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Patient has been positive for cocaine for the last two visits and still received Ativan from physician (my SP) last two months. Saw the patient today for the first time and told him I would not prescribe his med given the results from the last two months (today's urine was positive for benzo only but again he was using it the last two months so you never know). Pt denied any previous cocaine use, left the room infuriated, went to the front desk and scheduled another appointment with "his doctor"/my SP.  What are your thoughts on this? I just don't think he should receive any benzo from anyone in the office given his recent history.

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Needs confirmatory testing, most likely.  I don't know what substances might elicit a false positive on your urine tox assay, but it's worth looking into on behalf of a patient.  I give them the benefit of the doubt one time - make sure you understand your assay's sensitivities thoroughly.  IMO this is one of the drawbacks of a Utox - not specific enough to the substances we're looking for.

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One of the truisms of life is you can't control anyone else's opinion or habits. I am pretty tight about things like this and others aren't. So if they want to prescribe for this patient... oh well. You did what you feel is right.

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3 minutes ago, Acebecker said:

Needs confirmatory testing, most likely.  I don't know what substances might elicit a false positive on your urine tox assay, but it's worth looking into on behalf of a patient.  I give them the benefit of the doubt one time - make sure you understand your assay's sensitivities thoroughly.  IMO this is one of the drawbacks of a Utox - not specific enough to the substances we're looking for.

My decision was based on the last two confirmatory tests for the last two months. Today's test (done in the office) was positive for benzo only. 

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What I mean is that when a sample comes back positive, that should be sent out to a reference lab so they can do gas chromatography/mass spectrometry on it to confirm that the substance that turned the assay positive is actually cocaine and not something else.  2 positive tests on the same assay are not confirmatory.  If he says he didn't do cocaine, I would give him the benefit of the doubt if your assay has known imperfections with regard to false positives (and IIRC all point of care Utox testing does).

YMMV

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6 minutes ago, Acebecker said:

What I mean is that when a sample comes back positive, that should be sent out to a reference lab so they can do gas chromatography/mass spectrometry on it to confirm that the substance that turned the assay positive is actually cocaine and not something else.  2 positive tests on the same assay are not confirmatory.  If he says he didn't do cocaine, I would give him the benefit of the doubt if your assay has known imperfections with regard to false positives (and IIRC all point of care Utox testing does).

YMMV

Thank you for the clarification. Really helpful information. I'll keep this in mind next time. In this case, I still don't feel comfortable prescribing it because he also said that his friend probably mixed cocaine with his meds without his knowledge. Huh??? 

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6 minutes ago, BayPAC said:

Thank you for the clarification. Really helpful information. I'll keep this in mind next time. In this case, I still don't feel comfortable prescribing it because he also said that his friend probably mixed cocaine with his meds without his knowledge. Huh???

I'd say that your gut reaction is reasonable.  It's funny the excuses we get sometimes.

I just had a guy who ended up with unprescribed methadone in his UTOX, confirmed on GC/MS.  I confronted him and he said, "I was out of it from the kidney stone pain and a friend of mind gave me meds but mixed up my meds with his."  It's tough to know what to believe and how to help patients like this.  In select cases, I have a 1 strike rule.  If this ever happens again with any substance, we're done prescribing for you.


Again, YMMV.

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Sudafed will ring up for amphetamines. 

Our drug screen doesn’t catch benzos half the time and PharmD told me I need to order special benzo confirm. Pain in the butt to have to order sub tests.

The performing lab should have data on what will pass for a false positive. 

I agree, one benefit of doubt and then - done. Fool me twice - I am to blame.

 

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be aware - a fair number of benzo's might not show up on utox - some common one's (will not say here) are not on the typical utox POC test.  

 

Gotta grab the PI (and a pair of reading glasses as the type is tiny) and read up on them... BEFORE you accuse anyone of anything

 

As for not prescribing.  If this was the routine f/u for med refill and your CP was aware of results you might (might) have a duty to fill at least a litte script while the patient is given the chance to book with his CP.   I say might as it is more a style issue (and you don;t want to force the patient into w/d - and seizures)  

I would have contacted my CP - advised them of my desire to NOT fill the script - as it was their patient, and they are your CP - ask them what to do - if they say fill it - document that in your chart but also state your objection in a polite way, and clarify that you will not fill in the future in this situation.....  you voice your opinion, patient gets meds, and doc is 100% on the hook for the decision to prescribe...

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1 hour ago, ventana said:

As for not prescribing.  If this was the routine f/u for med refill and your CP was aware of results you might (might) have a duty to fill at least a litte script while the patient is given the chance to book with his CP.   I say might as it is more a style issue (and you don;t want to force the patient into w/d - and seizures)  

I would have contacted my CP - advised them of my desire to NOT fill the script - as it was their patient, and they are your CP - ask them what to do - if they say fill it - document that in your chart but also state your objection in a polite way, and clarify that you will not fill in the future in this situation.....  you voice your opinion, patient gets meds, and doc is 100% on the hook for the decision to prescribe...

I feel I have a lot to learn on how to deal with patients in situations like this. Wish I had done like you said. Would have avoided the trouble.  

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What I mean is that when a sample comes back positive, that should be sent out to a reference lab so they can do gas chromatography/mass spectrometry on it to confirm that the substance that turned the assay positive is actually cocaine and not something else.  2 positive tests on the same assay are not confirmatory.  If he says he didn't do cocaine, I would give him the benefit of the doubt if your assay has known imperfections with regard to false positives (and IIRC all point of care Utox testing does).
YMMV
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Two things - a bit redundant but worth repeating:

1 - several drugs do cause false positive results in urine tests for cocaine. Specifically, the aminopenicillins are notorious for this. If you have positive cocaine results in urine and are making decisions to stop benzodiazepine therapy in a chronic user, you MUST do confirmatory testing by GC-MS first.

2. If the person is actually positive for cocaine by GC-MS, you cannot abruptly stop the benzodiazepine if they have been on it for any prolonged period (the literature in psychopharmacology and pain management considers this 4-6 weeks or greater). Once GABA  receptors and ligands are upregulated in response to the presence of benzodiazepines, it takes literally, months to years to perform a proper wean. This is of course, dose dependent, but something even as small as 0.5 mg of Ativan PRN once a day requires a solid 6-8 weeks to properly wean.  Anything less puts a patient at risk for withdrawal seizures and guarantees a prolonged benzodiazepine withdrawal syndrome complex that is debilitating for most people. 

We all want to write off people who we think don’t somehow “deserve” these medications because we have “found” a reason to not give it to them. However, we have an ethical and moral responsibility to confirm what we see and find - not assume - when we are looking to withdraw psychotropic drugs that people have been taking for, in some cases, decades. The body seeks homeostasis as it’s the lowest form of free energy in whatever psychopharmacologic milieu we have created in patients. 

If one isn’t comfortable writing the Rx, as others have said - this is what your SP/CP is for. It’s their patient to begin with... you can always pass it along. But understand completely why something works (or doesn’t) first before making a life-altering medication change to someone that can have devastating consequences. As this political pendulum is swinging back and we are withholding more and more scheduled drugs, the pharmacological reality of what we have created, what we are doing to people, and what they in turn will do to feel “normal” when we decide to improperly wean people or deny them their medications, is becoming apparent - the illegal drug trade is booming. Washing our hands with a patient based on bad data starts far too many people down a road that we can prevent them from going down... and I’d argue we have the moral obligation to prevent them from doing so - particularly if we were the ones who started them on these therapies in the first place. 

G

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