The New World of Risk Management for Prescribing Controlled Substances
by Michael Matray, editor of Medical Liability Monitor
Prescription drug abuse is a public health crisis destroying American families and communities at an alarming rate. According to the White House Office of National Drug Control Policy, the number of people who abuse prescription drugs is more than double the number who report using heroin, cocaine and hallucinogens combined, and since 1990, prescription opioid overdoses have increased by 500 percent. Not all, but many prescription drug addicts are first introduced to opioid painkillers by their doctor following an injury, surgery or other medical issue.
State medical boards—and recently the Centers for Medicare & Medicaid Services—have been known to sanction physicians who overprescribe narcotic drugs by suspending their medical licenses and/or revoking their ability to prescribe Schedule 2 drugs. In some cases, addicted patients have sued their physician for medical malpractice, claiming the provider’s negligence resulted in their addiction. In even more devastating circumstances, patient estates have sued for medical malpractice, claiming the provider’s negligence resulted in an addiction that ultimately led to death.
The stakes for physicians who carelessly prescribe narcotic painkillers was upped in October 2015 when Dr. Hsiu-Ying Tseng became the first physician in the United States to be convicted of murder in the prescription overdose deaths of three patients who were under her care. The Tseng case was extreme. According to prosecutors, the doctor received nine visits in three years from authorities after patients of hers died with prescription drugs in their system. One of the patients Tseng was convicted of murdering would drive 300 miles from another state to see the doctor and receive his prescriptions. She also agreed to prescribe powerful painkillers to an undercover agent posing as a patient after the agent told her he was addicted to the drug he was seeking.
While Tseng is the first physician to be convicted of murder for overprescribing narcotic painkillers, other doctors have been found guilty of lesser crimes, like involuntary manslaughter.
The large majority of physicians who prescribe narcotic painkillers are not like Tseng. They care for their patients’ wellbeing and are genuinely trying to manage their pain, but prescribing opioids must involve great caution to avoid risk of drug abuse as well as to recognize an addict in your office.
When presented with a patient experiencing pain, a physician should routinely incorporate measures to assess risk for opioid abuse. The evaluation should begin with a comprehensive physical as well as conducting a medical history that explores psychosocial factors and family history, which can help to determine risk of abuse. A personal or family history of alcohol or drug abuse is the factor most strongly predictive of opioid abuse, misuse or drug-related behavior. Clinical tools that can assist in the determination of risk include The Screener and Opioid Assessment for Patients with Pain Version 1, The Revised Screener and Opioid Assessment for Patients with Pain, The Opioid Risk Tool and Diagnosis, Intractability, Risk, Efficacy Tool.
If the patient meets the criteria for opioid pain management, and all non-narcotic options have been exhausted, it is important to discuss with the patient common side effects of opioid therapy, risks of becoming opioid dependent, potential long-term risks and how to safely store controlled substances so that they are not diverted by family or friends. Alcohol and other drug intake should be discussed as the combination can result in adverse outcomes, including death. Thoroughly covering these risks is critical to gaining the patient’s informed consent.
Opioids would initially be started in a short-term therapeutic trial. A patient being treated with narcotic painkillers should be monitored to assess pain relief, dosage adjustment and adverse effects. Those patients who are at a higher risk for prescription drug abuse should be monitored more closely. Many states have a prescription drug monitoring program database that collects information on controlled substances prescribed with in the state. These databases are a good place to turn when concerned that a patient may be visiting multiple doctors soliciting prescription drugs. Narcotic painkillers should be discontinued if the patient is not meeting therapeutic goals, adverse effects are intolerable and/or the patient is exhibiting addictive behaviors.
Medical practices that prescribe narcotics should institute an office policy that requires patients sign a treatment agreement that includes procuring prescriptions from a single doctor or practice. The treatment agreement should also delineate the course of action should the patient violate the agreement or display addictive behavior.
According to the National Institute of Drug Abuse, a full 20 percent of prescription narcotics abused in any given month are obtained through a healthcare professional. As the gatekeeper to potentially addictive/lethal substances, physicians have a responsibility to evaluate a patient’s risk for addiction, thoroughly explain potential side effects and addiction risks to garner informed consent and ensure medications are taken as prescribed.