Question 3: As an anesthesiologist, what steps do you take to make sure opioids are not diverted?

Raymond Sinatra, MD: Neil, as a busy solo practitioner who uses opioids in his practice, what steps do you take to make sure that opioids are not being diverted?

Neil Jobalia, MD: I try to separate the issue. I see this issue as a social issue and a medical issue and I try to focus on the medical side of things. I think these medications, clearly there's literature to support the use of long acting opioids to treat chronic pain in every situation, both cancer related and non-cancer related pain. And unfortunately currently as far as monitoring goes the only I have monitor I have of my patients' response to opioid therapy is their report.

So on the medical side of things if I can't believe the report of my patients, then I don't have any monitor of whether they're taking the medication or not and therefore I'm kind of prescribing in a vacuum. I think it's sort of like prescribing insulin but not really checking blood sugars with any sort of regularity. So as far as my monitoring goes I try to monitor based on a medical issue of the fact that other than what I do I don't really have any way of knowing what the patient is doing, what their response is, what their side effects are, et cetera, what their medical response is to my treatment other than what they tell me and if I can't believe what they tell me then I've lost my monitor.

So what I've instituted is ... really what I do is random urine screens on all my patients along with an agreement that of course ... discussing with them the potential benefits and side effects of the medications that I prescribe. But the patients that don't comply with the therapy or the treatment plan as I've laid it out I won't treat with opioids because I don't feel that I'm able to adequately or medically treat them.

The issue of diversion to me is a social issue. I was reading the Cleveland newspaper about a month ago and there was a case of two teenage girls who had died from an overdose of morphine. I recently had two patients, one that took 75 milligram methadone tablets and another one that put eight Duragesic patches on them, and both ended up of course in the emergency room.

But to me the issue is not ... it's a class issue and it's a social issue. It's also kind of a patient issue and their view on these medications. I think that taking one of these medications off the market would only serve to increase the usage of the others in that I think OxyContin has introduced this whole concept of high dose, potent, long acting opioids for the abuse and diversion population of patients. So again, I try to focus on the medical side of things and as a result I'm able to prescribe pretty freely in my practice and am able to use these medications appropriately. And it's been very rewarding for me.