Thanks to CBC News British Columbia for linking to this report by the College of Physicians and Surgeons of British Columbia: A case study on safe prescribing. Excerpt:
A 39-year-old male taking high dose oxycodone and alprazolam for chronic abdominal pain started seeing a new GP. Based solely on the patient’s report, the GP continued his medications at the same reported dose. The following year, the patient was admitted to hospital with a resistant lower extremity soft tissue infection and abdominal pain secondary to fecal loading.
It was also discovered that he had an existing diagnosis of PTSD related to time spent in military service. Inpatient psychiatry diagnosed him with Axis 1: PTSD, agoraphobia and panic attacks. These diagnoses were solely based on the patient’s subjective report, which included denial of use or misuse of prescribed or illicit drugs.
After discharge, the GP started to notice red flags (lost medication and early refills) and instituted pharmacovigilance. Three random UDTs were positive for cocaine, hydromorphone and amphetamines respectively. Accordingly, the GP tapered the alprazolam and the patient agreed to opiate agonist treatment.
The patient only partially engaged in addictions care and eventually disengaged fully from the GP’s care. He saw a physician at a walk-in clinic and obtained IR oxycodone (65 x 20 mg) and clonazepam (180 x 0.5 mg) tablets. A week later the patient re-consulted and was given an oxycodone refill without inquiry as to why his one-month prescription (a daily morphine equivalent of 270 mg) had been taken in seven days.
Over the next four months, the patient received 26 more prescriptions from 10 different physicians, using 10 different pharmacies. Prescriptions were for one of: oxycodone, Kadian, clonazepam or M-Eslon, prescribed as either daily or weekly dispenses. The total daily doses varied dramatically between providers, putting the patient at ongoing risk.
The last physician he saw reviewed PharmaNet and relevant chart encounters, and recognized his underlying health and mental health challenges. He referred him to an addictions physician and allied health professionals for appropriate treatment. The patient is now stable on opiate agonist treatment and addressing his mental health and addiction.