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There is a host of new, ever changing, and conflicting guidelines from a multitude of regulators and academic societies. This evolving and uncertain landscape is making the life of a practicing pain physician in the midst of today’s nationwide opiate epidemic…painful.

Here are 10 tips to help you avoid Medical Board discipline when prescribing opiates:1

1.  Don’t Prescribe Opiates Unless…

  • The patient has exhausted all reasonable alternatives
  • There is medical indication
    – Recently documented objective evidence of/consistent with patient’s pain complaints
  • You have conducted a comprehensive history, initial exam, imaging, UDT’s, CURES, ORT’s, have a signed pain contract, and have provided informed consent

2.  Treat the 2014 MBC Guidelines as Dictating the Standard of Care (i.e. rules you must follow) – Deviations from these Guidelines must be justified and documented.

3.  Use a Team Approach

  • Include other professionals
    – Addictionologist/Pain Psychologist
    – Residential/Inpatient Detox
    – Physiatrist
    – Physical therapist
    – Psychiatrists (for psych medications)
    – Sleep Specialist
  • Document
    – Referrals
    – Patient Declinations/Refusals of Recommended Care or
    – Consultation
    – Communications with other providers
    – Plan of action based upon other providers’ recommendations

4.  Pay Attention to the Red Flags and Take the Following Precautions

  • Use opioid risk tools
  • Use screening questionnaires
  • Train your staff to pick up signs of abuse
  • Correct your staff if they miss a sign
  • Never dismiss calls from pharmacists, or insurance plans with questions about prescriptions
  • Beware of treating one patient differently than you treat all other patients
  • Do not ignore risk factors for history of abuse/addiction
  • Do not excuse failures solely because patient claims are not feasible

5.  Document, Document, Document, Including:

  • Patient questionnaires, pain scores, vitals, patient chief complaints for each visit
  • Make sure to have a pain contract signed & in chart
  • Physical exam for each new complaint
  • Treatment plan and objectives at each visit; document projected end point/re-eval point
  • Description of relief from pain medications on each body part, at each visit
  • Instructions & advisements
  • Beware of templates!

6.  Use CURES When2 …New patient

  • Reason for suspicion
  • Request for early fill
  • Changing medications
  • Patient has new complaint
  • If patient has any compliance issue with pain contract (and you decide not to discharge patient or stop writing prescriptions)
  • Document: Consistent with Pain Contract/ Inconsistent with Pain Contract/Questionable

7.  Conduct Drug Testing on Regular Basis

  • For all new patients
  • Anytime reason for suspicion:
    – Request for early fill
  • Anytime changing medications
  • Anytime patient has new complaint
  • Multiple times per year
    – Quarterly for every patient
  • Minimum 1x/year
  • Document: Consistent with Prescribed Medications/ Inconsistent/Questionable

8.  Only Use Electronic Prescriptions

9.  Audit Your Own Charts

10.  Keep Current on Regulations and News

1 This blog post is not intended to constitute specific legal advice, and it is not a substitute for advice from qualified counsel. The information on this website is general in nature and may not pertain to your specific circumstances.

2 As of October 2, 2018, any physician who prescribes Controlled Substances to a patient will be required to check CURES before the first time and at least quarterly (Health & Safety Code §11165.4)