Recent studies have shown steep increases in abuse of powerful opioids like Vicodin, Hydrocodone and OxyContin, says Robert Saenz, CEO of Tulsa (Okla.) Pain Consultants and president of VIP Medical Consulting, which helps practices with compliance and business development. Authorities have also been cracking down on physicians who have facilitated misuse, if only due to lax oversight, says Mr. Saenz, a former federal agent with the Department of Justice.
"We need to educate the physicians," he says. Physicians who are not properly monitoring patients may be referred to the state licensing board or to federal authorities who oversee their license to prescribe. Here Mr. Saenz details six steps pain physicians can take to curtail misuse of opioids.
1. Do a comprehensive evaluation. "Make sure there is a pain pathology," Mr. Saenz says. In some cases, this may require ordering an MRI that could pinpoint a cause for the pain such as a disc herniation. Review past medical records to understand the patient's history with these medications. "This is basically common sense due diligence," Mr. Saenz says. "If something goes wrong, authorities will ask, what steps did you take to understand the patient's history?"
2. Consider other treatments. There are other drugs or treatments for pain that reduce a patient's risk of dependency, such as steroid injections, spinal cord implants for chronic pain and even acupuncture or yoga. Physicians should counsel patients on their options. "Pain is subjective," Mr. Saenz says. "There is no one pill that fits all."
3. Conduct background checks. Before prescribing an opioid to a patient for the first time, make sure the patient does not have a history of unlawful distribution. About two-thirds of states, including Oklahoma, maintain secure websites where physicians' offices can make background checks. Once the practice has registered, the check takes about one minute. Mr. Saenz says there have been complaints that some state websites are not up-to-date, but he says consulting them is preferable to not doing anything.
4. Be firm but diplomatic with patients. Some patients put physicians under a great deal of pressure to prescribe pain medications, perhaps accusing them of not caring about the pain they are under. "The physician has to walk a tightrope," Mr. Saenz says. Background checks and other monitoring can put them in adversarial relationship with patients. "You have to balance compliance with privacy and confidentiality," he says.
5. Patient signs an agreement. Patients who are prescribed opioids should sign an agreement spelling out their responsibilities in securing the drugs, not giving them away to others and not taking more than the prescribed dose. Mr. Saenz says 60 percent of illegally used opioids were obtained from friends or family. The agreement should be signed in a face-to-face meeting with the physician. Agreements can vary, but generally they should state that overuse of an opioid could lead to serious health problems, including death. The patient agrees not to give the pills away or sell them and to be monitored in periodic follow-up visits. Finally, it states the prescription would be discontinued if the patient were found to be violating the terms.
6. Ongoing monitoring of patients. At the discretion of the physician, patients should come back for periodic follow-up visits to make sure no violations are taking place. In a face-to-face session, the physician can see aberrant behavior indicating overuse. "You wouldn't be able to know this if you only made a phone call," Mr. Saenz says. Patients might also be asked bring in their pills to be counted and to submit to a urinalysis. If there were no drugs in the patient's urine, it would raise suspicions that he is giving his pills to someone else. "These guidelines vary," Mr. Saenz says. "Some physicians are very strict and some want to follow a more open approach." Monitoring also can be costly for a practice, because the insurer may not pay for all services that are performed.
Learn more about VIP Medical Consulting.
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