Want to be fined? Follow CMS’ opioid guidelines.
https://www.physicianspractice.com/opioids/want-be-fined-follow-cms-opioid-guidelines
Recent federal guidelines on opioid prescribing have forced physicians to become extremely cautious in their prescribing habits and documentation as well as their handling of patients with opioid addictions.
With all the attention on opioid overprescribing, little attention has been paid to patients with chronic pain and a true need for high doses of pain medication. Even less attention has been paid to physicians trying to balance the government’s prescribing guidelines with the needs of these chronic pain patients.
In a recent case, the New Hampshire Board of Medicine investigated a physician who is board certified in pain management and anesthesiology after cutting back a chronic pain patient’s prescription opioid painkillers. The patient had been on a dosage of 80 mg of OxyContin twice daily and 30 mg of oxycodone four times a day for many years. After apparently reviewing the guidelines put out by CMS, which the physician read as allowing doctors to prescribe only up to 90 morphine milligram equivalents a day (MME), the doctor informed the patient he was reducing his dosage to comply with those guidelines. This reduction was less than one-quarter of what the patient had been taking (equivalent of 420 MME).
The patient subsequently complained that his pain was not being controlled by the lower dosage, and he was having a tough emotional time. The patient also failed a pill count and was later admitted to a hospital for threatening suicide. The physician informed the patient he was no longer comfortable prescribing opioids for the patient and would no longer treat him. The physician reported his concerns about the patient’s well-being to the local police department and the man’s primary care physician. The doctor also issued a prescription for an opioid withdrawal drug.
A complaint was filed against the physician, and the New Hampshire Board of Medicine found his handling of the case violated ethical standards of professional conduct. The physician was reprimanded, fined and required to participate in at least 12 hours of education in prescribing opioids for pain management. The physician was found to be at fault for not recognizing that the prescribing guidelines did not actually set an upper limit for opioid prescribing. Rather, the guidelines simply required pharmacists to discuss the cases with physicians who were prescribing higher doses. This physician is, however, certainly not alone in reading the CMS “guidelines” as rules that should be strictly enforced.
The physician in this case appears to have otherwise been in compliance with recommended protocols for pain management. He followed CMS “guidelines,” terminated a patient who did not comply with pill counts and alerted authorities when he felt the patient was in danger. He also checked the drug monitoring database and required urine tests.
But the rules related to prescribing pain medications and treating chronic pain patients are not so black and white. Physicians who believe that meeting the above requirements will keep them safe from enforcement action need to be cautious.
The prescribing guidelines set by CMS, CDC and other agencies are just that…guidelines. While physicians need to be cautious if they are not following those parameters, it’s important to actually understand the standards for prescribing and to use their professional judgment. Documenting all decision-making and seeking a second opinion (or consulting with the pharmacist) are also recommended.
For physician practices that prescribe opioids, my advice remains the same:
- Have a clearly defined prescribing policy to follow both within the practice and with the patient. Establish strict documentation requirements and mandate continuing education for physicians in the area of pain management.
- Have a plan of action for a patient who is noncompliant despite the physician’s exercise of his or her professional opinion when prescribing. This may mean referral to another pain physician for a second opinion or referral to an addiction specialist. Sometimes, patients do need to be terminated from the practice for noncompliance and/or activity that puts both the patient and the physician at risk. Being able to identify these different types of patient situations, and documenting all decisions appropriately, is key.
It’s a complicated time to prescribe opioids to patients. But there are many patients truly suffering from chronic pain who need the attention and empathy of their physicians. Being educated about the law — and the continuously changing national guidelines — as well as planning in advance for possible scenarios, can help protect both physicians and patients.
Ericka L. Adler, JD, LLM has practiced in the area of regulatory and transactional healthcare law for more than 20 years. She represents physicians and other healthcare providers across the country in their day-to-day legal needs, including contract negotiations, sale transactions, and complex joint ventures. She also works with providers on a wide variety of compliance issues such as Stark Law, Anti-Kickback Statute, and HIPAA. Ericka has been writing for Physicians Practice since 2011.
Filed under: General Problems
When corruption, pseudo science, lies, and propaganda drive policy this is what happens.
https://www.rawstory.com/2019/08/shouldnt-there-be-a-law-against-reckless-opioid-sales-turns-out-there-is/
“In 2011, then-DEA administrator Michele Leonhart testified before a Senate judiciary subcommittee that the agency was increasing its investigations of doctors and pharmacists who illegally diverted controlled substances. What I believe the DEA missed was that the manufacturers and distributors of opioids had gone rogue.”
The DEA was forced to go after patients, pharmacists and physicians, to protect the profits of the distributors and manufacturers. The big corporations are above the law. The mass media won’t cover this story, just like they did not cover it back in 2011 and before. It looks like the lies and paltering of the corporate media are deadly too, since so many people died due to their misreporting.
I can sympathize with doctors/clinics who are being put in a position where they are being threatened by such entities as the DEA. However, I strongly feel that it is not the responsibility of the patient to give up their physical/mental health, functional status, quality of life, and be driven to thoughts of suicide just because the patient is on the low end of the totem pole. There needs to be ‘push back’. If not at the pain doctor level, them certainly at the clinic level where the doctor works. In my opinion, the clinic needs to tell entities such as the DEA that it is not in the best interest of their intractable chronic pain patient (cpp) to remove him/her from medication that has been treating their condition for years. BUT, alas, it is the old story of “S–t Flows Downhill” and the cpp is at the bottom of the proverbial hill. So, it is so much easier for the clinic to force the cpp off their medication(s) than to push back against a government entity that is telling them they must do this. This is being done even though it is now recognized that forcing a cpp off their pain meds is a medically unsound practice. If the Clinic will not take a stand to defend the cpp, then it is up to the cpp to do so.
I speak from experience as I am/was on a relatively high dosage of opioids where I was considered stable. My doctor (a Doctor Boomgaard with http://www.aapain.com in Anchorage, Alaska) stated that the following on my records, “Medication medically necessary…Patients functional status greatly decreased with the reduction in medication.” This should have been all that was needed for the doctor/clinic to not place me on a Forced Medication Reduction (FMR) of 80%, but they have. I was told that they (i.e., the doctor/clinic) was being forced to do this.
I am trying to dissuade my doctor and clinic from continuing this. I have sent messages to my doctor on the clinic’s patient portal 3x, but have received no reply; their policy states they will reply in 2 business days. There is no way provided for the patient to directly contact the clinic.
I am currently contacting my congressional representatives to try and stop this FMR, but that is a s-l-o-w process, and I am not at all sure that they will take any steps to stop this FMR that the doctor/clinic has started. I started trying to contact them about 6 weeks ago and have run into nothing but delays in getting this situation handled.
If anyone has any other suggestions, I am open to ideas.
Thanks for reading my long comment. Pardon any typos as sitting to write this is a painful experience.
Even though it has been “established” that the 2016 CDC decree is only a “guideline”, that is NOT what physicians are being told by none other than the…..DEA! I know this to be FACTUAL at least with my physician who is a pain management specialist. My physician KNEW that it was not in my best interest to “taper” my dosage at the start of 2017 but, he did so to “comply” NOT with the CDC “guideline” but, with the DEA who had expressed to my prescriber that he IS under scrutiny to “comply” with said “guideline”. My prescriber acted in “his” best interest which was to taper my personal dosage by 80 PERCENT( in 8 weeks) after over two decades of well documented ,”pill counted”, DOUBLE “urine screening”, every freaking visit! I do not “blame” my prescriber. What would I/you do in the prescribers’ position?
I agree with and appreciate you comments Hayden. I am sorry for all of our troubles. AND I think I have been consistent in my remarks and many know where I stand. They should have stould for existent law, even anonymously, because they are interested in law, citizenship and the abandoned pain patients, its the American Way at the very least. They could not arrest them all, and a firm stand would prevent it even happening again. I would have thought that would have been obvious. Many of the doctors of courage that we know did exactly that.
Agreed. Whether a Democrat or Republican or an Independent vote caster, I am bombarded DAILY with donation seekers. I e-mail EVERY last “donation seeker” that we are STILL here but, you, the elect are NOT listening. Maybe, just maybe if we ALL do similar they will be forced to listen. Our Veterans are getting the shaft and so are 20 million or so voters. Fight you war Dems and Republicans however, we are STILL HERE waiting for something to be done.
The severe pain sufferer is the only one REALLY suffering for ‘opioid thing’.
Why should physicians and their patients be put through all this crap when the real cause of overdose is heroin, fentanyl analogs, and mixing street drugs?? All it does is to make everything more difficult for those who actually need medication and makes the expense of treating chronic pain ridiculously high!! I don’t know of anyone using/addicted to street drugs going to such ridiculous lengths! We aren’t the problem but as usual those who follow the rules are the ones to pay through the nose!!
JMO,,,,I believe this was all about the $$$$,,,insurers did not want to pay for pre-existing,,ie that’s us,,,all chronic pain patients are a pre-existing patient,,We all know the insurers have fought tooth and nail NOT to insure the pre-existers,,they’ll be dammed if their going to pay for our medicines.Come on the ceos of bc,bs,,aetna,,need to make 18 million a year and of course the golden parachutes.They want us to pay for our own care,,here comes the 7,000 A PIECE deductables,,forced visits,,,forced pee test,,etc,,ITS ALL ABOUT THE $$$,,,,,,,AND SORRY,,,,DOCTORS SHOULD OF ALSO FOUGHT TOOTH AND NAIL TO STOP THIS LITERAL TORTURE willfully onto the medically ill..Also many believe were just addict’s,,hey there grampa didn’t need these medicine in the early `1900 why should we,,we should just suffer to death literally.
I went for a counsel on Monday to a guy closer to us,,he refuse to acknowledge opiates work long term,,nothing over 50 me,,most chronic pain is emotional based,,,,I quickly pointed out to him,,i was a advocate for not accepting torture upon the medically ill and I disagree w/your bullshit THEORIES.Also he quoted that dame krebbs study as gospel ,,as their ebm,,,Now this was a p.m doctor,,,a doctor agreeing w/the dea,,even stating no innocent doctors are ever arrested.I couldn’t get out of their quick enough,,,,but,,,,is this the future pain management doctor???Kissing the dea’s ass??
Also I discovers a paper out of wisco on how thee seek and destroy doctors.The use medicares/caid data to see which doc;s prescribe the most,,,top 7,,,get harassed,,,after taking down those top seven,,they take out the next top 7 at a lower standard of ,”what high prescribers are,”.They just keep this up ,,till there will be no-one left…
They want us,our doctors,and our medicines gone.They will do anything,legal or not to accomplish this,,,and sooo far,,,us doing it the legal way,,the moral way,,,,isn’t working for CPP’s,,,,jmo maybe start doing it their way,,illegally,,,jmo,,maryw