There is a host of new, ever changing, and conflicting guidelines from a multitude of regulators and academic societies. This evolving and uncertain landscape is making the life of a practicing pain physician in the midst of today’s nationwide opiate epidemic…painful.
Here are 10 tips to help you avoid Medical Board discipline when prescribing opiates:1
1. Don’t Prescribe Opiates Unless…
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The patient has exhausted all reasonable alternatives
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There is medical indication
– Recently documented objective evidence of/consistent with patient’s pain complaints
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You have conducted a comprehensive history, initial exam, imaging, UDT’s, CURES, ORT’s, have a signed pain contract, and have provided informed consent
2. Treat the 2014 MBC Guidelines as Dictating the Standard of Care (i.e. rules you must follow) – Deviations from these Guidelines must be justified and documented.
3. Use a Team Approach
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Include other professionals
– Addictionologist/Pain Psychologist
– Residential/Inpatient Detox
– Physiatrist
– Physical therapist
– Psychiatrists (for psych medications)
– Sleep Specialist
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Document
– Referrals
– Patient Declinations/Refusals of Recommended Care or
– Consultation
– Communications with other providers
– Plan of action based upon other providers’ recommendations
4. Pay Attention to the Red Flags and Take the Following Precautions
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Use opioid risk tools
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Use screening questionnaires
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Train your staff to pick up signs of abuse
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Correct your staff if they miss a sign
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Never dismiss calls from pharmacists, or insurance plans with questions about prescriptions
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Beware of treating one patient differently than you treat all other patients
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Do not ignore risk factors for history of abuse/addiction
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Do not excuse failures solely because patient claims are not feasible
5. Document, Document, Document, Including:
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Patient questionnaires, pain scores, vitals, patient chief complaints for each visit
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Make sure to have a pain contract signed & in chart
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Physical exam for each new complaint
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Treatment plan and objectives at each visit; document projected end point/re-eval point
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Description of relief from pain medications on each body part, at each visit
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Instructions & advisements
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Beware of templates!
6. Use CURES When2 …New patient
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Reason for suspicion
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Request for early fill
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Changing medications
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Patient has new complaint
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If patient has any compliance issue with pain contract (and you decide not to discharge patient or stop writing prescriptions)
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Document: Consistent with Pain Contract/ Inconsistent with Pain Contract/Questionable
7. Conduct Drug Testing on Regular Basis
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For all new patients
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Anytime reason for suspicion:
– Request for early fill
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Anytime changing medications
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Anytime patient has new complaint
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Multiple times per year
– Quarterly for every patient
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Minimum 1x/year
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Document: Consistent with Prescribed Medications/ Inconsistent/Questionable
8. Only Use Electronic Prescriptions
9. Audit Your Own Charts
10. Keep Current on Regulations and News
1 This blog post is not intended to constitute specific legal advice, and it is not a substitute for advice from qualified counsel. The information on this website is general in nature and may not pertain to your specific circumstances.
2 As of October 2, 2018, any physician who prescribes Controlled Substances to a patient will be required to check CURES before the first time and at least quarterly (Health & Safety Code §11165.4)