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A Letter Released to Medical Practitioners on
September 4, 2009

   
 

When a Health Story Becomes a Crime Story

- 10 Requirements for Prescribing Opiates -

NC

In 2003, the Drug Enforcement Agency (DEA) issued a press release to deflect accusations that their aggressive “War on Prescribed Drugs” was negatively affecting pain management practices nationwide.  In this press release, the DEA pointed out that in the first 10 months of 2003, less than 0.1% of registered doctors were sanctioned.  Unfortunately, the defense was a gross understatement.  Dr. David Haddox, a VP at Purdue Pharma, estimates that only 4,500 of the nearly 1 million registered physicians write prescriptions for oxycodone at levels that would suggest long-term management of moderate to severe pain.  Furthermore, compared to “sanctions,” DEA investigations serve as the better measure of intrusion into the medical profession.  The DEA does not have police powers and cannot make arrests.  They investigate and refer to law enforcement agents.  A DEA investigation alone, even one that does not result in sanctions, can involve seized assets, shut down of practices, and ruined reputations.1  In 2001, the DEA conducted “criminal” investigations of 861 doctors (a number amounting to 17% of doctors who prescribe oxycodone at chronic pain management levels).  In that same year, DEA investigations resulted in 79 doctors (almost 2 out of 100 per year) losing their DEA registrations completely.2  While considering that chilling fact, add this: The DEA states that it conducts less than half of the nation’s criminal investigations of doctors.  Local and state agents carry out more investigations of doctors than does the DEA.

Law enforcement practices over the past decade suggest that doctors can be held liable for the drug misuse of their patients.1  Unfortunately, studies focused on opiate therapy for chronic pain in primary care practice have shown an incidence of opioid abuse as high as 32%.3  Prescribers need to protect themselves by following the current standard in protocols (including verifying each prescription against the North Carolina and South Carolina prescription databases).  Below, I summarize the 10 Universal Precautions in Pain Medicine as laid out in the Comprehensive Textbook of Substance Abuse4 and describe the methods used at my pain management practice.

  1. Diagnosis. Thorough, appropriate imaging, electromyography, and other testing are needed to correctly identify the source of pain to sufficiently support the use of opiate therapy.
  2. Psychological assessment since addressing depression can decrease the need for analgesics and thereby reduce the chance of adverse affects from opiate therapy.
  3. A signed informed consent that details the risks, benefits, and side effects of the treatment plan.
  4. Treatment agreement / narcotic contract. A signed contract specifying the conditions under which opiate therapy will be continued or discontinued.
  5. Pre and post intervention assessment of pain level and function.
  6. Appropriate titration trials.
  7. Periodic reassessment of pain score and level of function.
  8. Regular assessment for aberrant behaviors.  Patient questionnaire screening tools. Regular drug screening including urine and saliva.  Patients should test negative for illicit drugs and positive for the prescribed drugs. Participation with both the North Carolina and South Carolina prescription databases to verify that patients are not receiving opiate therapy from more than one prescriber.
  9. Periodic review of diagnosis and diagnostic testing to document continued existence of pathology or discover improvements.  Assess for new disease process.
  10. Documentation. Careful recording of every visit, phone call, and precaution taken.

At the office of Dr. Neal Taub in Charlotte, we also take care to document the failure of previous analgesic attempts to justify the use of opioids.  If you have patients suffering from chronic pain, you can refer those patients to the private practice of Neal S. Taub, MD for specialized pain management which may or may not involve opioid analgesics.  Because we manage a larger portion of chronic pain cases, we have in place a structured approach to opioid prescriptions that protects both patient and physicians.



References

  1. Libby R. “Drug cops and doctors.” Cato Policy Report. November/December 2005: 12-13.
  2. McCarberg B, et al. “Managing Pain: Dispelling the Myths. Video CME program. Leawood, Kan.: American Academy of Family Physicians, January 2003.
  3. Katz N, Adams E, et al. Challenges in the development of prescription opioid abuse-deterrent formulations. Clin J Pain. 2007; 31 (8): 648-660.
  4. Portenoy R, Payn R. Acute and chronic pain. In: Lowinson J, Ruiz P, MIllman R, editors. Comprehensive textbook of substance abuse. 3rd ed. Baltimore: Willliams and Wilkins; 1997. Table 57, p. 564.



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