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Medical-legal Risks of Prescribing Pain Medications
Nevada Orthopaedic Society
November 14, 2016
David H. Sohn, JD MD
Chief, Shoulder and Sports Medicine
Head Orthopaedic Surgeon, Toledo Football Rockets
Associate Professor of Orthopaedic Surgery
University of Toledo Medical Center
Kristin A. Toy, MS
Justin A. Julian, BS
Risks of Prescribing Pain Medication
The Problem: Prescription Drug Abuse
US Physicians prescribe 82.5 opioid prescriptions per 100 people
(CDC M&M weekly report 2012)
So, we are prescribing a lot, and this costs money.
$62 billion per year spent on prescription pain meds
(CBO 2010)
Much of this however gets diverted from legitimate medical
purposes, and is used for nonmedical purposes.
Risks of Prescribing Pain Medication
The Problem: Prescription Drug Abuse
Diversion is
Risks of Prescribing Pain Medication
The Problem: Prescription Drug Abuse
Where do abusers get their narcotic drugs from?
64% from a friend or family member who had extra
4.3% from a drug dealer
(Source: HHS Publication No. (SMA) 134795, 2013)
So, we are overprescribing, and the excess finds its way into abuse.
Worse, we are prescribing more and more.
1997: 670,000 prescriptions for Oxycontin
2006: 6,200,000 prescriptions for Oxycontin
(Source: General Accounting Office-04-110
2003)
Risks of Prescribing Pain Medication
The Problem: Prescription Drug Abuse
This has led to what the Center for Disease Control has called an
epidemic
Prescription pain meds = gateway drugs for other street drugs
Prescription pain med abuse
Facts:
Overdose deaths have quadrupled in the last decade
1 of 4 people who receive pain meds struggle with addiction
1,000 ER visits for overdose PER DAY
(Source: CDC 2016)
Risks of Prescribing Pain Medication
The Problem: Prescription Drug Abuse
Not surprisingly, the government has reacted by instituting pressure
to PRESCRIBE LESS PAIN MEDS upon doctors
Federal level (DEA)
State level (State Medical Boards)
There are also lawsuits initiated to prescribe less pain meds
Addiction lawsuits
Overdose lawsuits
This talk will review these pressures and review the
risks of overprescription
Risks of Prescribing Pain Medication
Ironically, physicians actually HATE
prescribing narcotics. We don’t need the
government to tell us about risks taught in
med school, internship, residency,
fellowship, and practice
Risk of addiction
Risk of legal repercussions
Risk of overdose and death
However there are very real pressures to
prescribe pain meds
Risks of Prescribing Pain Medication
“Pain is the 5th vital sign”
In 1996, the American Pain Society introduced the phrase “Pain is the 5th vital sign”
Among the core principles of pain management, they asserted
“Patients have the RIGHT to appropriate assessment and management of pain”
“Pain can exist even when no physical cause can be found”
“Pain is always subjective. Therefore, the patient’s self report of pain is the single most reliable
indicator of pain. A clinician needs to accept and respect this self report.”
Source: National Pharmaceutical Council 1996
a
Risks of Prescribing Pain Medication
Joint Commission on Accreditation of Healthcare
Organizations
The problem is that JCAHO embraced these principles and
institutionalized them
“Patients
have the right to appropriate assessment and management of
pain (JCAHO Standard RI 1.2.8, 2000).
This meant that for hospitals to remain accredited, they had to
implement “Pain as a 5th vital sign”
Narcotics had to be given until patients were satisfied.
This is a problem with addictive materials
Most of the numbers then, such as 10 fold increases in narcotic
prescriptions, coincided with this implementation in the late 90’s
and early 2000’s.
Risks of Prescribing Pain Medication
Joint Commission on Accreditation of Healthcare
Organizations
In other words, good care began to be equated with “no pain”.
Patients also began to believe that if there was pain, there was
something wrong.
Many medical conditions however are painful, and it is unrealistic to
believe that there should be no pain.
Ankle fracture surgery: Netherlands vs. US
US: typically receive Vicodin, yet rate their pain as 7/10
Netherlands: typically receive Tylenol, yet rate their pain as 2/10
Difference? In Netherlands, they expect surgery will be painful.
In US, we now believe we have a right to be painless
Risks of Prescribing Pain Medication
This then creates another set of pressures
When patients are in pain, they are angry and demand more pain meds
“If you have a sympathetic client, you can always find a legal hook to
hang your hat on.”
There are now more than 16 consumer advocacy groups who exist to
pressure doctors to prescribe more and more pain meds, and have found
ways to successfully sue or prosecute doctors… (Source: CPATF)
Even when the amounts demanded are dangerous
Even when the current amounts given meet the standard of care
This talk will also review these pressures and
risks of underprescribing
Risks of Prescribing Pain Medication
“Can I have another Rx for Percocet?”
Common
question we hear as orthopaedic surgeons
Common
fears
Can
I be sued for prescribing too little?
Can
I be prosecuted for prescribing too much?
Are
there any guidelines to this?!?
Risks of Prescribing Pain Medication
Goals of presentation
1.
Review risks of underprescribing
2.
Review risks of overprescribing
3.
Suggestions to navigate risk
Risks of Prescribing Pain Medication
Risks of underprescribing
Case presentation
85M
with terminal lung cancer, respiratory disease and suspected
metastatic back pain
Dr.
Chin, an internist, prescribed 25-50mg demerol IV q3 prn,
as well as duragesic patch
Pt
rated pain between 7 and 10
Family
demanded a scheduled pain delivery, rather than prn
Risks of Prescribing Pain Medication
Risks of underprescribing
Case presentation
85M
with terminal lung cancer, respiratory disease and suspected
metastatic back pain
Dr.
Chin refused, citing fear that higher and more frequent
doses could cause respiratory compromise
Pt
left hospital, went to hospice and was prescribed around
the clock morphine. He expired within 2 days
Risks of Prescribing Pain Medication
Risks of underprescribing
Case presentation
85M
with terminal lung cancer, respiratory disease and suspected
metastatic back pain
Family
was irate at Dr. Chin, but hospital and medical board
defended his actions as meeting standard of care.
Plaintiffs
agreed it was standard of care, but sued under elder
abuse statutes for failure to deliver adequate pain control
Risks of Prescribing Pain Medication
Risks of underprescribing
Case presentation
Elder
●
●
●
Abuse and Dependent Adult Civil Protection Act
"Abuse of an elder or a dependent adult" means either of the following:
(a) Physical abuse, neglect, financial abuse, abandonment, isolation,
abduction, or other treatment with resulting physical harm or pain or mental
suffering.
(b) The deprivation by a care custodian of goods or services that are necessary
to avoid physical harm or mental suffering.
WIC. CODE § 15610.07 : California Code Section 15610.07
CAL.
Risks of Prescribing Pain Medication
Risks of underprescribing
VERDICT:
$1.5 million for plaintiff
Defense
attorney stated this was a “very scary verdict” because
Dr. Chin felt if he acceded to family’s wishes, Mr. Bergman
could have died of respiratory distress and he would have been
sued for prescribing too much pain meds.
Bergman v. Chin, No. H205732-1 (Cal. App Dept Super Ct 1999)
Risks of Prescribing Pain Medication
Risks of underprescribing
VERDICT:
●
●
“I think we are at a new place in law and medicine …
[where] [f]ailure to treat pain can now be something that
physicians are held accountable for.”
Susan Okie, Calif. Jury Finds Doctor Negligent in Managing Pain, WASH. POST, June 15, 2001, at A2, available at
2001 WL 23174418 (quoting Kathryn Tucker, the director of legal affairs at the Compassion in Dying Federation in
regards to Bergman v. Chin, No. H205732-1 (Cal. Super. Ct. June 13, 2001), and its legal impact on how the medical
field treats pain).
Risks of Prescribing Pain Medication
Risks of underprescribing
North
Carolina: In a similar case, a nursing home was found
guilty of under-treating pain in a patient with metastatic cancer.
The jury awarded the plaintiff’s estate $15 million.
Source: COLUMN ONE : How Much Painkiller Is Enough? : Health care
workers are often on guard against giving too much medication. A landmark
case against a nursing home has sent a warning not to provide too little.
http://articles.latimes.com/1991-12-10/news/mn-154_1_nursing-home
Risks of Prescribing Pain Medication
Risks of underprescribing
Oregon:
The Oregon Board of Medical Examiners disciplined a
doctor for not prescribing enough narcotics for six patients.
Ordered
to complete communication training
Ordered
to complete physician education program
Ordered
to undergo psychiatric evaluation
Source: http://www.nytimes.com/1999/09/04/us/oregon-boarddisciplines-doctor-for-not-treating-patients-pain.html
Risks of Prescribing Pain Medication
Risks of underprescribing
Oregon
(cont.): Examples include
82M
with CHF stated “he could not breathe” and wanted
narcotics.
35F
on ventilator wanted pain meds and anxiolytics for
“wheezing.”
Interestingly,
the mode of overdose death is typically from
respiratory depression.
Risks of Prescribing Pain Medication
Risks of underprescribing
●
''I think they're going to end up driving doctors crazy. A
decade ago, the board was questioning doctors for
overprescribing drugs. Now all of a sudden, the fashions
have changed and the board's going to start harassing
doctors for not prescribing enough pain medication. It
makes it extremely difficult for the average Oregon
physician to know what to do to make the board happy.''
●
-Dr Leigh Dolin, past president of Oregon State Medical
Board
Risks of Prescribing Pain Medication
Risks of underprescribing
This
is NOT a malpractice claim.
Malpractice
alleges a deviation from standard of care which results in damages. It is
defensible by adherence to standard of care, and is covered by malpractice insurance
This
is a new form of liability, stemming in part from California’s Patient Bill of Rights
““[a]
patient suffering from severe chronic intractable pain should have access to
proper treatment of his or her pain.”
“[a]
patient suffering from severe chronic intractable pain has the option to
request or reject the use of any or all modalities to relieve his or her severe chronic
intractable pain.”
CAL.
HEALTH & SAFETY CODE § 124960 (West 2000).
Risks of Prescribing Pain Medication
Risks of underprescribing
Patient
●
●
●
entitlement to pain meds
“Extremely challenging behavioral issues may emerge during an opioid taper .
38
Behavioral challenges frequently arise when a prescriber is tapering the
opioid dose and a patient places great value on the opioid he/she is receiving.
In this setting, some patients may feel overwhelmed or desperate and will try
to convince the prescriber to abandon the opioid taper. “
-
Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care
and safety with opioid therapy 2010 Update
Risks of Prescribing Pain Medication
Risks of underprescribing
Patient
●
entitlement to pain meds
Challenges may include:
–
Focus on right to pain relief (“You don’t believe I have real pain”)
–
Arguments about poor quality of pain care with threats to complain to
administrators
–
Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety
with opioid therapy 2010 Update
Risks of Prescribing Pain Medication
What about OVER prescribing?
Risks of Prescribing Pain Medication
Risks of overprescribing
Case
presentation 1
Physician
prescribed oxycodone to 75M with metastatic lung
cancer.
Patient
fell asleep at the wheel and struck a pedestrian
Pedestrian
sued physician for negligently prescribing
narcotics without warning of possible sedative side effects
Physician
defends by claiming no duty owed to third party
Risks of Prescribing Pain Medication
Risks of overprescribing
VERDICT:
for plaintiff
Appeals
court finds that physicians do have a duty of reasonable
care to everyone foreseeably put at risk by the medications
prescribed
Combs v. Florio, 450 Mass 182
Risks of Prescribing Pain Medication
Risks of overprescribing
Again,
this is NOT a medical malpractice case. This is a
significant expansion of liability to beyond just the patient, and
now includes all those the patient might foreseeably harm
Combs v. Florio, 450 Mass 182
Risks of Prescribing Pain Medication
Risks of overprescribing
●
●
●
Joshua Murphy, Mayo Clinic Legal Counsel
"A physician can be held liable for injuries caused by the
impairing effects of medications prescribed by the
physician.”
"The physician may be liable to the patient or to a third
party if the patient is in a car accident caused by the
impairing effects of the medication prescribed by the
physician".
Risks of Prescribing Pain Medication
Risks of overprescribing
●
●
Joshua Murphy, Mayo Clinic Legal Counsel
"The physician may be liable if he/she prescribed a
medication or combination of medications that was
inappropriate for the patient, and even if the medications
were appropriate for the patient, the physician may be
liable if he/she did not appropriately warn the patient of
the side effects and risks associated with the medication.“
–
Source: American Academy of Pain Management 30th National Meeting,
“Ability to Drive a Critical Concern in Opiate Prescribing”,
–
http://www.medscape.com/viewarticle/822082
Risks of Prescribing Pain Medication
Risks of overprescribing
●
●
So, the first medical legal risk in prescribing pain
medication is liability to third parties for failure to warn
of sedating effects when driving or operating heavy
machines.
Recommendation:
Document discussions of sedating effects, either in a pain
contract or in clinic notes
Risks of Prescribing Pain Medication
Risks of overprescribing
Case
presentation 2
Physician
saw a patient complaining of low back pain and
requesting narcotics
Physician
listened to lungs and performed five minute interview
Physician
then prescribed 120 tablets of narcotic pain medication
Problem?
Risks of Prescribing Pain Medication
Risks of overprescribing
Title 21 United States Code Controlled Substances Act
“No controlled substance may be dispensed without a prescription,
except when dispensed directly by a practitioner to the ultimate user”
DEA interpretation of CSA
Prescription must be issued for 1) a “legitimate medical purpose”, 2) by a
registered physician, acting 3) within the usual course of professional
practice
Risks of Prescribing Pain Medication
Risks of overprescribing
The
“patient” mentioned here was an undercover agent. The
liberal dispensation of narcotics triggered an entire office search
which revealed that a high percentage of the physician’s patients
had criminal records, and that he had written them a large number
of oxycodone prescriptions
Physician
was arrested and prosecuted for racketeering and drug
trafficking in Florida 2012
Risks of Prescribing Pain Medication
Risks of
overprescribing
Similar
case in
Delaware in 2015
Risks of Prescribing Pain Medication
Risks of overprescribing
“Detectives
Steven Bannar and John Newell testified during
a weeklong trial before Judge Anthony Scanlon that they
were able to receive prescriptions for Xanax, Percocet and
Oxycodone from Wean without having any examinations or
tests performed and providing no medical history.”
Source:
http://www.delcotimes.com/generalnews/20151002/delco-doc-convicted-of-99-drug-counts-inpill-mill-case
Risks of Prescribing Pain Medication
Risks of overprescribing
Similarly,
some states require as part of professional standards that a
physical exam accompany the dispensation of narcotics.
In
an interpretation of the Intractable Pain Treatment Act, [CAL. BUS. &
PROF. CODE § 2241.5 (West 2000)], a physician found to prescribe
controlled substances without a physical examination or indication that
the drugs were therapeutically required is guilty of unprofessional
conduct warranting the revocation of his license to
See
Kolnick v. Bd. of Med. Quality Assur., 161 Cal. Rptr. 289 (Cal.
Ct. App. 1980).
Risks of Prescribing Pain Medication
Risks of overprescribing
Overprescribing,
as judged by standard of care by state medical
boards, has also led to censure, fines, and restriction on license to
practice medicine by state medical boards.
Pain
management doctor treating patients with intractable pain was
placed on 2 years probation, $4000 fine, and sent to remedial courses
for prescribing excessive amounts of opioids.
This
was based on testimony of two doctors who were not pain
management experts

- Hoover v. Agency for Health Care Administration, 676 So. 2d 1380 (Fla.
Ct. App. 1996)
Risks of Prescribing Pain Medication
Risks of overprescribing
In
another case, based on expert witness testimony stating she
prescribed excessive pain medications, an Arkansas doctor was
Placed
on 1 year probation
Required
to take 50hrs of CME
Restricted
from prescribing narcotics
Subjected
to frequent medical board monitoring
-
Hollabaugh v. Arkansas State Medical Board, 861 S.W.2d 317
(Ark. Ct. App. 1993)
Risks of Prescribing Pain Medication
Risks of overprescribing
More
LA
cases from this year:
Times “Doctor get 5 years in prescription drug case.”
- http://www.latimes.com/local/california/la-me-doctor-sentenced-20150106story.html
Salt
Lake Tribune “Utah doctor/lawyer pleads guilty in
prescription drug case.”
-http://www.sltrib.com/home/3079519-155/utah-doctorlawyer-pleadsguilty-in-prescript
Risks of Prescribing Pain Medication
Risks of overprescribing
Painkiller prescription prison sentence
upheld for Kansas doctor and wife
Kansas:
http://www.cbsnews.com/news/painkiller-prescription-prison-sentence-upheldfor-doctor-and-wife-in-kansas/
Birmingham-area doctors charged in
federal prescription drug crackdown
Alabama:
http://www.al.com/news/birmingham/index.ssf/2015/05/birminghamarea_doctors_charge.html
Risks of Prescribing Pain Medication
Risks of overprescribing
DEA’s
Operation Pillution 2015
280
arrests, including 22 doctors
4
states – Arkanas, Alabama,
Louisiana, Mississippi
15
month operation involving over 1000 federal agents
Risks of Prescribing Pain Medication
Risks of overprescribing
DEA’s
Operation Pillution 2015
Single
largest pharmaceutical initiative in DEA history
Search
warrants were issued based on phone calls and
complaints about too easy access to oxycodone, xanax and
percocet
Source:
http://www.nbcnews.com/news/us-news/drug-enforcementadministration-raids-pill-mills-four-southern-states-n361956
Risks of Prescribing Pain Medication
Recommendation:
Prescribe according to protocol
Document a physical exam
Risks of Prescribing Pain Medication
Goals of presentation
Unfortunately,
there is a third
potential form of liability
Although
patients are the ones
who demand pain meds, they
are now starting to blame
physicians for “getting them
addicted”
Risks of Prescribing Pain Medication
●
“When is a doctor negligent in prescribing opiates/pain
killers?
●
Imperial Beach, CA | on Jun 4
●
Filed under: Medical malpractice Pain and suffering
●
“I was prescribed opiates for 4 and 1/2 years by a doctor. The doctor
never explained the side effects or dangers of opiate use. He never
altered the prescription and never came up with a treatment plan, just
kept giving out the pain killers. The doctor would not come into the
same room for more than 5 minutes and wouldn't know who I am if
he saw me. I stopped taking the pills and went through withdrawal
thinking I was just sick. Ended up losing my job and short term
memory”
●
Source: http://www.avvo.com/legal-answers/when-is-adoctor-negligent-in-prescribing-opiates--2212847.html
Risks of Prescribing Pain Medication
Goals of presentation

Final liability risk of prescribing pain meds: overdose
As
overdose deaths rise, DEA is clamping down on doctors,
viewing them as the main source of the problem.
Source:
http://www.ctpost.com/news/article/America-s-drug-problemstarts-in-the-doctor-s-6584975.php
Risks of Prescribing Pain Medication
Goals of presentation

It
is only a matter of time that patients who have demanded
pain meds from doctors will start to be the ones who sue them
“Doctors
make easy targets for lawsuits because they often are
seen as placing would-be weapons into patients' hands. It's a growing
problem. You have suicides. You have overdoses or near-deaths. Of
course, they want to blame the doctor. He is blamed for having set
patients on that course.””
-Michael A. Moroney, a health law attorney at Weber Gallagher
Simpson Stapleton Fires & Newby LLP in New Jersey
http://www.amednews.com/article/20130304/profession/130309978/4/
Risks of Prescribing Pain Medication
Goals of presentation

In fact, the future is already here.
In
May 2012, an Alabama jury awarded a widower $500,000 after
he sued his wife's family physician. Attorneys for the husband said the
woman died of an accidental overdose after being prescribed narcotic
pain medications and central nervous system depressants.
In
April 2012, a woman was awarded $1.9 million after she sued her
family physician. She claimed he overprescribed her methadone,
leading to brain damage after she stopped breathing.
Source:
Physician liability: When an overdose brings a lawsuit
http://www.amednews.com/article/20130304/profession/130309978/
4/
Risks of Prescribing Pain Medication
Recommendation:
Prescribe
according to a protocol. This establishes that meds are
given according to a standard, not haphazardly or arbitrarily.
Risks of Prescribing Pain Medication
Goals of presentation
1.
Review risks of underprescribing
2.
Review risks of overprescribing
3.
Suggestions to navigate risk
Risks of Prescribing Pain Medication
Are there any guidelines?
Answer:
There
No, but they are on the way
used to be guideline available at the DEA website
DEA
actually removed their guidelines, for fear that these would
be used to justify maximum dispensation for minor conditions
However,
some helpful principles remain
Risks of Prescribing Pain Medication
Guidelines
Title 21 United States Code Controlled Substances Act
“No controlled substance may be dispensed without a prescription,
except when dispensed directly by a practitioner to the ultimate user”
DEA interpretation of CSA
Prescription must be issued for 1) a “legitimate medical purpose”, 2) by a
registered physician, acting 3) within the usual course of professional
practice
Risks of Prescribing Pain Medication
Red flags (what NOT to do)
Inordinate
No
quantities prescribed
physical exam performed
Prescriptions
given even after physician told the patient was
selling his meds
Inconsistent
Use
No
intervals
of street slang instead of formal names (i.e. “Vikes”)
logical relationship between meds and underlying condition
US v. Rosen, 582 F.2d 1032 (5th Cir 1978)
Risks of Prescribing Pain Medication
Red flags (what NOT to do)
Inordinate
No
quantities prescribed
physical exam performed
Prescriptions
given even after physician told the patient was
selling his meds
Inconsistent
Use
No
intervals
of street slang instead of formal names (i.e. “Vikes”)
logical relationship between meds and underlying condition
US v. Rosen, 582 F.2d 1032 (5th Cir 1978)
Risks of Prescribing Pain Medication
Are there any guidelines?
Answer:
Yes!
The
CDC in October of 2015 presented a webinar on
prescription pain meds, and verbalized a 12 pt guideline
which it will submit to HHS for publication in 2015
Source:
http://www.painnewsnetwork.org/stories/2015/9/16/cdcopioids-not-preferred-treatment-for-chronic-pain
Risks of Prescribing Pain Medication
There are 12 points, listed as follows:
●
●
1. Non-pharmacological therapy and non-opioid pharmacological therapy are
preferred for chronic pain. Providers should only consider adding opioid
therapy if expected benefits for both pain and function are anticipated to
outweigh risks.
2. Before starting long term opioid therapy, providers should establish
treatment goals with all patients, including realistic goals for pain and
function. Providers should continue opioid therapy only if there is clinically
meaningful improvement in pain and function that outweighs risks to patient
safety.
Risks of Prescribing Pain Medication
CDC Draft Guidelines
●
●
●
●
3. Before starting and periodically during opioid therapy, providers should
discuss with patients risks and realistic benefits of opioid therapy and patient
and provider responsibilities for managing therapy.
4. When starting opioid therapy, providers should prescribe short-acting
opioids instead of extended-release/long acting opioids.
5. When opioids are started, providers should prescribe the lowest possible
effective dosage. Providers should implement additional precautions when
increasing dosage to 50 or greater milligrams per day in morphine equivalents
and should avoid increasing dosages to 90 or greater milligrams per day in
morphine equivalents.
(FYI: 20mg oxycodone = 30mg morphine)
Risks of Prescribing Pain Medication
CDC Draft Guidelines
●
●
6. Long-term opioid use often begins with treatment of acute pain. When
opioids are used for acute pain, providers should prescribe the lowest effective
dose of short-acting opioids and should prescribe no greater quantity than
needed for the expected duration of pain severe enough to require opioids.
Three or fewer days will usually be sufficient for non-traumatic pain not
related to major surgery.
7. Providers should evaluate patients within 1 to 4 weeks of starting long-term
opioid therapy or of dose escalation to assess benefits and harms of continued
opioid therapy. Providers should evaluate patients receiving long-term opioid
therapy every 3 months or more frequently for benefits and harms of
continued opioid therapy. If benefits do not outweigh harms of continued
opioid therapy, providers should work with patients to reduce opioid dosage
and to discontinue opioids when possible.
Risks of Prescribing Pain Medication
CDC Draft Guidelines
●
●
8. Before starting and periodically during continuation of opioid therapy,
providers should evaluate risk factors for opioid-related harms. Providers
should incorporate into the management plan strategies to mitigate risk,
including considering offering naloxone when factors that increase risk for
opioid-related harms are present.
9. Providers should review the patient’s history of controlled substance
prescriptions using state Prescription Drug Monitoring Program data to
determine whether the patient is receiving excessive opioid dosages or
dangerous combinations that put him/her at high risk for overdose. Providers
should review Prescription Monitoring Program data when starting opioid
therapy and periodically during long-term opioid therapy (ranging from every
prescription to every 3 months).
Risks of Prescribing Pain Medication
CDC Draft Guidelines
●
●
●
10. Providers should use urine drug testing before starting opioids for chronic
pain and consider urine drug testing at least annually for all patients on longterm opioid therapy to assess for prescribed medications as well as other
controlled substances and illicit drugs.
11. Providers should avoid prescribing of opioid pain medication and
benzodiazepines concurrently whenever possible.
12. Providers should offer or arrange evidence-based treatment (usually
opioid agonist treatment in combination with behavioral therapies) for
patients with opioid use disorder.
Risks of Prescribing Pain Medication
Recommendations
Prescribe
according to a protocol
Prescribe
only in clinic after a physical exam
Do
not allow unsupervised prescription of pain meds by
nonphysicians
Document
signs of abuse to protect against suits for
undertreatment
Do
not prescribe once you find out a patient is abusing
Risks of Prescribing Pain Medication
Recommendations
Consider
Red
random urine testing
flags can give rock solid reasons for discontinuing pain
meds
Presence
of street drugs
Presence
of benzodiazepems
Presence
of alcohol
Lack
of prescribed meds  Are they selling the drugs?
Risks of Prescribing Pain Medication
Recommendations
It
may be best to consider the dispensation of pain medications as
an informed consent process, complete with signatures on
protocols to act as contracts.
Protects
against third party liability
Protects
against accusations of “pill-mills”
Protects
against lawsuits of addiction/overdose
Protects
against demands for narcotics beyond the 90 day window