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Feature

D.R.U.G.S. to Keep Our Patients
and Community Safe

By Mark E. Romanoff, MD

NCMB-CSRS Advisory Committee, 2016

N.C. Project Lazarus Core Faculty, 2013-15

N.C. Controlled Substance Reporting Service Advisory Board, 2007-present

C Past President, Mecklenburg County Medical Society, 2006 Some quick notes to help understand the “DRUGS” scaffolding.
hronic pain is a serious problem in our nation. More than 40 1. Diagnoses: Some disease states, such as fibromyalgia,
percent of the U.S. population suffers from pain. The cost chronic headaches, and chronic neck and low back pain (without
of treatment and lost productivity is more than $600 billion structural abnormalities), are usually not amenable to the use of
each year and it is the leading cause of disability. Opioids
for the treatment of Chronic Non Cancer Pain (CNCP) is controversial, opioids. A diagnosis supporting opioid use should be a painful

but widespread. We are now familiar with the crisis of the use, abuse and condition that is chronic and not acute. It should be severe >7/10

misuse of controlled substances, but here are a few facts: pain. Sometimes consultations to neurology, orthopedics or

1. There are more than 700 deaths per year in North Carolina due to surgery providers are necessary.

opioid overdose (100 percent increase over the last 10 years. Ref: N.C. 2. Rx or treatment options prior to opioids are plentiful and include

State Center for Health Statistics, August 2015). any number of medications — NSAID’s, Central Sensitization

2. N.C. county-by-county death rates from opioids vary from medications (gabapentin, pregabalin, etc.), muscle relaxants (but not

2-50/100,000 (for perspective, motor vehicle accidents 39/100k; breast carisoprodol or SomaReg) and antidepressants (duloxetine), to name

CA deaths 13/100k; firearm deaths 10/100k; Mecklenburg County opioid a few. Physical therapy, behavioral therapy, acupuncture, injections

deaths 2.2-6.7/100k). (trigger point, epidural steroid, nerve block) and possibly a pain

3. About half the people who have died from prescription opioids in management evaluation are appropriate. If these are unsuccessful, then

the state never received an opioid prescription. Diversion was the source a “trial” of opioids may be reasonable. It is important to let the patient

of these medications. know that this is a time-limited trial and the trial will be stopped

4. Neonatal Abstinence Syndrome (NAS) is a growing problem if there is no improvement in pain or function or they experience

in the state. More than 25 percent of patients of child bearing age intolerable side effects. The choice of opioid is beyond the scope of

in the state are taking opioids (my research). And NAS, intrauterine this article.

growth issues, prematurity, NICU admissions and increased costs are 3. Understand that aberrant behaviors can occur in up to 20 percent

associated with opioid use in pregnancy. of patients taking opioids and they may be indicative of misuse,

5. When the front page of the cutting-edge medicine journal abuse or addiction. A comprehensive discussion of these behaviors is

“Consumer Reports” described this as a national problem last year, it beyond this brief introduction. Certainly, repeated loss of medications,

must be serious. obtaining opioids from other providers, forging prescriptions and

As a core faculty member for Project Lazarus, I have interacted with repeated unauthorized escalation of dosage should elicit concern

hundreds of participants, and they have asked for a quick way to remember and a response from the provider. This response may be tapering or

the information we presented. So, using my background in the Armed discontinuation of controlled substances and/or a referral to an opioid

Services, where nothing is official until it has an acronym, I came up with treatment program.

an acronym I think will be helpful as a “best practice” for using Opioids to 4. Guidelines need to be in place at the time of starting opioids.

treat CNCP. It hits the highlights of the NCMB position paper on opioids. These guidelines should include an opioid “agreement” describing

Project Lazarus, the interactive live course for Primary Care Providers on the patient’s and the provider’s responsibilities concerning these

appropriate opioid prescribing has just finished a two-year grant. Some medications. It is recommended that this “contract” include a

of the content is now online as part of the chronic pain initiative at pharmacy “lock in” (only one pharmacy used), not obtaining pain

www.projectlazarus.org/doctors/community-care-chronic-pain-initiative. medications from other providers, pill counts, random drug screens

The Acronym is D.R.U.G.S. (RUDS) and frequent checking of the Controlled Substance
Reporting Service (CSRS) prior to the first prescription and then

at specific intervals during treatment. Discontinuing the use of

D – “Diagnoses” that support the use of chronic opioids. benzodiazepines and carisprodal also is recommended.

R – “Rx” or treatment of pain conditions prior to, and including, An excellent resource on RUDS is Dr. Paul Martin’s video at https://

the institution of a trial of opioids. youtu.be/ Wuire10DI3Y.

U – “Understanding” aberrant behavior related to the misuse and 5. Subsequent visits or follow-up visits should address opioid

abuse of opioids — who is at risk? treatment outcome.

G – “Guidelines” are in place. CONTINUED ON PAGE 8

S – “Subsequent” or follow-up visit procedures.

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