The Los Angeles Times ran an article entitled "Oxycontin maker guards its closely guarded list of suspect doctors" about Purdue Pharmacy and how it has sold $27 billion worth of Oxycontin since 1996. It criticizes the company for not alerting law enforcement or medical authorities to the physicians who are suspected of overprescribing or illegal prescribing. This is part of a series of stories ran by the Times regarding prescription drugs and is a reminder that practitioners in this field are currently under a microscope.
We have had a number of clients whose records have been reviewed by the Board to see if their patient care for pain management was within the standard of care. The request for records are often triggered by a single complaint (such as a pharmacy complaining about overprescribing for a single patient). The Board runs the CURES report on the physician and selects for additional review 8 to 10 patients who are younger, middle-aged or on high opioid treatment dosages or where there are some other red flags with these patients.
In these cases, it is important to get legal counsel immediately even for a consultation to ensure that you are well prepared for any interview and that your complete file is submitted (and in many cases with a summary of the patient's care). In some of our cases, we found weaknesses in our client's practices and procedures and while not conceding any problems, we made positive changes immediately and it was helpful in showing that we had responsible professionals who are staying current with the changing landscape. In some cases, early expert retention may be needed or we found that a patient or two was diverting medications and had to make adjustments at that point.
If pain management treatment is part of your practice, it is time to perform an audit of your practice and make sure that your record keeping, consent forms, screening tools, treatment agreements, referrals for depression, referrals to other physicians as needed, patient education forms, and monitoring practices (urine testing, CURES reports, pill counting, etc.) are keeping up with the changing standard of care and changing laws and regulations. Do you modify your treatment plan when the patient reaches in excess of 120 mg morphine equivalent dosage (MED)? Do you document with specifics how the benefits of opioid treatment outweigh the risks? Build this into your staff and practice so it's part of the process.
It is becoming more important to have "universal" precautions in dealing with patients to ensure there is no risk of diversion. We have had clients who run urine tests and CURES reports on some patients but not on others who seem low risk. However, you cannot simply assume that just because someone is elderly (for example) that they do not pose a risk for diversion. This also makes it easier in your practice in that you then can tell the patients -- this is how we manage everyone -- and they do not take it personally. Drug tests are becoming the standard of care since you're ensuring that the patient is taking the medication as prescribed and that there is not diversion. CURES reports are also the standard of care now since you're ensuring that the patient is not doctor shopping.
Keep up with new monitoring methods. For example, one relatively new practice is to have the patients bring their pill bottles in for a "pill count" (sometimes randomly) -- especially for high risk patients -- for additional monitoring. Follow up on any issues raised by family members or the patient (nodding off during the day, sleep issues at night, preoccupation with the prescribed opioid, etc. Use the opioid risk management tools to assess the patient especially since many of these such as SOAPP are available free on the Internet.
For those in California, review the California Medical Board website on pain management periodically for updates on pain guidelines. even though it is behind the times and do not set forth in detail the standard of care and medical necessity -- but it is does set forth the basic law and policies of the Board.
Chronic pain is complicated and implementing audits for your practice will not only help with any investigation by the Board or DEA but will also help protect yourself against any potential malpractice case and help prevent any potential criminal liability. The law is clear that unless there is legitimate medical purpose for prescribing scheduled narcotics -- the prescription is not legitimate. If the records are not sufficient or if the patients are diverting medications, there can be a criminal or DEA investigation. We have also represented physicians in criminal investigations, search warrants and criminal cases involving pain management medications -- and our goal is to prevent such cases and investigations.
With the issue of prescription overdose deaths featured prominently in the press, physicians need to take these issues seriously even if they are board certified pain management specialists. We help practitioners ensure legitimate patients' access to appropriate pain care and the right of physicians to practice responsible pain medicine.
Posted by Tracy Green, Attorney at Law
Green and Associates,
(213) 233-2260
Email: tgreen@greenassoc.com
