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PRESCRIBING CONTROLLED SUBSTANCES: MANAGING THE RISKS
Charles D. Cash, JD, LLM Assistant Vice President, Risk Management Professional Risk Management Services, Inc. (PRMS)
Mr. Cash has no relevant financial relationships with commercial interests.
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OBJECTIVES • Describe the prescription drug abuse problem and plans to address it relevant to clinical practice • Explain the risks associated with prescribing controlled substances • Implement three strategies for minimizing risk associated with prescribing controlled substances
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WHAT WE WILL COVER Medical malpractice basics Prescribing controlled substances – issues and responses Risks of prescribing controlled substances Risk management strategies
• • • •
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WHAT WE WILL COVER Medical malpractice basics Prescribing controlled substances – issues and responses Risks of prescribing controlled substances Risk management strategies
• • • •
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ELEMENTS OF A LAWSUIT 1) Duty of Care The physician owed a duty of care to the patient (to meet the standard of care)
2) Breach of Duty The physician was negligent (the care provided fell below the standard of care)
3) Damages The patient suffered an adverse outcome (injury)
4) Causation
The patient’s damages were a direct result of the physician's negligence
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DETERMINING THE APPLICABLE STANDARD OF CARE Many items may be admissible, along with expert testimony, to determine the issue of standard of care. The following items could be relied upon as evidence of the appropriate standard of care: • • • •
Statutes – federal and state Regulations – federal and state Case law – federal and state Other materials from federal and state regulatory agencies – state medical boards, DEA, FDA, etc. ›
Rules / Guidelines / Policy Statements
• Authoritative clinical guidelines
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DETERMINING THE APPLICABLE STANDARD OF CARE • • • • • • • •
Policies and guidelines from professional organizations Learned treatises Journal articles Research reports Accreditation standards Facility’s own policies and procedures Drug label / manufacturer recommendations Other items
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CONTROLLED SUBSTANCE ACT: 21 USC 801‐890 DEA is responsible for ensuring that all controlled substance transactions take place within the closed system of distribution established by Congress.
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DEA REGULATIONS Ex: 21 CFR 1306.04(A): “A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose…by an individual practitioner…acting in the usual course of his professional practice”
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www.deadiversion.usdoj.gov/pubs/manuals/pract/pract_manual012508.pdf
http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf
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ALABAMA MEDICAL BOARD POLICY FOR THE USE OF OPIATES FOR THE TREATMENT OF PAIN
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U.S. V. ROSEN, 582 F2D 1032 (1978) “We are, however, able to glean from reported cases certain recurring concomitance of condemned behavior, examples of which include the following: 1) An inordinately large quantity of controlled substances was prescribed. 2) Large numbers of prescriptions were issued. 3) No physical examination was given. 4) The physician warned the patient to fill prescriptions at different drug stores. 5) The physician issued prescriptions to a patient known to be delivering the drugs to others.
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U.S. V. ROSEN, 582 F2D 1032 (1978) (CONTINUED)
6) The physician prescribed controlled drugs at intervals inconsistent with legitimate medical treatment. 7) The physician involved used street slang rather than medical terminology for the drugs prescribed. 8) There was no logical relationship between the drugs prescribed and treatment of the condition allegedly existing. 9) The physician wrote more than one prescription on occasions in order to spread them out. 15
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FSMB: MODEL POLICY ON DATA 2000 AND TREATMENT OF OPIOID ADDICTION IN THE MEDICAL OFFICE SECTION II: GUIDELINES • • • • • • •
Physician Qualifications Patient Assessments Treatment Planning Educating the Patient Informed Consent Treatment Agreement Induction, Stabilization, and Follow‐up
• Adjusting the Treatment Plan • Preventing and Managing Relapse • Duration of Treatment • Medical Records
www.fsmb.org/pdf/2013_model_policy_treatment_opioid_addiction.pdf
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FSMB: MODEL POLICY FOR THE USE OF OPIOID ANALGESICS IN THE TREATMENT OF CHRONIC PAIN SECTION II: GUIDELINES • Understanding Pain • • Patient Evaluation and Risk • Stratification • • Development of a Treatment Plan and Goals • • Informed Consent and • Treatment Agreement • Initiating an Opioid Trial • Ongoing Monitoring and Adapting the Treatment Plan
Periodic Drug Testing Consultation and Referral Discontinuing Opioid Therapy Medical Records Compliance with Controlled Substance Laws and Regulations
www.fsmb.org/pdf/2013_model_policy_treatment_opioid_addiction.pdf
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FSMB: MODEL POLICY FOR THE USE OF OPIOID ANALGESICS IN THE TREATMENT OF CHRONIC PAIN UNIVERAL PRECAUTIONS – SUMMARIZED: 1) Make a diagnosis with an appropriate differential. 2) Conduct a patient assessment, including risk for substance use disorders. 3) Discuss the proposed treatment plan with the patient and obtain informed consent. 4) Have a written treatment agreement that sets forth the expectations and obligations of both the patient and the treating physician. 5) Initiate an appropriate trial of opioid therapy, with or without adjunctive medications.
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FSMB: MODEL POLICY FOR THE USE OF OPIOID ANALGESICS IN THE TREATMENT OF CHRONIC PAIN UNIVERSAL PRECAUTIONS – CONTINUED 6) Perform regular assessments of patient and function. 7) Reassess the patient’s pain score and level of function. 8) Regularly evaluate the patient in terms of the “5 A’s”: Analgesia, Activity, Adverse effects, Aberrant behaviors, and Affect. 9) Periodically review the pain diagnosis and any comorbid conditions, including substance use disorders, and adjust the treatment regimen accordingly. 10) Keep careful and complete records of the initial evaluation and each follow‐up visit.
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COMMON ALLEGATIONS Failure to: • • • • • •
Perform adequate history and physical Properly prescribe Properly diagnose Obtain consultation or make referral Adequately inform of side effects Obtain informed consent
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COMMON ALLEGATIONS Failure to: • Appropriately order and monitor lab testing • Recognize and appropriately respond to adverse drug reactions • Communicate with other providers • Adequately screen for contraindications
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ALLEGATIONS Failure to: • Access and review PMP data • “New kid on the block”
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WHAT WE WILL COVER • • • •
Medical malpractice basics Prescribing controlled substances – issues and responses Risks of prescribing controlled substances Risk management strategies
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THE ISSUE: MISUSE OF CONTROLLED SUBSTANCES Abuse Addiction Overdose Diversion
• • • •
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PRESCRIPTION DRUGS MOST COMMONLY ABUSED Pain Relievers Tranquilizers Stimulants Sedatives
• • • •
National Institute on Drug Abuse. www.drugabuse.gov/publications/topics‐in‐brief/prescription‐drug‐abuse.
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OVERDOSE DATA: 2000 ‐ 2014 •
Since 2000, the rate of deaths from drug overdose has increased 137%
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During 2014: ›
47,055 drug overdoses
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Rate of drug overdose deaths has increased significantly for: • Both sexes • 25‐44 year olds and >55 year olds • Northeastern, Midwestern, and Southern regions of US
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States with highest rates of OD deaths: • WV, NM, NH, KY, OH
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1.5 time more drug OD deaths in US than deaths from motor vehicle crashes
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Opioids are main drugs in ODs • Painkillers • Heroin www.cdc.gov/drugoverdose Accessed May 21, 2016
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THE RESPONSE: REGULATION • •
Federal State
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FEDERAL STATE COMITY • • •
DEA works closely with state licensing boards and state local law enforcement Majority of investigations of controlled substance laws are done by state authorities DEA will also conduct investigations of federal law
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FEDERAL ONDCP’S PRESCRIPTION DRUG ABUSE PREVENTION PLAN • • • •
Education Monitoring Proper medication disposal Enforcement
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FEDERAL FDA Can require REMS when potential risks of a drug outweigh the benefits Seeking prescribers’ help in curtailing opioid epidemic by:
• •
› › ›
Ensuring adequate training Knowing the content of the most current opioid drug labels Educating patients
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FEDERAL DOJ / DEA Primary agency charged with policing the issuance and dispensing of controlled substances ~ 5,000 Special Agents, ~ 600 Diversion Investigators $2.018 billion 2015 budget Per CSA: must be a legitimate medical purpose and must be acting in usual course of practice Penalties: imprisonment, fines, loss of DEA license
• • • • •
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FEDERAL DEA VISITS CSA authorizes DEA to enter controlled premises and conduct periodic inspections Buprenorphine prescribers:
• • ›
• ›
“Inspection” – investigators look at records for buprenorphine patients Need log of buprenorphine patients and prescriptions in location listed on DEA registration “Audit” – if also dispenses, will look at meds received and dispensed
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FEDERAL DEA PROBLEM AREAS: 1)
Failure to recognize doctor shoppers ›
Red Flags •
Symptom incompatible with reported injury
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Visit physician some distance from home
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History of problems with no medical records
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Multiple accidents
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Insist on drug of choice
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Loss of prescription or medication
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Fails to provide or go for testing
•
Takes more meds than directed
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Requests meds early
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Meds from multiple physicians
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Prescriptions filled at multiple pharmacies www.acponline.org/about_acp/chapters/az/rivera‐armando.pdf
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FEDERAL DEA PROBLEM AREAS: 2) Diversion ›
Methods • • • • • • •
Practitioners / Pharmacists Employee pilferage Pharmacy theft Patients / Drug Seekers Medicine Cabinet / obituaries Internet Pain Clinics www.mbc.ca.gov/board/meetings/materials_2013_02_21_prescribing‐2.pdf
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FEDERAL (CONTINUED)
›
Possible indicators • • • • • • • •
Inordinately large quantity of controlled substances was prescribed Large numbers of prescriptions were issued No physical exam Physician warned patient to fill prescriptions at different pharmacies Physician issued prescriptions to patient known to be delivering drugs to others Physician prescribed controlled substances at intervals inconsistent with legitimate medical treatment Physician used street slang rather than medical terminology for drugs prescribed No logical relationship between drugs prescribed and treatment of alleged condition www.acponline.org/about_acp/chapters/az/rivera‐armando.pdf
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FEDERAL DEA PROBLEM AREAS: 3) Excessive / Unauthorized Prescribing 4) Internet Prescribing
www.acponline.org/about_acp/chapters/az/rivera‐armando.pdf
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AL ADMINISTRATIVE CODE 540‐X‐4‐.08 (2) Requirements. The Board requires the following when a physician evaluates the use of controlled substances for pain control: (a) Evaluation of the Patient. A medical history and physical examination must be conducted and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. The medical record should also document the presence of one or more recognized medical indications for the use of a controlled substance. (b) Treatment Plan. The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved function, and should indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the physician should adjust drug therapy to the individual medical needs of the patient. Alternative non‐opioid treatment modalities or a rehabilitation program may be necessary and should be considered. (c) Informed Consent and Agreement for Treatment. The physician shall discuss the risks and benefits of the . . .
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FEDERAL DEA SUGGESTIONS Document: • Legitimate reason for prescribing • Analysis of prior records • Adequate history and physical examination • History of drug abuse • Supporting x‐rays, etc. • Continued re‐evaluation of pain relief and function • Treatment plan
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FEDERAL DEA SUGGESTIONS Document (Continued): • Patient’s compliance with meds and treatment • Amount of controlled substances prescribed • Amount used since last visit • Amount of dosages remaining • Amount of pain relief • Improvement in function • Evidence of abuse / diversion
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FEDERAL DEA SUGGESTIONS • • • • •
Pain management contract Pill counts Surprise drug testing PMP Adhere to clinical guidelines
www.acponline.org/about_acp/chapters/az/rivera‐armando.pdf
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FSMB – INAPPROPRIATE PAIN MANAGEMENT •
• • • • •
Inadequate attention to initial assessment to determine if opioids are clinically indicated and to determine risks associated with their use in a particular individual with pain Inadequate monitoring during use of abusable medications Inadequate attention to patient education and informed consent Unjustified dose escalation without adequate attention to risks or alternative treatments Excessive reliance on opioids, particularly high dose opioids for chronic pain management Not making use of available tools for risk mitigation www.fsmb.org/pdf/pain_policy_july2013.pdf
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WHAT WE WILL COVER • • • •
Medical malpractice basics Prescribing controlled substances – issues and responses Risks of prescribing controlled substances Risk management strategies
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RISKS OF PRESCRIBING CONTROLLED SUBSTANCES • To patients • To third parties • To prescribing physicians
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RISKS TO PATIENTS • Side effects › Including withdrawal
• Misuse › OD › Death
• Addiction • Diversion
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RISKS TO THIRD PARTIES • Diversion • Third party injury
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RISKS TO PRESCRIBING PSYCHIATRISTS • Civil litigation / medical malpractice › Underprescribing for pain › Overprescribing for pain › Diversion, abuse, overdose › Failure to recognize addiction › Other • Patient’s defense • Third party actions
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LIABILITY TO THIRD PARTIES Two lines of cases imposing liability: 1) Controlled substance (usually methadone) was ADMINISTERED despite risks that were known or should have been known 2) Controlled substance was PRESCRIBED without warning patient of known side effects that could impair driving
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RISKS TO PRESCRIBING PSYCHIATRISTS • Licensing board action • DEA action • Criminal action
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WHAT WE WILL COVER • • • •
Medical malpractice basics Prescribing controlled substances – issues and responses Risks of prescribing controlled substances Risk management strategies
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AL ADMINISTRATIVE CODE 540‐X‐4‐.08 (2) Requirements. The Board requires the following when a physician evaluates the use of controlled substances for pain control: (a) Evaluation of the Patient. (b) Treatment Plan. (c) Informed Consent and Agreement for Treatment. (d) Periodic Review. (e) Consultation. (f) Medical Records.
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Copyright © 2012 Professional Risk Management Services, Inc. (PRMS). All Rights Reserved.
COLLECT INFORMATION • • • •
Patient Medications Treatment / standard of care Abuse / diversion
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COLLECT INFORMATION – ABOUT THE PATIENT • History • PMP
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COLLECT INFORMATION – ABOUT THE MEDICATIONS • REMS: Strategy to manage known or potential serious risks associated with a drug product and is required by the FDA to ensure the benefits of a drug outweigh its risks
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REMS ELEMENTS • MUST INCLUDE: ›
Timetable for assessments of strategy
• MAY INCLUDE: › › ›
Medication guide; patient package insert Communication plan Elements to assure safe use (ETASU)
21 U.S.C.A. § 355‐1(c)‐(f) (West 2012)
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MEDICATION GUIDES • Information needed to prevent serious adverse effects • Support informed decision‐making by patient • Patient adherence to directions is essential to effectiveness • E‐mail alerts when updated
www.fda.gov/Drugs/DrugSafety/ucm085729.htm
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COMMUNICATION PLAN • Letters to providers • Disseminating REMS information to providers › Encourage implementation of REMS › Explain safety protocols, i.e., medical monitoring by periodic lab tests
• Using professional societies to educate providers on serious risks and protocols to assure safe use 21 U.S.C.A. § 355‐1(e)(3) (West 2012)
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ELEMENTS TO ASSURE SAFE USE (ETASU) • Provide safe access • Minimize burden • Assure safe use › › › › › ›
Prescriber training or certification Dispenser certification Dispensing restricted to hospitals or infusion centers Evidence of safe‐use conditions, i.e., lab test results Specified patient monitoring Patient registry 21 U.S.C.A. § 355‐1(f) (West 2012)
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ELEMENTS TO ASSURE SAFE USE (ETASU) • Implementation system › ›
Monitor implementation by providers, etc. Work to improve implementation
• Evaluation • Additional mechanisms to assure safe access ›
Unapproved therapies
• Waiver in public health emergencies • Limitation ›
Shall not be used to block or delay approval of other drugs 21 U.S.C.A. § 355‐1(f) (West 2012)
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ER/LA OPIOID ANALGESICS REMS • Physician Training • Patient Counseling › Patient Counseling Document
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ER/LA OPIOID ANALGESICS REMS (Continued) • Emphasize understanding medication guide • Consider other tools › Treatment agreement › Assessment instrument › Other items
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COLLECT INFORMATION – ABOUT THE MEDICATIONS • Label
› Know the label › Can change • FDA’s MedWatch: www.fda.gov/Safety/MedWatch/default.htm
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www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm367726.htm
NEW SAFETY INFORMATION In response to new safety information, review the appropriateness of your prescriptions • Communicate new information to patient – and document • If medication is changed ‐ › › ›
Document your decision‐making process Obtain informed consent Document informed consent discussions
• If not clinically appropriate to change ‐ › › › › ›
Document your decision‐making process Obtain updated informed consent Document updated informed consent Consider modifying patient monitoring Do not hesitate to seek consultation 65
COLLECT INFORMATION – ABOUT TREATMENT / STANDARD OF CARE • Medication‐specific › Ex: opioids
• Patient‐specific › Ex: C&A
• Expectations of regulators › State › Federal
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FDA’S BLUE PRINT FOR PRESCRIBER EDUCATION FOR EXTENDED‐RELESE AND LONG‐ACTING OPIOD ANALGESICS Pharma must provide: • CME education for prescribers • Information of patients
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COLLECT INFORMATION – ABOUT ABUSE COMMON CHARACTERISTICS OF THE DRUG ABUSER • From the DEA: › › › ›
Unusual behavior in waiting room Assertive personality, often demanding immediate action Unusual appearance Unusual knowledge of controlled substances and/or textbook symptoms › Evasive or vague answers to questions regarding medical history
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COLLECT INFORMATION – ABOUT ABUSE (CONTINUED) › Reluctant or unwilling to provide reference information › No regular doctor; no health insurance › Will request a specific controlled drug and is reluctant to try a different drug › No interest in diagnosis; fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation › Exaggerates medical problems and/or simulates symptoms › Cutaneous signs of drug abuse
www.deadiversion.usdoj.gov/pubs/brochures/pdfs/recognizing_drug_abuser_trifold.pdf
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COLLECT INFORMATION – ABOUT ABUSE COMMON CHARACTERISTICS OF THE DRUG ABUSER • From the CA Department of Justice: › › › ›
Hesitates or is unclear about personal information Requests specific controlled substances Repeatedly runs out of medication early Rapid requests for increase in controlled substances
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COLLECT INFORMATION – ABOUT ABUSE COMMON CHARACTERISTICS OF THE DRUG ABUSER • From the CA Department of Justice (Continued): › › › › › › ›
After‐hour, holiday or weekend requests for controlled substances Unscheduled refill requests Unwilling to try non‐opioid treatment Ongoing use after medical problem has resolved Doctor‐shopping Moving from one PCP to another frequently Evidence of withdrawal symptoms
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COLLECT INFORMATION – ABOUT ABUSE MODUS OPERANDI / SCAMS USED • From the DEA: › › › › ›
Must be seen right away Wants an appointment toward end of office hours Calls or comes in after regular business hours Traveling through town, visiting friends or relatives Feigning physical problems
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COLLECT INFORMATION – ABOUT ABUSE MODUS OPERANDI / SCAMS USED • From the DEA (Continued): › › › › › ›
Feigning psychological problems States that specific non‐narcotics do not work or he is allergic to them States prescription has been lost or stolen Requests refills more than originally prescribed Pressures by eliciting sympathy or guilt Utilizes a child or elderly person when seeking stimulants or narcotics
www.deadiversion.usdoj.gov/pubs/brochures/pdfs/recognizing_drug_abuser_trifold.pdf
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COLLECT INFORMATION – ABOUT ABUSE MODUS OPERANDI / SCAMS USED • From the MO Task Force: › › › › ›
Obese person scam Grandparent scam Pain while traveling scam Hyperactive child scam Forged or stolen records scam
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COLLECT INFORMATION – ABOUT ABUSE MODUS OPERANDI / SCAMS USED • From the MO Task Force (Continued): › › › › ›
Help me, I’m an addict scam Police report scam Friend in doctor’s office scam Asleep at wheel scam Aggravated stump scam
http://health.mo.gov/safety/bndd/doc/PreventingPrescriptionFraud.doc
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COMMUNICATE – ASSESSMENT AND MONITORING • Conduct thorough patient examination, interview, and assessment • Consider standardized assessment and documentation tool › Especially for pain • Ex: PADT from Janssen
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COMMUNICATE – INFORMED CONSENT Standard Elements: • Nature of proposed medication • Risks and benefits of proposed medication › Including potential for tolerance, dependence, addiction, overdose
• Alternatives to proposed medication • Risks and benefits of alternative treatments • Risks and benefits of doing nothing
Plus: • Prescribing policies • Reasons for which medication may be changed or stopped 77
COMMUNICATE – INFORMED CONSENT “MATERIAL RISK” • • • •
Disclose risk if SEVERE, even if infrequent Disclose risk if FREQUENT, even if not severe Disclose possible driving impairment Golden Rule
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COMMUNICATE – INFORMED CONSENT Medication Guides • FDA › www.fda.gov/drugs/drugsafety/ucm085729.htm
• AACAP / ParentsMedGuide ‐ ADHD › www.aacap.org/App_Themes/AACAP/Docs/resource_centers/adhd/adhd_p arents_medication_guide_201305.pdf
FDA’s Patient Counseling Document for Opioids › www.fda.gov/downloads/forindustry/userfees/prescriptiondruguserfee/ucm 361110.pdf
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COMMUNICATION WITH PATIENTS Educate the patient on issues such as: • • • • •
Restrictions (driving, diet, activity, etc.) associated with the medication Monitoring, such as blood work, that is needed Purpose, dose, and frequency of the medication How to identify side effects, and what to do if patient experiences Ensuring patient’s other physicians are aware of new prescriptions
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COMMUNICATION WITH PATIENTS Communicate to obtain informed consent: • Reminders if you choose to use medication information sheets: › ›
You are responsible for tailoring them to meet your patient’s needs and for ensuring the information is up‐to‐date Be sure to document in the record that the medication information sheet was reviewed with the patient and the patient was provided a copy
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COMMUNICATION WITH PATIENTS Communicate to obtain informed consent (continued): • Remember that informed consent is an ongoing communication process • Know who has decision‐making authority ‐ obtain and retain proof of that authority • Understand that communication is crucial to your patients’ understanding of the treatment plan • Document the informed consent process
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COMMUNICATION WITH PATIENTS Communicate to obtain informed consent (continued): • If you are prescribing off‐label, discuss off‐label nature of the use with the patient › FDA position › All off‐label prescribing is NOT the same in terms of medical malpractice risk
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COMMUNICATE – TREATMENT AGREEMENT • Can Cover: › Intended benefits of using controlled substances › Risks of the treatment – tolerance, dependence, abuse addiction › Prescription management – security of meds
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COMMUNICATE – TREATMENT AGREEMENT • Can Cover (Continued): › Office policies • Only one prescriber • Only one pharmacy • Not replacing lost or stolen prescriptions • Prohibiting dose or frequency increased by patient • Use of PMP • Random pill counts • Random urine screening
› Termination for • Failure to adhere to treatment plan • Aberrant Behavior
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COMMUNICATE – DISPOSAL OF UNUSED MEDICATIONS The FDA’s “Disposal of Unused Medicines: What You Should Know” www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm
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COMMUNICATE – WITH OTHERS • Other providers: › Covering › PCP, specialists › Consultants
• Family › Remember: safety = exception to confidentiality
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CAREFULLY DOCUMENT Generally: • Medication log • Evaluation • Medial indication for prescription • Treatment plan › Initial › Updated
• Treatment agreement, if any › Subsequent discussions about agreement
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CAREFULLY DOCUMENT Generally (Continued): • Informed consent › Patient Education Materials
• Ongoing assessment › Adherence to treatment plan › Medication monitoring › Aberrant behavior
• Referral / consultation, if necessary • Basis for clinical decision‐making
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CAREFULLY DOCUMENT Consider: • Treatment agreement • Standardized assessment form
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CAREFUL DOCUMENTATION Remember: • There’s no such thing as a perfect record • Defense attorneys can work with adequate records • Defense attorneys cannot work with no records or altered records
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CAREFUL DOCUMENTATION Professional Judgment – Bottom Line: • By articulating the basis for medical decisions in the record, the psychiatrist’s professional medical judgment will be clear and available to defend the psychiatrist against allegations of malpractice.
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SPECIAL SITUATION: MULTISTATE LICENSURE AND TELEPSYCHIATRY Remember: • A DEA registration • Required one in‐person examination › Federal telemedicine exception is limited
• Other state requirements
RM Strategies: • Understand federal requirements • Check with each states’ licensing board
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SPECIAL SITUATION: MULTISTATE LICENSURE AND TELEPSYCHIATRY
Accessed September 23, 2016 www.linkedin.com/pulse/what‐does‐ryan‐haight‐have‐do‐telemedicine‐ donna‐vanderpool‐mba‐jd?trk=mp‐reader‐card
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SPECIAL SITUATION: CANNABIS Remember: • Illegal under federal law • Research that might inform the standard of care is lacking • Serious issue for psychiatrists
RM Strategies: • Best to refrain from recommending • Never prescribe
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SPECIAL SITUATION: CANNABIS
Accessed September 22, 2016 www.linkedin.com/pulse/why‐marijuana‐still‐high‐risk‐physicians‐ donna‐vanderpool‐mba‐jd?trk=prof‐post
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