As you are probably aware, more and more state boards of dentistry and state legislatures have enacted laws and/or rules requiring things like provider education, patient assessment guidelines, prescribing parameters, big brother is watching programs, and so on. With some exceptions, states have availed (even required) providers to review their prescriber histories and their patients’ controlled substance histories prior to issuing prescriptions for controlled prescription drugs.
Whatever the state drug database is called (Prescription Drug Monitoring Program (PDMP), a Prescription Monitoring Program (PMP) or something far more unique (CURES in California, OARRS in Ohio)) and whatever your state’s requirements here are some ‘red flags’ dentists should be alert for in their patients:
(a) Selling prescription drugs (rumor or actual knowledge);
(b) Forging or altering a prescription;
(c) Stealing or borrowing controlled drugs;
(d) Increasing the dosage of controlled drugs in amounts that exceed the prescribed amount (altering prescriptions);
(e) Suffering an overdose, intentional or unintentional (history of);
(f) Having been arrested, convicted, or received diversion or intervention in lieu of conviction for a drug related offense while under the dentist's care;
(g) Receiving controlled drugs from multiple prescribers, without clinical basis;
(h) Traveling with a group of other patients to the dentist's office where all or most of the patients request controlled substance prescriptions;
(i) Traveling an extended distance or from out of state to the dentist's office;
(j) Having a family member, friend, law enforcement officer, or health care professional express concern related to the patient's use of illegal or controlled drugs;
(k) A known history of chemical abuse or dependency;
(l) Appearing impaired or overly sedated during an office visit or exam;
(m) Requesting a certain controlled drug;
(n) Requesting reported drugs by street name, color, or identifying marks;
(o) Requesting early refills of reported drugs;
(p) Losing prescriptions for reported drugs;
(q) A history of illegal drug use;
(r) Using multiple pharmacies (especially small, privately owned, as those pharmacies are often slow to report prescription information to drug databases);
(s) Doctor shoppers;
(t) After-hours call to dentist in pain (not a patient);
(u) Claimed allergy to certain controlled drugs, but suggests other (often more powerful) controlled drugs;
(v) Presents as new patient in acute pain with no photo identification (and often no insurance);
(w) Sharing controlled drugs with another person; or
(x) Recurring visits to non-coordinated sites of care, such as emergency departments, urgent care facilities, or walk-in clinics to obtain reported drugs.
NOTE: none of these red flags are diagnostic or definitively mean your patient is a drug addict or should not be prescribed controlled substances (that is your decision to make).
What to do when you encounter one or more red flags with your patient? Trust your gut and investigate!
Do you know the patient? Do you really know they are who they say they are (did they present a photo ID)? Is the source of their dental pain a new or old problem (the later doesn’t preclude your ability to treat their pain as you deem appropriate, but may merit a frank discussion about their continued care)? If everything checks out fine, do what you will. However, if things do not check out well or you are not satisfied that all is on the ‘up and up’ then do not issue a prescription for a controlled substance or consider prescribing a non-controlled drug you deem appropriate.
Remember, just because you CAN prescribe controlled substances does not mean you have to prescribe them. Proper pain management is NOT doing what the patient wants, but rather what you deem appropriate based on their presentation of signs and symptoms (think totality of the situation). Pain management is a doctor-patient partnership. You are the pilot, and your patient is the co-pilot on this journey of care.
Effective communication and collaboration with your patients (and maybe outside resources) are crucial. Get comfortable having uncomfortable conversations with your patients about drugs, pain and pain management. It is not what you ask, but how you ask that can unlock important information you need to make solid, informed decisions; avoid being judgmental.
Ask your patients about what has worked/not worked to manage this and other types of pain in the present/past. What is their pain tolerance? Even if the patient IS a bad actor or does have a drug problem you still have a responsibility to manage their pain. What are YOU comfortable doing to manage their pain? What resources do you need to access to help you decide how to manage your patients’ pain?
I am not qualified to tell you (clinically) how to manage your patients’ pain. However, as a licensed healthcare professional YOU ARE qualified to make such determinations. You will get it wrong sometimes. You will make mistakes. After all, you are a practitioner, not a perfectionist.
Remember this Turkish proverb: “No matter how far you have gone on the wrong road, turn back.” There are few errors or mistakes you cannot undo, but when necessary you must undo them (turn back, don’t just proceed and adjust course). Don’t let your ego lock you into a set course of action that you are unable or unwilling to change from – even when you know you made a wrong (or bad) decision.
Proceed with caution and always Be On the Look Out (BOLO) for bad actors and pitfalls you should avoid.
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