I gradually reached a comfort level discussing testing with patients, but many delicate areas of medicine require some practice. "Roll over, it’s time for your annual rectal exam," is tough to say when you’re a shy medical student, but after a while it becomes second nature. Asking patients for a urine drug screen should be relatively easy by comparison, but there are many issues involved. Psychologically it is much easier for me to tell a new patient, "Okay, if I am going to prescribe opioids for you, this is one of the prerequisites." I’m much more squeamish explaining this change of protocol to patients that I have been seeing for years.
My practice finally seemed to iron out many of the small details that had previously hampered me from testing. The lab shipped us a box that was so large, and so heavy, I thought that perhaps FedEx had delivered a toilet, but in fact the box was crammed with specimen cups, plastic bags, and lab requisitions as a sign of the lab’s optimism about the amount of business they expected me to generate for them.
One of my long-term patients with chronic back pain came in. I’m on chummy terms with him, and over the course of many years I learned many details about his divorces, his kids, and their college plans. He’s been on a hefty dose of oxycodone for many years, and over the last 10-15 years I let him talk me into increasing the dose a few times, against my better judgment.
I gave him a nice little speech, and I explained that I had been prescribing his pain medication for many years, but I felt that my practice needed to incorporate urine drug testing to be consistent with the current standard of care. He agreed readily, and I dispatched him to the restroom with his specimen cup. I heaved a sigh of relief, and congratulated myself on my suave little speech.
Unfortunately, I wasn’t so suave or well prepared when I got his test results back a few days later. After a few more days of intense deliberation, I mailed him a note which read as follows: "I regret to inform you that you failed your urine drug screen. There was no evidence of oxycodone in your urine, even though I have been prescribing a large dose of this medication for you. Therefore, I will be unable to prescribe further pain medication for you."
I felt like a fool for prescribing so much pain medication without ever confirming that he was actually using it. I’m suspicious that he was selling his pills, and my prescriptions probably put his kids through college, but I’ll never know for sure. It was a tough pill for me to swallow, but it’s better late than never.
Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.