Tips for Steering Clear of Problems with Pain-Med Prescribing

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By Mary-Lynn Ryan, Risk Management
PMSLIC Insurance Company and The NORCAL Group

The following tips will help you prescribe narcotics/opioids appropriately to patients in chronic pain:

Obtain a thorough history and determine the specific cause of pain. In an article on treating patients’ pain, Eliot Cole, MD, a physician associated with the American Academy of Pain Management, advises, “Do not call [a patient’s] pain a headache or backache but try to find a specific pathological process to explain why your patients hurt.”1 Stephen Richeimer, MD, Chief of Pain Medicine at the University of Southern California, says, “Assessment is a key issue. The history and physical examination provides the information that allows the physician to judge if the patient is legitimately in pain or if the patient is improperly seeking drugs.”2

Document well. Cole advises, “Chart everything you see, think, feel, and hear about your patients. Leave nothing to the imagination of the future reader… Explain what you are doing, why you believe opioid analgesics will be helpful or continue to be helpful, what alternatives have been considered, that your patient agrees to the treatment, and how you intend to follow your patient over time.”1 Richeimer agrees: “Good record keeping is part of good medicine, and it is also your best protection from frivolous lawsuits,” he says.2

Ask chronic-pain patients to agree to use a single pharmacy. Discussing pain treatment with the patient and getting the patient to agree to certain parameters associated with long-term pain management are mutually beneficial strategies: they help you avoid inadvertently supplying medication that might be diverted for street sale, and they reassure the patient in pain that he or she can count on obtaining needed medication. An especially useful rule is that the patient will use a single pharmacy for all pain medications.

Make use of a written pain medication agreement with chronic-pain patients. A signed agreement by the patient that he or she will follow rules for obtaining pain medication will improve the likelihood of appropriate behavior by the patient. It discourages patients from seeking an unlimited supply of medication and helps staff members verify the legitimacy of refill requests.

Monitor patients over time on their needs for and use of pain medication. Richeimer observes that patient trustworthiness “can only be assessed by monitoring the patient over time.”2 Cole suggests talking with patients periodically to reduce dosage appropriately, as well as periodically ordering “urine drug screens for… patients of concern to document that you are able to recover their prescribed medications.”1

If you keep controlled substances in your office, establish a reliable process for safeguarding and reconciling such medications and for tracking their distribution. The federal Drug Enforcement Administration (DEA) requires physicians who administer or dispense controlled substances from their offices to have effective controls to guard against theft and diversion. Controlled substances must be stored in a securely locked, substantially constructed cabinet. Using a controlled substances inventory log can help you account for each and every dose of medication that goes through your office.

These strategies are aimed at fostering appropriate pain management within the limits of professional practice. Furthermore, they can help physicians and staff consistently meet regulatory requirements on the management of pain medications.

References

1. Cole E. Prescribing opioids, relieving patient suffering, and staying out of personal trouble with regulators. The Pain Practitioner. 2002;12(3):5-8. Available at: http://www.aapainmanage.org/literature/PainPrac/V12N3_Cole_PrescribingOpioids.pdf. Accessed June 3, 2009.

2. Richeimer S. Opioids for pain: risk management. California Society of Anesthesiologists Online CME Program. Available at: http://www.csahq.org/cme2/course.module.php?course=3&module=12. Accessed June 3, 2009.

PMSLIC

PMSLIC is a leading Pennsylvania physician-directed medical professional liability insurer committed to protecting physicians and their practices with comprehensive coverage and industry-leading risk management services. Since its inception in 1976, PMSLIC has gained the insight and expertise to help physicians improve patient safety and reduce their liability risk. And in the unfortunate event that an adverse outcome does occur, PMSLIC supports its insureds every step of the way. Rated ‘A’ Excellent by A.M. Best, PMSLIC has the financial strength and stability to support physicians now and for the long-haul. No other insurer is more committed to protecting your practice and your reputation. For more information, visit www.pmslic.com.

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