This interview takes place in an urgent care clinic in a downtown hospital.
Substance abuse disorders: The drug seeker
Think about the interview between the physician and Elisabeth.
- What techniques or styles does he employ to deal with her manipulative behaviour?
- What techniques or styles does he employ to deal with her anger?
- What evidence does he obtain that she is a drug abuser?
- He remains in control of the interview. How does he do that?
- What attitudes does the physician exhibit?
- The patient leaves angry and unsatisfied. Has the physician given good professional care? Why or why not?
- Is there any harm in giving her one pill?
Legal and ethical issues in narcotic prescription
Read the policy on narcotic prescription in your province or territory then answer the following, based on the scenario you watched:
The physician refuses to provide a prescription for Percocet.
Prescription drug abuse
The following is excerpted from the policy on Prescribing Drugs of the College of Physicians and Surgeons of Ontario but the broad concepts apply to other provinces and territories, each having a similar policy. Please check with your medical regulatory authority for more information.
Narcotics and controlled substances
Narcotics and controlled substances are important tools in the safe, effective and compassionate treatment of acute and chronic pain, mental illness and addiction. Physicians with the requisite knowledge and experience are advised to prescribe narcotics and controlled substances for these reasons, when clinically appropriate.
One of the risks when prescribing narcotics and controlled substances is the potential for prescription drug abuse. The non-medical use or abuse of prescription drugs is a serious and growing public health problem. Virtually any prescription drug can be consumed for reasons other than its medical purpose however, it is usually drugs with psychoactive properties (e.g., opioids) that are the focus of abuse.
Physicians may be able to reduce or impede the diversion, misuse and/or abuse of narcotics and controlled substances by: carefully considering whether these drugs are the most appropriate choice for the patient; recognizing patients who may be double doctoring, diverting, misusing or abusing prescription drugs; sharing information with others, as appropriate; instituting measures to prevent prescription pad theft or tampering; taking measures to prevent the theft of drugs from their offices; and educating patients.
The purpose of this section of the policy, along with the related guidelines, is to clarify for physicians their obligations when prescribing narcotics and controlled substances and their role in preventing and addressing prescription drug abuse. This policy does not attempt to curb the prescribing of narcotics and controlled substances for legitimate reasons (i.e., acute or chronic pain, mental illness or addiction), but does reinforce the requirement that physicians prescribe these drugs in an appropriate manner.
In addition to complying with the general requirements set out for prescribing any drug and any applicable legislation, physicians must carefully consider whether the narcotic or controlled substance is the most appropriate choice for the patient, even if the patient has been prescribed these drugs in the past. Special consideration is necessary given that narcotics and controlled substances are highly susceptible to diversion, misuse and/or abuse because of their psychoactive properties. These drugs are extremely harmful to patients and to society when they are diverted, misused and/or abused, so physicians must first consider whether an alternate treatment or drug is clinically appropriate. If there are no appropriate or reasonably available alternatives, physicians are advised to record this fact in the patient’s medical record. The benefits of prescribing narcotics and controlled substances must be weighed against their potential risks when used long-term.
Physicians typically prescribe drugs within the context of a physician-patient relationship. In most cases, this means that an appropriate clinical assessment of the patient has been conducted, the physician has made a diagnosis or differential diagnosis and/or has a clinical indication based on the clinical assessment and other relevant information, and informed consent has been obtained.
Before prescribing a drug, physicians must have current knowledge of the patient’s clinical status. This can only be accomplished through an appropriate clinical assessment of the patient. An assessment must include:
- An appropriate patient history, including the most complete and accurate list possible of drugs the patient is taking and any previous adverse reactions to drugs. A physician may obtain and/or verify this information by checking previous records and databases, when available, to obtain prescription and/or other relevant medical information; and if necessary,
- An appropriate physical examination and/or any other examinations or investigations.
If physicians intend to prescribe a drug, they are required to make a diagnosis or differential diagnosis and/or have a clinical indication based on the clinical assessment and other relevant information. There must be a logical connection between the drug prescribed and the diagnosis or differential diagnosis and/or clinical indication.
Physicians must consider the risk/benefit ratio for prescribing that particular drug for that patient. In addition, physicians must consider the combined risk/benefit ratio when prescribing multiple drugs. If using technology to prescribe (e.g., Electronic Medical Record), clinical decision support tools may be helpful in assisting physicians to determine whether the drug(s) are appropriate for the patient.
Physicians are also required to consider the risk/benefit ratio when providing long-term prescriptions. The duration of the prescription must be balanced with the need to re-assess the patient and the potential harm that may result if the patient runs out of the medication.