From the Chair: The Pain Management Dilemma
Alex J. Hagan
Several years ago, a young man fell from a deer stand while hunting, severely injuring his back. His condition was inoperable. He sought help for his pain from his primary care physician. The physician tried several non-opiate pain medications before resorting to opioid medications. Recognizing his obligations to his patient and the state licensing agency, the physician entered a pain contract with the patient, ordered random urine drug screens, and continuously attempted other non-opioid therapies for the patient. The patient found no relief from anything other than opioid treatment.
The physician struggled with how to help his patient. He saw the need to address the pain, but also the concern for the patient’s increasing opioid use. An attempted referral to a pain clinic failed. Referral for mental health counseling failed. Numerous attempts to transition off opioid medication failed. At the same time, the patient’s pain increased, as did his need for pain medication.
One day, the physician received a call from a local pharmacy advising him that the patient had recently submitted a prescription for another controlled substance prescribed by another practice. As this violated the patient’s pain contract, the physician confronted the patient. The patient admitted that he was taking additional medications. As a result, the physician made the difficult decision to terminate the physician/patient relationship.
Thus began the most difficult year of the physician’s career. One Friday afternoon, the physician learned that the patient had entered a pharmacy and with gun in hand, demanded opioid medication from the pharmacist. While attempting to flee, the patient was shot and killed by a responding officer. The physician learned this through the state investigator who came to the physician’s office to retrieve his medical chart. He was reminded again of this tragic event when the state licensing board notified him he was under investigation.
Never before had this physician been investigated, let alone sued. Yet now he was questioning every medical decision he had ever made. As he looked at this patient population, he saw a trend. A large number of patients were taking opioid medication, and the trend showed that number was growing.
This physician’s patient population is not unique. Of all the opioid medication produced worldwide, a majority is consumed in the United States. Over one hundred million Americans suffer from chronic pain. Most of these patients are treating this pain with opioid medications. In fact, while this country comprises only five percent of the world population, studies show it consumes 80 percent of the world’s supply of opioids. Several southern states top the charts with opioid use, especially in rural areas. In North Carolina alone, four towns have made the list of the top 25 opioid abusing cities in the United States. One of those cities, Wilmington, North Carolina, leads the nation in opioid abuse. While older patients are more commonly using opioids, younger patients on opioids tend to take higher amounts of the medication and often build up tolerance levels to prescribed dosages.
As physicians become concerned about the level of opioid medications their patients are taking, they often find themselves locked in a pattern of prescribing. For example, as one physician tried to encourage his patient to try alternative treatments, the patient protested, arguing that it was the physician who got him addicted in the first place. Other patients and family members have reported physicians to the state licensing board, accusing the physician of creating their addiction. In Ohio, the state licensing board has investigated approximately 35 allegedly improper prescribing cases each year since 2010. In North Carolina, over 25 percent of all quality of care investigation involved allegations of improper prescribing. These cases stem not only from patient complaints, but also from reports from other providers, pharmacies, and law enforcement officers. In addition to reporting certain prescribers, some pharmacy chains have reportedly declined to fill opioid prescriptions by family care providers, or have required production of the treatment plan and pain contract before doing so.
- The prescribing physician is within the top one percent of those prescribing 100 milligrams of morphine equivalents per patient per day;
- The prescribing physician is prescribing 100 milligrams of morphine equivalents per patient per day incombination with any benzodiazepine and is within the top one percent of all controlled substance prescribers by volume;
- The prescriber has had two or more patient deaths in the preceding 12 months due to opioid poisoning.
It is the Board’s intent to determine the appropriateness of the prescribing patterns of physicians meeting the above criteria through independent expert medical reviews of the relevant records and written responses from the prescriber. Thus, heavy opioid prescribers can expect to be the subject of review.
It is unknown at this stage whether the North Carolina program will impact the opioid prescriptions in North Carolina. However, a logical byproduct is an increase in the number of opioid prescribing investigations and resulting disciplinary actions.
As for the physician whose story opened this article, this initiative likely will not affect him. Since the death of his former patient, he has begun removing opioid medicated patients from his practice. To the extent possible, he refers those chronic pain patients to other providers.
*This article was originally published June 24, 2016 in the DRI Medical Liability and Health Care Law Committee The Medlaw Update – Volume 21 Issue 2.