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keeping opioid prescribers out of trouble

Posted by pseudoname on November 10, 2005, at 12:03:45

In reply to Re: Buprenorphine Concerns, posted by bigcat on November 4, 2005, at 0:45:45

> I would'nt dare bring up the Buprenorphine idea if writing the script could even remotely put him at any legal or professional risk.

I've come across this stuff in the last few days:

Eliot Cole, MD. "Prescribing opioids, relieving patient suffering and staying out of personal trouble with regulators." The Pain Practitioner, Fall 2002, 12(3): 5-8. http://www.aapainmanage.org/literature/PainPrac/V12N3_Cole_PrescribingOpioids.pdf

<quote>
WHAT CAN GET YOU INTO TROUBLE?
During the past few years, I have found several common practices that have gotten physicians into trouble regarding opioid prescribing:
 1. Failure to evaluate patients (i.e. no history or physical examination)
 2. Failure to make any diagnosis prior to the initiation of treatment
 3. Failure to obtain outside medical records or to talk with previous practitioners (any verification at all)
 4. Failure to establish goals for treatment (i.e. reduction in pain, improvement in function)
 5. Failure to suspect misbehavior or substance abuse (i.e. no screen for addictive potential and no monitoring through treatment)
 6. Failure to document the diagnosis, treatment plan, goals for treatment, continuing need for medication and lab results
 7. Failure to understand what drug testing can and cannot tell you
 8. Deviation from the “contract” (i.e. misbehavior is never addressed either verbally or written)
 9. Blind acceptance of whatever is said by patients
 10. Trying to bully law enforcement or regulatory agents or assuming an arrogant “I-know-best” attitude when confronted by them
      This ... is a fair representation of what I have seen in the records that have been submitted to the Academy for review through the Second Opinion Utilization Review program.

TEN TIPS FOR STAYING OUT OF TROUBLE
1.  Obtain a thorough history and perform a first rate physical examination...
2.  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, what alternative have been considered, that your patient agrees to the treatment, and how you intend to follow your patient over time.
3.  Obtain informed consent from your patients so there is no doubt about the treatment proposed....
4.  Get your patients to agree to use only one pharmacy.....
5.  If you are seeing your patients in the capacity of a primary care practitioner ... get a second opinion.... Share the responsibility to prescribe opioid analgesics....
6.  Prescribe long acting opioid analgesics on a time contingent basis so that stable levels are achieved. Avoid "as needed" medications...
7.  See your patients who are receiving opioid analgesics on a regular basis. ...
8.  Determine the minimum dose necessary to maintain function and useful activities of daily living....
9.  Order urine drug screens for your patients of concern to document that you are able to recover their prescribed medications (to rule out
significant diversion) and that you are thinking about their potential use of illicit substances....
10.  Continue to receive opioid analgesic education by attending recognized...

[DEA suggestions include...]
 • perform a thorough examination appropriate to the condition
 • document examination results and questions you asked the patient
 • request picture I.D., or other I.D. and Social Security number. Photocopy these documents and include them in the patient's record
 • call a previous practitioner, pharmacist or hospital to confirm patient's story
 • confirm a telephone number, if provided by the patient
 • confirm the current address at each visit
 • write prescriptions for limited quantities.
<unquote>

——————

A lot of places recommend written "opioid agreements" between the doc and the patient, spelling out treatment goals and agreeing that "lost" pills won't be replaced and that urine testing may be done to make sure the patient is actually the one taking the meds.

——————

This article tells how drug agencies conduct opioid "sting" operations on physicians. They send in a healthy-looking person as a new, unreferred patient with vague pain complaints who asks for an opioid but doesn't cooperate with getting further tests or prior medical records. Or he tells the doc at the second visit that he gave some of the med to his girlfriend. If the doc continues to write opioid prescriptions for such a patient, the doc could get charged: http://www.aapainmanage.org/literature/PainPrac/V13N2_Cole_PrescribersUpdate.pdf

——————

The only buprenorphine charge I could find was a Colorado doctor who HANDED bupe to someone who wasn't his patient. (He also prescribed the stimulant Phentermine to a woman intending that it actually be given to her husband, an NFL player. That was the heart of the charge.) http://rockymountainnews.com/drmn/local/article/0,1299,DRMN_15_2481985,00.html


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