local DEA agent to discuss these scenarios.

 

[Doctodd]

Ok...now the follow up to this hypothetical scenario. This should come as no surpirse due to all the media attention given to athletes and congress. The schedule 3 med is actually Nandrolone, an anabolic steroid. Also known as Deca, it is probably the safest and mildest of the anabolics when comparing side effect profiles and organ metabolism. The patient is a 35 y/o male s/p MVA with neck pain that hasnt responded to anything else. He asks if Nandrolone will help with healing and his pain. He wants to be monitored while on Nandrolone. He doesnt want any narcotics or other medications because he wants to get better, but has become extremely frustrated thus far because the pain is affecting his life.

Opinions and comments please. Please reread the original post at the top of this thread.

T

 

[Doctodd]

Great participation.....& bumpage.

T

 

[lobelsteve]

I use a bit of Androgel and test cypionate in my practice. This is for pateitns that test low or low normal for free and total testosterone as a result of chronic opioid use. It is unethical, in my opinion, to use anabolic agents without having free and total testosterone, PSA in males, and estradiol levels tested. LFT's and a CBC are also good to have for baseline. If this pateint comes in using steroids illegally, you are morally bankrupt in thinking he will use a prescribed medication legally. I think it is the same situation when a UDS comes back positive for cocaine or marijuana. I end opioid therapy and offer non scheduled medications, addiciton psychiatry, psychology, and injections when needed. They thank me and walk out the door.

Steve