PAINKILLER LAW BLOG POST: Be Like Mike (Alstott)

Two recent news items about the prescription drug crisis in the U.S. offer larger insights when taken together.
The first item is a recent study released by the CDC, which found that prescription opioid “abuse” is down nationwide. This is good news, but it has to be taken with a grain of salt. Originally, the notion of “abuse” of prescription opioids was, pardon the pun, pushed by the pharmaceutical companies whose mass-marketed, mass-prescribed painkillers unexpectedly ended up addicting huge numbers of people who had never been addicted to anything else in their lives. “Abuse” was the dismissive term applied to ordinary pain sufferers to blame patients and absolve manufacturers for problems associated with widespread opioid prescribing for chronic pain.  So to say “abuse” is down sounds great, and it is great, but such a finding must be noted with qualification.

The CDC study also found that even though abuse is down, accidental overdose deaths are up nationwide. To the cynical eye, this means that when taken as directed, opioids for chronic pain can kill you. And today, this isn’t an entirely cynical view – it is the medical and scientific insight gaining steam in study after study. The data increasingly voices the concern that opioids for chronic pain could be typically addictive and ultimately ineffective.

BUT – have hope, because the second news item is the launch of a new education campaign which offers promise to both patients and doctors about the present situation.

The campaign is called “America Starts Talking,” and among its featured spokespersons is ex-NFL great Mike Alstott. He is the former pro running back whose bruising, consistent and reliable play season after season over his long career prompted TV announcers to quip “You’re in Good Hands With Alstott” whenever he had a carry. Alstott also got injured 47 times over his playing career and first took opioids (for acute pain) in college on the advice of team doctors and trainers. Fortunately, and unlike many other players, he never got addicted. Alstott is now working to educate patients on how to interact with their doctors and learn about the medicine in a full and responsible way, and to learn life-saving tips in the event a patient experiences a drug-related emergency.

Alstott’s participation in this effort resonates in important ways with the things I’ve always talked about in the Painkiller Law Blog. First, just as no running back will gain 40 yards or score each time he touches the ball, there is no panacea for chronic pain. Second, team media departments can promise all they want in pre-game ads, just like drug manufacturers can in commercials, but the real story is when the game is played, or the prescription written and the drug taken. Third, an initial game plan is essential, but if circumstances on the field change, adaptability becomes key, and responding creatively and wisely to a new situation is the only viable alternative. The original message from drug manufacturers that opioids for chronic pain are generally safe and effective is being disproven. Doctors and patients, pharmacists and police and Medical Boards and regulators, therefore must adapt. Education about whether to prescribe, not just how often and how much, is essential to practicing safe medicine and ensuring compliance with the law. Failing to change with the changing science is a formula for poor patient care, and will invite law enforcement scrutiny and possible criminal prosecution. Burying one’s head in the sand and hoping nothing bad will happen is foolhardy.  Steady, consistent training and play yield the same results as steady, consistent education, compliance and medical practice.  When it comes to safe, smart prescribing and safe, smart pain relief, be like Mike.

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PAINKILLER LAW BLOG POST: TO Rx OR NOT TO Rx? THAT IS THE QUESTION

Apologies to Hamlet for borrowing his line to open this post.  When I wrote a few weeks ago, I said that one of the things I’d be talking in September and October would be doctors’ need to turn to current science in deciding about opioid prescribing.  That is the subject of today’s post.

“There is a lack of high-quality guidelines on opioid prescribing.”  -CDC staff, testifying before Congress, May 2015

Today, every state in the country has opioid prescribing guidelines in one form or another.  The State of Washington pretty much led the way in forming the guidelines which states like California, Pennsylvania, Florida and other jurisdictions have since put in place.  In addition, medical societies, workers’ compensation insurance carriers, medical specialty associations and other groups have their own opioid prescribing guidelines, which sometimes go farther than the guidelines of the state where an individual member-physician practices.  In addition, there are documents which compare all 50 states’ prescribing guidelines; there are papers, studies, speeches, initiatives, bills, calls for action and other efforts to ensure patient safety and medical legitimacy in opioid prescribing.  And, there are multiple law enforcement agencies in each state, there are 50 different medical boards across the country, and of course there’s the DEA.  The interpretations of prescribing guidelines by members of all of these agencies might vary substantially, even within the same state.

Amid all that, amid that plethora of paper and deluge of deliberation, the CDC still boils it down to the conclusion that “there is a lack of high-quality guidelines on opioid prescribing.”

Let’s figure the CDC is right.  How to explain the lack of high-quality guidelines if there are so many, many sets of guidelines out there?   The answer is that guidelines today only tell a physician what to do when he or she chosen to prescribe, instead of asking a physician to more carefully decide whether to prescribe at all, or whether to continue opioid therapy.

What today’s guidelines are missing, pretty much uniformly, in my view, is a thorough and careful, current and scientifically faithful discussion of the efficacy of opioid prescribing.  If you look at today’s various sets of guidelines, their introductions and updates pay generous lip service to the notion that the whether of opioid prescribing is very important, but the guidelines themselves are still rooted in the view that opioids are generally safe and effective for chronic pain.  The problem is, the view that opioids are generally safe and effective for chronic pain is being steadily and credibly challenged by new scientific evidence.  So the guidelines, despite the good faith with which they have been drafted, are necessarily behind the times.

What is needed is a new approach, an “evidence-based” look, to use the term so in vogue now in medicine, enabling physicians to take a more careful and complete look at the medical and legal aspects of whether, not just how often or how much, to prescribe.  Guidelines will not be the source of this information, because they’re reduced to paper or online documents, they are subject to lengthy legislative or administrative processes, and scientific studies and data continue to emerge after any set of guidelines is published.  But that doesn’t mean doctors can’t gain access to the information they need.  Clinically legitimate and legally compliant decisions on whether and when and how much and how often to prescribe opioids can still be made, if all the right ingredients go into the mix from the beginning.

More on that soon!

 

 

 

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PAINKILLER LAW BLOG: ASSUMPTIONS CHANGING ABOUT OPIOIDS FOR CHRONIC PAIN

The assumption that opioids are safe and effective for chronic pain is being repeatedly and fundamentally called in into question by a steadily accumulating collection of new scientific data.  Against this backdrop, it is no longer medically or legally sufficient for doctors to accept certain drug manufacturers’ theories that a patient who gets addicted to opioid painkillers has no one to blame but themselves or the doctor.  Doctors must take note of these developments and make allies of the changing assumptions.  This is the best way for prescribers to protect their patients and themselves, to practice good medicine, and to comply with the criminal laws of controlled substance prescribing.

The prescription drug crisis facing our country and other parts of the world today has its origins in a research study from the late 1980′s, conducted by a drug manufacturer which wanted to sell opioids for chronic pain.  The study said, to most everyone’s surprise, that opioids were generally effective and safe when prescribed for chronic pain.  This had never been said before, because nearly a century of medical experience had shown that for acute pain, on the one hand, and end of life cancer pain on the other, opioids were sometimes the only painkillers that worked — but for chronic pain, the evidence of addiction was high, and the evidence of effectiveness was low.  The new research in the late 1980′s turned this conventional wisdom on its head.  The FDA approved opioids for chronic pain, which led to mass marketing by drug manufacturers, new education and instruction for doctors and medical students, and patients’ being prescribed the drugs on an essentially permanent basis.  It also lead to today’s epidemic (the CDC’s term) of opioid addiction, overdose and death.  The present crisis has forced reexamination of the basic assumptions about safety and effectiveness of opioid painkillers, and the developments cannot be ignored.

Here is what some of the leading voices in the nation are saying:

-”Neuropathic pain [pain not from a specific injury or with a specific, identifiable cause] typically responds poorly to…opioid painkillers.” – Medical Board of California, 2014.

-”Prescription opioids can help with pain, but they will not take away all of your pain and they might not improve your functioning or quality of life.” -Intermountain Healthcare Group (Utah), 2015.

-”Long term benefits for Chronic Opioid Therapy have not been established.” -Physicians for Responsible Opioid Prescribing, 2015.

-”Long term daily opioid use of 90 days or more is no longer considered good clinical practice for non-cancer pain.” -Los Angeles County Prescription Drug Abuse Medical Task Force, 2015.

-”Uncertain Long Term Efficacy; Clear Evidence of Harm.” -Washington State Agency Medical Directors’ Group, 2015.

 

While new studies and new statements might not mean a doctor’s pain management practice has to shift 180 degrees or close to it immediately, it does mean that the landscape is shifting, and doctors have to shift with it. Put another way, if the science is changing, you have to change along with it, otherwise you’ll be doing the same old thing when the science says you maybe shouldn’t be.  Sooner or later, law enforcement agencies like the DEA and your state’s medical board will figure things out, and will accuse you of clinging to the old medical way when you should have been embracing the new.  If you as a prescriber have done nothing, or done too little, to show you know what’s going on and have responded appropriately in your decisions about prescribing — whether to prescribe, not just how much or for how long — you’ll be in trouble.

From this perspective, the changing assumptions about the safety and effectiveness of opioids for chronic pain are a doctor’s ally, not adversary.  Keep up on the new data, get help learning the law, get good advice on whether you are complying with the criminal laws of controlled substance prescribing, and together with your scientific knowledge and the right legal advice, you’ll be doing all you can to practice the medicine you want to be able to practice, and taking the best care of your patients and yourself.

 

 

 

 

 

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PAINKILLER LAW BLOG: CHANGES ARE IN STORE FOR OPIOID PRESCRIBING

THE COMING MEDICAL, LEGAL AND REGULATORY CHANGES IN OPIOID PRESCRIBING FOR CHRONIC PAIN

 

Hello! The Painkiller Law Blog went on hiatus for part of summer, and there really is nothing like a change of scenery to recharge the batteries and get perspective on things. So with Labor Day now behind us I’m back, and want to share with you what the summer break illuminated for me about the prescription opioid crisis and what it means for my healthcare provider-clients and their patients. In a nutshell, a steadily accumulating amount of new scientific and research data is debunking old assumptions about the safety and effectiveness of opioids for chronic pain. A rethink and reboot will soon be required for doctors to practice safe and legitimate medicine and to comply with the criminal laws of controlled substance prescribing.

 

Here are the things I’ll be talking about, starting today and in the coming weeks:

 

  • We are in a major public health, public policy and law enforcement crisis. Medication designed to help patients is not supposed to be killing them in large numbers and creating what the Centers for Disease Control calls a national epidemic of unintended addiction, accidental overdose, and death.

 

  • The assumptions that underlie today’s prescribing – that opioids are generally effective and non-addictive for chronic pain patients – are seriously in question, and some would say the assumptions have already been proven wrong. Some of course would say that the skyrocketing addiction, overdose and death rates are all the proof required.
  • Medical Boards have to create guidelines that reflect current science. Only based on current science can doctors truly know when to prescribe, when not to, and when to stop.

 

  • Lawyers advising and representing opioid prescribers have to identify where the medicine is going, and the implications of that, to know how to advise clients today and prepare for changes tomorrow.

 

In the coming weeks I will talk about each of these topics in detail. In the meantime, here are some current manifestations of the prescription drug crisis:

 

  • Manufacturers of Narcan and other opioid-antidote (overdose reversal) drugs are making money hand over fist. Nothing wrong with making money, but the need for opioid overdose reversal drugs only arose from a nightmarish rise in accidental overdose from opioid prescriptions.
  • Opioid addiction rehab programs are a growth area for substance abuse treatment centers nationwide. Again, there’s everything commendable in meeting this need, but it’s a tragic commentary.
  • Communities around the country hold candlelight vigils for their numerous dead, victims of accidental prescription drug overdose, while organizations host International Overdose Awareness Day events around the world.
  • Local and state governments plead for more federal money to address what governors, legislators, doctors and police call a “medical emergency” of addiction, overdose and death from prescription drugs.
  • Heroin use across the country is by some estimates worse and more widespread than ever before, as everyone from soccer moms to senior citizens loses access to prescription opioids and turns to the street for pain relief and to avoid going into withdrawal. The active ingredient in heroin and prescription opioids is, after all, essentially the same.
  • Mexican drug cartels have long since spotted the new heroin trafficking opportunity and are making a killing, on killing Americans.
  • The State of Maine plans to do undertake two major efforts this Fall season: Preparing for the annual tourism bonanza as people come to see the leaves turn; and activating the National Guard to fight the dramatic rise in heroin trafficking within the state.

 

Is this what the pharmaceutical industry expected when it said new evidence proved opioids safe and effective for chronic pain?

 

Is this what the FDA expected when it approved the studies and allowed drugs like Oxycontin to be mass marketed and mass prescribed?

 

Is this what the Federation of State Medical Boards expected when it wrote guidelines for prescribing opioids to chronic pain patients?

 

Is this what your neighborhood internist or family practitioner expected when patients starting asking requesting opioid therapy for chronic pain?

 

Is this what patients or their spouses, siblings, parents, kids expected when someone in the family was prescribed an opioid for a sports injury, bad back, arthritis or other condition?

 

The answer to all of those questions is probably “no.” But that’s the situation we have. The time will soon be upon us for a rethink and reboot, medically, legally and regulatorily. Stay tuned for more posts on these topics.

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PAINKILLER LAW BLOG POST: Safe Prescribing = Indictment-Free Living

Two important news stories came out this past week: One a survey by Johns Hopkins/Bloomberg showing that many doctors don’t understand how opioid prescriptions really work, and one a report by Massachusetts’ governor saying that one way to help stem the prescription drug epidemic is to educate doctors in safe prescribing. Taken together, these two items are cause for optimism and encouragement in improving patient safety and helping doctors not get criminally prosecuted for aspects of their medical practice.

First, the Hopkins/Bloomberg study’s key findings are of concern for anyone who assumes that his or her doctor always knows what’s really going on with pharmaceuticals and the patient’s care. Doctors surveyed didn’t know, for example, that abuse-deterrent pills are just as addictive as non-abuse-deterrent formulations. Doctors surveyed also believed that “abuse” by patients is usually from injecting or snorting an opioid, not from swallowing a pill.

Both of these findings are telling, in my view, because both reflect that even doctors don’t uniformly know prescription opioids’ powerfully addictive properties. Abuse-deterrent formulations are supposed to prevent a patient from, for example, crushing an Oxy-80 tablet to get a powerful immediate dose of a drug that’s normally time-released into the body. What the doctors surveyed don’t get is that the drug itself, not the manner of ingestion, is what can addict people. (Thanks again to the pharmaceutical industry for not telling doctors that part before marketing the drugs as safe and generally non-addictive.)

Additionally, doctors surveyed seem to assume that “abuse” of opioids by patients is done most commonly via snorting or injecting the drug, when in fact most patients who end up becoming addicted or otherwise misusing prescribed drugs ingest the drugs the “legal” way – by swallowing them. That doctors seem to behaviors like snorting or injecting with “abuse” reflects doctors’ naivete about how easy it is for a patient to become dependent or worse on legally approved, lawfully prescribed medication. It also shows a lack of understanding of how even legitimate medical practice can pose risk of harm to a patient when it comes to prescription painkillers.

But the report from Massachusetts governor Charlie Baker is a thorough set of recommendations on how to stem the tide of addiction, overdose and death. Massachusetts in particular has been ravaged by opioid and heroin problems in recent years. Among Baker’s key recommendations is that doctors need to be educated – not indicted, not recklessly targeted or reflexively blamed – but educated in safe opioid prescribing. I have no doubt that any physician practicing in good faith would eagerly embrace and warmly welcome the chance to learn more about how to safely and properly conduct themselves in an important area of medicine. Good for the governor for endorsing physician education, and let’s hope Massachusetts follows through and implements this recommendation vigorously and efffectively.

It’s too early to say that the tide is turning when it comes to blaming doctors for the prescription drug crisis, but this week’s news is very positive in terms of good ideas emerging on how to collaboratively, holistically and smartly tackle a major public health problem.

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PAINKILLER LAW BLOG POST: Your Friendly Neighborhood DEA Snitch

A recent story out of the Southeast caught my eye. A local pain management doctor has been cut off by local pharmacies, or more precisely, the patients of that doctor have been cut off because local pharmacies are refusing to fill pain scrips written by that doctor. In these instances, which I’ve seen some of my own doctor-clients’ experience, the pharmacies’ actions range from altruistic and concerned, to cowardly and hasty disassociation from a provider who may or may not have done anything wrong.

The doctor who was the subject of the news story does, admittedly, write many, many pain prescriptions, and perhaps he does deserve a close second look by pharmacists. Pharmacists, after all, have a very important job, not only to fill a prescription correctly and consider drug interactions, appropriate dosage, and medical necessity, but they also have a responsibility under federal law to double-check the legitimacy of the prescription to begin with. This is especially true when it comes to pain prescriptions, and so says the DEA. Loudly, in fact. So loudly does the DEA make this pronouncement to pharmacists, that many times I have seen pharmacists inform on doctors just to get the DEA off the pharmacy’s back.

While a pharmacist can always say, perhaps legitimately, that he or she was righteously concerned about the sheer volume of pain scrips coming out of a certain doctor’s office, that same pharmacist might be getting visits from DEA agents. The pharmacist knows from the get-go that “naming names” is often a good way to get the DEA to redirect its focus. So pharmacists name names. And then other pharmacists in the area get word, and cut off the same doctor or the doctor’s patients. A type of local hysteria takes over, and pretty soon, there are a lot of pain patients finding pharmacy counters off limits to them.

What happens to these patients? An excerpt from the recent news story gives you an idea:

“I didn’t have a real good feeling about cutting people off cold turkey, but in some cases it was warranted,” a local pharmacist said.

The pharmacist interviewed is admitting that an abrupt cut-off of one’s prescription drug dosage can force people to go “cold turkey,” without tapering off of powerful medication on which the patient may have become physically dependent or developed a tolerance. What does it mean when there’s no tapering off? It means a patient risks going into withdrawal, which can be very dangerous and which subjects innocent people to great physical and psychological agony.

According to prescribing and pharmacy practice guidelines, doctors and pharmacists SHOULD NOT subject patients to abrupt, 100% cut-off from opioid dosage, even if a patient is exhibiting signs of misuse. Medication is to be titrated down, patients provided with enough medication for a reasonable time to allow them to find another provider, or be referred to substance abuse treatment programs if necessary, and patients are NOT to be placed at unnecessary risk of going into withdrawal.

And when the DEA is breathing down your neck, Mr. Pharmacist? It’s OK to kick patients to the curb then? No, it’s not. The pharmacist interviewed in the story is actually violating prescribing guidelines and probably running afoul of rules of professional conduct. He is certainly not placing patient safety ahead of his own survival. And without doubt, he is not alone in his self-serving behavior. Unfortunately, as is often the case, people who otherwise act with dignity and compassion in their professional lives fail to show courage in the face of government intimidation. It’s easier to name names.

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PAINKILLER LAW BLOG POST: MED-LEGAL RX COMPLIANCE VIDEOS

I am pleased to share these videos which have been produced by the Cooperative of American Physicians, an outstanding medical malpractice company based in Los Angeles. I am proud to be close with CAP and its fine and extremely capable professionals. Together we created this video series for physicians and healthcare risk managers, about prescription painkillers and how to comply with the law, be ready for an official inquiry, and practice good medicine and patient safety in a dangerous enforcement environment.

I hope you watch and enjoy the videos!

http://www.capphysicians.com/risk-management/compliance-resources/pain-medication-compliance

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PAINKILLER LAW BLOG POST: BEST FRIEND, OR FURRY CRIMINAL?

One of my dogs will have surgery this week to repair a torn ACL in his hind leg. It appears a recent hike or trip to the beach did not cause the injury, but rather, as the vet said, it is just a matter of wear and tear. So I can safely blame God for a flaw in canine orthopedics (I saw the x-rays; the bones in a dog’s knee don’t fit together the way they really should). The dog will require two months’ rest to recover fully, and for the first days following surgery, he will be given an opioid painkiller. Today’s post is about the protocol the vet is following to make sure my dog is not a drug dealer.

You see, the dog will not just be given any opioid painkiller. He will be on doggie-specific Fentanyl. I had to sign a release and authorization at the vet’s the other day to permit the dog to get the powerful medicine after the procedure. The liquid opioid will be applied (first by the vet, then by us) to the fur and skin at the top of the neck, the same way you might apply monthly flea or tick repellent to a pet. Two things came up at the vet’s when I was having this explained to me.

First, when doggie Fentanyl was being tested for safety and effectiveness prior to its being approved and marketed, scientists tested the prototypes on humans. Human subjects were brought into the lab, the medicine was applied to a dog’s neck, and the humans would immediately and vigorously rub their fingers on the wet fur and then lick their fingers in an attempt to ingest the drug. That really happened! The manufacturer wanted to make sure the drug’s euphoria-creating properties did not transfer to the human subjects. Apparently, all was well, as the drug was approved.

Second, since some human Fentanyl users continue to seek the drug through nefarious means, for purposes of use or sale, my dog’s vet had to run my name on CURES, California’s prescription drug monitoring database, to make sure I was not doctor shopping through my pet. The vet had to make sure I was not pretending to need Fentanyl for my dog, while in reality seeking it for my own use or for narcotics sales.

I passed the CURES test. The medicine is ready for purchase and administration. Further, I remain confident that my dog is not peddling Fentanyl. I like to think I’d have sensed something by now. Just because he always keeps his pager nearby and regularly does online research on how to beat a wiretap doesn’t mean I should take a jaundiced view of my loyal hound.

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PAINKILLER LAW BLOG POST: Rolling Target Spotted At Local Bank

Recently I parked my car in a bank parking lot and walked up to the ATM. After paying an extra $3.00 for my own money, I was returning to my car when I noticed a rolling target was parked a few spaces over. A rolling target? Yes. A Maserati with the license plate, “4DRFLGD.” That is, “For Dr. Feelgood.”

In fairness, the car’s owner may be a psychologist, or a chiropractor, or an acupuncturist. Or, given the neighborhood of LA I was in at the time, the car’s owner may practice some sort of Eastern medicine which not even Eastern medicine has heard of and his clients may optimistically address him as “doctor.” Or, worst case scenario, he is a pain specialist. Worst case scenario because in today’s aggressive enforcement environment against physicians who prescribe opioid painkillers, this guy may as well mount a megaphone to his car’s hood and park in front of the local DEA headquarters chanting, “Come get me. Come get me.”

A few years ago the LA Times’ groundbreaking series of reports called “Dying for Relief” highlighted the opioid painkiller epidemic, and the reporters even found an Orange County physician whose luxury sedan bore the license plate, “PAINDOC.” Bad idea.

You see, DEA agents and sheriff’s narcotics detectives – who, between the two agencies, are doing the criminal investigations into possible overprescribers – have a sense of the dramatic when it comes to looking for evidence of guilt in these cases. If they come upon an item during a search warrant at a doctor’s office, for example, they will not only understand its probative value in court, but they’ll have an appreciation for the “visual” a particular item might offer if introduced at trial and viewed by a jury. This is why a few years ago, detectives raiding a pain doctor’s office made sure to photograph a book that was sitting on a bookshelf near the doctor’s desk. The book was a medical guide to safe opioid prescribing. The book’s mere presence, though, was not of interest to detectives. What got their attention was that the book was still wrapped in plastic, unopened since its arrival a year or so before.

Think of the power of that photograph before a jury. While a defense attorney would love to argue that the presence of that book on the shelf shows a doctor who is conscientious, current on the science, and dedicated to patient safety, the plastic wrap on an unopened, unread book suggests something very different. One photograph doesn’t prove guilt, of course, but think about this situation, then consider the adage that a picture is worth a thousand words.

Then think about the license plate on the Maserati. What narcotics investigator wouldn’t notice that plate if they saw it on the street, or in a parking lot, or in a parking structure? What police lieutenant or supervising detective, or DEA Agent in Charge, wouldn’t encourage an agent to make some preliminary inquiries into what that car’s owner does for a living, just in case? At a time when law enforcement doesn’t think it needs much to open an official inquiry, even the most upright, upstanding, properly-prescribing physician is running a big risk by appearing to act flippantly about a public health crisis. If I were this car owner’s lawyer, I’d tell him or her to lose the plate, forthwith. If they want to assert their rights, they can buy my very favorite welcome mat for their home: “Come Back With a Warrant.” But having a plate like “4DRFLGD” is making yourself into probable cause on wheels. Not a good thing to be.

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PAINKILLER LAW BLOG POST: The (Non-Narcotic) Rx for The Sore-Thumb Client

The lesson from a recent case in Connecticut is, “Don’t stick out like a sore thumb, but if you do, then hope it’s either for something you can be proud of or at least can successfully defend.” An ongoing investigation is underway in Connecticut into a pain clinic and its nurse practitioner. The NP during the last few years has written more prescriptions for opioid painkillers than any other healthcare provider in the state. Not an auspicious title against the backdrop of the US’ epidemic of prescription painkiller addiction, overdose and death. In Connecticut, there are some Final Fours you want to make, but not when it comes to “highest painkiller prescribing rate.” The Connecticut case is instructive on how providers might attract unwanted attention, and what to do about it if that happens.

First, this NP really did stick out like a sore thumb. She was by a good distance the leading opioid prescriber in the entire state. She worked alongside an MD at a privately run pain management clinic, and she wrote far more painkiller prescriptions than even the state’s leading pain specialists. She had been cited previously by regulators and had paid a fine, but no restrictions were subsequently placed on her license. Apparently the prescribing rates did not drop after that slight brush with the law, and authorities continued to investigate her. She probably also didn’t do a lot to show “good faith” with the investigators and possibly prosecutors who were looking into her practice — may not have revamped her patient care and chart documentation regimen, may not have sought advice on how to comply and show that she was complying with all applicable laws. Very recently, she surrendered her license, presumably under legal pressure.

High prescribing rates will make one stick out these days. In Connecticut as elsewhere around the country, investigators don’t comb prescription monitoring databases to see who is writing the most scrips. But when a provider comes to investigators’ attention, the database for that state is one of the first things they check. If someone’s prescribing rates truly stand out, it’s a red flag which will set investigators on the hunt for a perceived lawbreaker. Of course, someone will always be the one who writes the most opioid prescriptions, someone will always write the least, and everyone else will be somewhere in the middle. The person writing the most opioid prescriptions could be operating in a completely lawful and medically appropriate manner. So what if you or a provider you represent or service, perhaps as an insurer or risk manager, occupy/occupies the “#1 spot”?

This is where the provider must be protected, both from law enforcement, and from themselves. The – forgive me – “prescription” for helping them is the same whether the danger is from law enforcement or just a provider’s stress over taking the extra time to do things right: Careful diagnosis, diligent follow up, conscientious patient monitoring, dosage watch, seeing whether the medication actually helps, compliance by provider and patient with a treatment plan, regular checks by the provider to make sure the patient is not doctor-shopping, and full charting and documentation of all aspects of the patient’s care. That’s just the basic formula, without all the particulars and specifics investigators will be looking for in a given case. But without the basics in place, a provider can count on a rough and dangerous ride if investigators ever pick up the scent.

It is impossible to stop an investigator from investigating. If they want to look, they’re going to look, because that’s their job. Before an investigation ever starts, and once one has, it is critical that the provider have taken the above steps in good patient care and detailed chart maintenance. If the care is proper and the documentation is sufficient, the chart will show it. If there are minor tweaks to make in a provider’s practice or documentation, investigators can require that and the provider can adjust, without the investigators thinking they’re dealing with a criminal. But if there is a sore-thumb level of opioid prescribing, without the medical basis and detailed records to fully support it for every single patient, it’s a starkly different story. Just ask the nurse practitioner in Connecticut. At the moment, her two biggest questions are more than likely, “What am I going to do for a living now?” and, “Do you know any good criminal lawyers?”

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