They've gotten OPIOIDS from 5 different prescribers and you're number 6!

With over 174 Opioid Overdoses per day, Opioids continue to ravage the U.S. yet, they are still very effective for pain management so it is very unlikely that they are going anywhere, anytime soon... Drug Companies and Physicians have been accused of adding fuel to this Nationwide FIRE. Insurance companies, in addition to the above are creating ways to minimize abuse and diversion of Opioids considering that 75% of people who abuse Heroin state that they got their start by abusing prescription drugs. Whether it's an elderly man who received Vicodin AND Tylenol 3 with Codeine for teeth extractions or a mother who got too many Opioids post C-Section, many people receive twice as many Opioid pills as they need. This fact alone can put a patient and their families at risk of Opioid Addiction and Opioid Overdose.

In many states, registration and utilization of Prescription Drug Monitoring Programs (PDMP's) are required. PDMP's continue to be one of our most promising state-level interventions to inform clinical practice decisions and support patient protection. They are a great tool and resource when developing quality care plans with patients. Buprenorphine, Methadone and other Medication Assisted Treatment Options, PDMP data, a comprehensive treatment plan and fair but stern treatment providers can put any patient on the road to recovery. When my company Vantage Clinical Consulting LLC is working with Buprenorphine prescribers we always ask about the "What ifs?". "What if you receive a call from a patient seeking care, they arrive for their appointment then you find out through the PDMP that they are also getting Opioids from other prescribers?" "What do you do?"

There is rarely a therapeutic response to this question...

The PDMP is a great tool and it is equally important that you have an appropriately trained and integrated care team along with networks of treatment providers that include primary care providers and Addiction treatment programs. Instead of viewing the above patient and situation as unacceptable, let's look at it for what it is... A great opportunity to save a life, RIGHT NOW. DON'T judge and DON'T threaten jail. DO leverage their time with you to encourage them to choose a different path than what has been selected in the past. Look past what is being presented to you in the moment to who they can become if they (with your help) get their life back on track.

So, your patient has obtained Opioids from 5 different prescribers and you're number 6, what do you do?

1) The first thing that you can do is to give your patient the benefit of the doubt and ensure that their information is correctly listed in the system. PDMP's are still relatively new to many; however, name misspellings and other data entry errors occur at a rate high enough for you to double check before you confront your patient.

2) Your receptionist is one of (if not) THE most important person on your treatment team... They are the FIRST person to see your patient and the last to make a difference in their lives. Make certain that you, TRAIN them, EDUCATE them, REHEARSE with them, and be prepared to help them to make appropriate REFERRALs when necessary.

Train and Educate- Proper initial screening skills are paramount. Put your receptionist on notice regarding expected patient and ask them to be EXTRA nice because the patient is very sick and needs their help. Of course every patient visiting your office is special and needs your help but let your staff and receptionist know that they can help you save a life TODAY and how rewarding this can be for them (personally and professionally). Remind them that it could easily be their loved one or friend and we are ALL one prescription away from an addiction. Know what's in the patients PDMP profile before you have your receptionist to accept the appointment as opposed to waiting until the patient arrives for their visit. Share with your staff what you're planning to do and bring all of them together for a meeting. Spend a few minutes telling them about the life changing work that you're going to do together with this special patient. Be open with your staff. Address their questions and concerns. The PDMP can help you to establish clear guidelines/protocols in your practice and give patients in need a fresh start when you proceed with a positive attitude.

Rehearse- If your receptionist is nervous about their new responsibility, consider role-playing. Tell them to speak with you as if you were the patient and you can both see how the discussion can sound in real time. Bounce ideas off each other to see what sounds good for your practice. Not only are you training and educating, you are also building a culture within your organization where your staff can respect this type of work and understand its importance to your community.

Referral- Even though your practice may be good at many things, there may be some co-occurring disorders or medical issues that require a more intense strategy. The patient may not be stable enough for outpatient treatment for Opioid Addiction in your office. So, you require strong community partnerships with peers that you trust for effective referrals. During any "down time" in your office, please have your staff to research and reach out to programs and providers in your area to ensure that your patient has access to all of the services that they need.

Once you confirm that you are indeed dealing with the "right" patient after consulting the PDMP, your staff is in a good place and its time to confront your patient, what can you do next?

3) I'd like for you to envision your favorite teacher. For me, it was my second grade teacher, Mrs. Smith. Mrs. Smith made sure that I would learn to spell all of my weekly vocabulary words so that I could get on the "Book Truck". The Book Truck would come to our school once monthly and ONLY the children who could spell all of their words correctly could be first in line for the Book Truck. NO ONE wanted to be last! I had been last a few times and hated every minute of it but Mrs. Smith was stern with me and helped me to get better week after week. As you think about your favorite teacher, you will find that it was often the one who challenged you the most... This situation in treating patients with Opioid Dependence is no different, they can handle being challenged, rules and tough love.

I always like to say "Counsel before Confrontation". Its important to get your facts straight first... In addition to the PDMP, conduct a Urine Drug Screening to determine if they're actually taking the medications listed on their PDMP profile. You may then encourage them to have a therapeutic discussion with a professional counselor (CADC) within our outside of your practice regarding "Readiness To Change" and dangers of overdose. Finally, prescribe Naloxone to them whether they continue under your care or not and tell them where they can obtain it with or without a prescription.

If you feel comfortable and you decide to provide counsel but find that you are at a lost for words, here are a few ways that you can begin the discussion with your patient:

"I checked a database and know that you've gotten medication from several people. From this day forward, you will only get your medication from me. Is this a deal?"

"I know that you're tired, I can't imagine what it is like keeping up with a life that you never wanted"

"Were going to help you through this but we have to be honest with each other. I won't turn my back on you. Today you get to start a new life if you want to. I know that you're not well and I want to help"

Imagine if you began a therapeutic discussion with any of the above statements versus judging the patient and kicking them out of your practice. They ARE tired. They DO want to stop, they just don't know HOW. You CAN help. A stern but fair approach can set the tone of your therapeutic relationship moving forward in addition to setting/managing expectations for you and your patient.

4) Referral with option to return- Not every patient will be appropriate for your practice. You will need to use and trust your gut when you determine what patients you can help versus those who may need to seek care in the offices of your colleagues or community partners. Be honest with yourself and willing to admit when they would be better served elsewhere. They can always return to you when their level of care is appropriate for the services that you offer. Make sure that you share with the patient that they are welcome to come back once they have sought care that should stabilize their immediate medical issues. They may need residential treatment for Opioid Use Disorder, Detox, Medical Health or Mental Healthcare. Whatever their needs, give them the option to come back to you post stabilization.

5) Diversion Programs- Treating a patient who suffers from Opioid Dependence or Opioid Use Disorder is a community problem that requires a community solution. We have learned that criminalizing O.U.D's are not the answer. Because of this, our therapeutic intervention options are growing. One of these options are Law Enforcement Diversion Programs. These programs are considered a second chance for someone who could be at risk of committing a crime due to their O.U.D. Instead, they can bring their unused drugs or medications to participating police departments, turn them in and accept treatment placement as a possible alternative to arrest for drug possession. If you create a trusting relationship with your local Law Enforcement and their diversion program where struggling patients can turn in unused medications and obtain treatment, patients can still return to you for outpatient Medication Assisted Treatment if needed.

Prescription Drug Monitoring Programs are used to address Drug misuse, abuse and diversion. How you address the information that you obtain in the PDMP is up to you. I hope that you use it to leverage your position with patients in a therapeutic way. I hope that you will use it to have honest discussions with patients and encourage them to pursue recovery in the best way that is appropriate for them. The PDMP can be used to help or to harm. Which will you choose?

Jamelia Hand MHS, CADC, MISAI is the owner and principal consultant of Vantage Clinical Consulting LLC where she provides Strategic Direction and Training to Healthcare Organizations on Opioid Addiction topics. She is a professor, author, and treatment advocate for Addiction and Recovery issues. She speaks passionately to many family groups, treatment centers and corporate organizations nationwide and is often recruited to deliver Motivational Keynotes, Management and Staff Training on Opioids in the Workplace. Her message always includes that Substance Use Disorder is a family disease and should be treated as such. She was awarded by the IL House of Representatives for her advocacy in Opioid Overdose. For almost 20 years, she has taken great pride in being knowledgeable about resources to support recovery and has enjoyed being able to translate that excitement to anyone who will listen, especially students who are interested in working in the field of Substance Use Disorders.

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