Ted O’Connell, MD
I serve as an Expert Witness and Medical Consultant for the Medical Board of California. There are many reasons why a physician may be reviewed by the Medical Board, and issues related to controlled substances are a common occurrence. Sometimes there is criminal intent involved, but more commonly the issues are related to inadequate documentation, excessive prescribing, potentially dangerous combinations of prescriptions, failure to appropriately monitor ongoing prescribing of controlled substances, inadequate knowledge on the topic, or even lack of familiarity with state laws and society guidelines.
The opioid epidemic in the United States has been well-chronicled by the media and is receiving heightened attention from health care professionals and organizations. This blog post is intended to provide resources to help physicians and physicians-in-training learn how to appropriately evaluate pain and how to prescribe and monitor opioids for noncancer pain when such a prescription is indicated. The links at the bottom of the post are excellent resources to help physicians manage patients using opioids or potentially needing opioids. Included in these resources are multimodal approaches to pain control and warning signs for abuse and diversion. Also included are elements of an appropriate evaluation, documentation guidelines, and ongoing monitoring which includes 4A Assessment, urine drug screening, Adult Outcome Questionnaire (AOQ), Screener and Opioid Assessment for Patients with Pain (SOAPP-5), Opioid Medication Agreement Letters, and prescription drug monitoring programs.
Opioid pain medication use presents serious risks, including overdose and opioid use disorder. In the past decade, the death rate associated with opioid pain medication has increased markedly while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. More than 50 people die of opioid overdoses each day in the U.S., a rate that surpasses overdose deaths from illicit drugs and motor vehicle accidents. Sales of opioid pain medication have increased in parallel with opioid-related overdose deaths. The Drug Abuse Warning Network estimated that >420,000 emergency department visits were related to the misuse or abuse of narcotic pain relievers in 2011, the most recent year for which data are available
Rates of opioid prescribing vary greatly across states in ways that cannot be explained by the underlying health status of the population, highlighting the lack of consensus among clinicians on how to use opioid pain medication. Prevention, assessment, and treatment of chronic pain are challenges for health providers and systems. Pain might go unrecognized, and patients, particularly members of racial and ethnic minority groups, women, the elderly, persons with cognitive impairment, and those with cancer and at the end of life, can be at risk for inadequate pain treatment. Given all these factors, physicians should be well-trained in evaluating pain and know how to appropriately prescribe and monitor opioid therapy when it is indicated. The resources below provide useful information and guidelines for evaluating pain, appropriately prescribing opioids, and monitoring patients who are on opioid therapy.
Useful Resources and Further Reading:
CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016
How to Monitor Opioid Use for Your Patients with Chronic Pain
Physician Guide to Appropriate Opioid Prescribing for Noncancer Pain