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…

• The patient has exhausted all reasonable alternatives
• There is medical indication
  – Recently documented objective evidence of/consistent with patient’s pain complaints
• 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

• Include other professionals
  – Addictionologist/Pain Psychologist
  – Residential/Inpatient Detox
  – Physiatrist
  – Physical therapist
  – Psychiatrists (for psych medications)
  – Sleep Specialist
• 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

• Use opioid risk tools
• Use screening questionnaires
• Train your staff to pick up signs of abuse
• Correct your staff if they miss a sign
• Never dismiss calls from pharmacists, or insurance plans with questions about prescriptions
• Beware of treating one patient differently than you treat all other patients
• Do not ignore risk factors for history of abuse/addiction
• Do not excuse failures solely because patient claims are not feasible

5.  Document, Document, Document, Including:

• Patient questionnaires, pain scores, vitals, patient chief complaints for each visit
• Make sure to have a pain contract signed & in chart
• Physical exam for each new complaint
• Treatment plan and objectives at each visit; document projected end point/re-eval point
• Description of relief from pain medications on each body part, at each visit
• Instructions & advisements
• Beware of templates!

6.  Use CURES When² …New patient

• Reason for suspicion
• Request for early fill
• Changing medications
• Patient has new complaint
• If patient has any compliance issue with pain contract (and you decide not to discharge patient or stop writing prescriptions)
• Document: Consistent with Pain Contract/ Inconsistent with Pain Contract/Questionable

7.  Conduct Drug Testing on Regular Basis

• For all new patients
• Anytime reason for suspicion:
  – Request for early fill
• Anytime changing medications
• Anytime patient has new complaint
• Multiple times per year
  – Quarterly for every patient
• Minimum 1x/year
• 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)