How to Avoid Opioid-related Prescription Risks: 12 Tips
Your medical license is likely your most valuable – and expensive – investment. Don’t lose it by taking needless risks that could result in the diversion of prescription drugs to illegitimate use.
Understand the laws designed to prevent diversion, know how the government investigates and prosecutes it, and apply practical steps you can take right now to stay on the right side of the DEA, the U.S. Attorney’s Office and the your state’s Attorney General’s enforcement unit, and the licensing board. Your medical license and prescription privileges depend on it.
Opioid Drug Diversion
Drug diversion redirects legitimate prescription medication, usually scheduled narcotics, to illegitimate purposes. Federal DEA agents work alongside state Attorney General investigators to “make” criminal and administrative cases based on diversion against providers: M.D.’s, O.D.’s, P.A.’s, nurses and nurse practitioners, dentists, pharmacists, and even veterinarians and academic researchers. Prosecutions have far reaching consequences, especially for licensing, insurance and patient eligibility, for years to follow.
Your Practice Could Be on the Line
Even those who escape prosecution and retain their licenses may still face the loss of DEA-controlled substance prescribing authorization, resulting in suspension or revocation of hospital privileges, required reporting to the National Practitioner Data Bank, exclusion from participation in Medicare and Medicaid, loss of credentialing by patient insurers, and even possible inability to obtain or retain malpractice coverage.
Prosecutors and state board enforcement attorneys primarily rely on providers’ patient records in carrying out their investigation in the first instance:
- Have records documenting diagnosis, treatment and overall care been kept?
- Does the patient chart demonstrate that the practitioner conducted a verifiable, in-depth (or at least not cursory) patient examination?
- Does a physician’s appointment list reflect that some unreasonably large number of patients were seen in a single day, making it virtually impossible for the practitioner to exam each of them properly?
Beware Prescription Monitoring
In tandem with increased governmental enforcement efforts, private medical practices, hospitals, and even provider institutions are establishing prescription monitoring programs designed to collect, analyze and report information on controlled substance prescribing by practitioners to an easily–accessed central data bank. Many states have mandated participation in state-wide Prescription Drug Monitoring Programs, their records can serve as damning evidence. Be careful. Keep your license.
12 Tips for Trouble-Free Drug Prescription Practices
Here are 12 key tips based on actual cases where federal and state criminal and regulatory enforcement agents brought charges against licensed practitioners. All of these cases were avoidable, provided the doctors had used good judgment and applied proactive compliance protocols.
These tips should strike every medical practitioner as self-evident, but every one of them is based on some enforcement action where a medical professional faced the prospect of state board discipline, loss of DEA registration, or worse.
1) Document Your Prescriptions
Always write your scripts with the patient in front of you. Do not pre-sign any script in blank, and keep your prescription pads secure and inaccessible to patients. Don’t ever sign scripts for your staff to fill in the name of a patient when you aren’t present.
2) Avoid manually dispensing controlled substances
Other than where an automated dispensing station (i.e., a “pharmacy robot,”) is used, avoid manually dispensing narcotics if at all possible. You can’t be arrested for diverting something you don’t have. Stores of scheduled narcotics are simply too attractive as targets for patients and staff to take and abuse or resell on the street.
If you must dispense, maintain physical security of narcotics, and maintain your medication log. Always record the name of the patient/recipient, the date, the quantity and the dosage of dispensed narcotics, as well as the diagnosis that made the prescription necessary. There have been cases filed involving blank “med” logs, falsified ones, and even logs where the doctor knowingly recorded the truthful, accurate date, amount, strength and name(s) of the person(s) with whom the prescription narcotic was knowingly (and wrongfully) shared, i.e., diverted (e.g., wives, mistresses, etc.)
3) Don’t dispense or prescribe controlled substances for yourself, immediate family, friends, or neighbors
Other than in a true medical emergency that occurs in an isolated setting where there is no other qualified physician available, practitioners should not prescribe or dispense controlled substances or scheduled narcotics for themselves or their family members. And if they must, perform a real examination and document it in writing, with a diagnosis requiring prescription medication. Note the amount, strength, frequency and date of the script, and keep the record of the exam and treatment.
4) Don’t prescribe pharmaceuticals outside of an established medical relationship
New state-wide PDMP programs require prescription entry into a database before the end of the next business day – there is no “Friends & Family” exception.
5) Avoid “courtesy” writing of prescriptions
For the renewal of non-conflicting medication prescriptions written by another treating physician, which the patient requests as a “courtesy,” the practitioner should never prescribe without independently assessing the condition or illness for which the drug is being prescribed, or obtaining the medical records from the original prescribing physician documenting the condition. Beware of simply relying on a patients “naked” request, not supported by an examination and a diagnosis.
6) Don’t write a prescription without examining a new patient first—and being in the same room with them
Medical protocols are changing, and “telemedicine” envisions doctors completing examinations and treatment of new patients even when the physician is halfway across town or halfway across the globe. But we are not there yet.
Do not provide scripts for controlled substances for the husband or child of a patient you never met, the mistress of your medical practice partner, or anyone else who could have easily come in person for an office examination but didn’t. It may be one thing to “call in” a script to the pharmacy for an existing patient who calls for a refill, or who e-mails about a reaction to a prescribed medication and wants a substitute – but it’s entirely another for someone just passing through town and who never “presents” to your practice for a proper examination and diagnosis.
7) Be aware of “frequent flyer” pharmaceutical consumers, especially those of scheduled substances and narcotics
If a patient presents with the need for an amount of drugs that, under the circumstances, is “consistent with a readily-diagnosable condition,” consider if she should be referred to a pain management clinic or other specialist. Otherwise, protect yourself by documenting in the patient’s file why the treatment would be recognized as proper by “a responsible segment of the medical profession,” as regulations most states and the federal government require.
8) When it comes to dangerous drugs, especially narcotics, practice medicine defensively
While a physician should not automatically distrust a patient, experience teaches that they don’t always tell the truth. Not everyone you see in your medical practice always acts in good faith. The life you save could be theirs, but the career you save is your own.
9) If a request for narcotics, from anyone — including from another physician — sounds suspect, it probably is.
When you get a request for a narcotics prescription — even if from a trusted colleague, friend, or family member — and it sounds suspicions, it probably is. Fellow practitioners, medical professionals, and loved ones are not immune from addiction and misuse. A large minority of enforcement proceedings against practitioners involve diversion to colleagues, friends and family whom the doctors know and trust.
10) Avoid the “Holy Trinity” at all costs.
Everyone has a pet peeve and all diversion enforcement agents share the same one: practitioners who prescribe Oxycodone or Hydrocodone, along with Soma and Xanax (or other drugs from their classes) together. If you have justifiable medical reasons to prescribe a drug from each of these three categories of controlled substances simultaneously, be certain to document your reasons each and every time you write the prescriptions.
Be certain you have entered the drug orders into the state Prescription Drug Monitoring Program as required. If scripts aren’t medically necessary, don’t write them, regardless of patient pressure.
11) Be attuned to “Red Flag” prescribing situations.
There are other “hot buttons” for the prescription police to watch out for: doctors who write scripts for the same or similar opioids in the same quantities for large numbers of patients, often on the same day or in the same week, patients who routinely travel long distances just to see you, especially when other, closer clinics closer to them could be consulted, patients arriving in the waiting room as a group, but who act as if they don’t know each other, and prescriptions written for the same quantities of controlled substances for family members or other patients who all share the same last name(s) on the same day of treatment.
12) Addiction Treatment Requires Special Considerations
Even though Buprenorphine may well be at least one of the “wonder drugs” that helps end the opioid crisis, law enforcement is still coming down hard on practitioners who prescribe it in ways that support usage outside of legitimate medical treatment. If you practice office-based (i.e., non-methadone) addiction therapy, be certain to confirm that a patient seeking Suboxone or Subutex in fact has an addiction, instead of a resale business, and determine if the patient is seeking other necessary treatment (such as therapy) to manage their addiction, before you prescribe.
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