Physicians may be forgiven for a feeling of whiplash after emerging from an era of pain-medication permissiveness to today’s opioid vigilance. Nevertheless, practitioners must always be alert to the warning signs of a patient who is abusing the trust of the physician- patient relationship.
Dr. A, an anesthesiologist and pain-management interventionist, began seeing a 28-year-old patient who reported a right shoulder snowboarding injury and surgery five years earlier. The patient said he was constantly dealing with aches and pains arising from reinjuries. Physical therapy had not helped and the patient reported a history of taking five to six Norco pills daily for three to four years. He also reported having used Vicodin, Lortab, ibuprofen, Motrin, Flexeril, Soma, and Ultram for pain.
Based on his examination of the patient, Dr. A diagnosed cervicalgia and myositis and prescribed Feldene, Ultram, and Norco for pain.
The patient returned to Dr. A monthly with varying complaints of neck and back pain. In addition to Norco, Dr. A’s prescriptions early in his care included Robaxin and Relafen. On his third visit, the patient said his pain was 8/10, with increased back pain related to work activity as a delivery-truck driver. Dr. A found no radiculopathy or neurologic deficits. He continued the Robaxin and Norco, and put the patient on light work duty. He suspended the Relafen.
Two days following that third visit, Dr. A received a letter from the California Department of Justice that included a CURES report showing the patient receiving Norco prescriptions from several other providers at multiple pharmacies. When Dr. A asked his patient about this report at the next month’s visit, the patient responded that he had been the victim of identity theft and that the other prescriptions were not his. Dr. A did not dispute the patient’s explanation, continued the medications, and renewed a prescription that the patient had from another physician for Wellbutrin.
Monthly visits continued into the next year with Dr. A’s impression continuing to be cervicalgia and lumbago. The Robaxin and Norco prescriptions were continued. At one visit early in the year, Dr. A renewed the patient’s prescriptions for Wellbutrin and Lexapro, noting that the patient had reported his PCP was out of town.
During the early part of the year, Dr. A received two letters from Medco, the first concerning the patient’s use of Wellbutrin “significantly greater than the six-month minimum as recommended by the American Psychiatric Association” and the second showing the patient receiving multiple prescriptions by multiple providers. Dr. A’s records show the patient explaining that he had received opioid prescriptions from his dentist and orthodontist for some dental work.
The monthly visits continued, and Dr. A charted a plan to attempt to wean the patient off some of the medications. A new prescription of Norco was reduced from 150 pills to 135, and prescriptions for Wellbutrin, Lexapro, and Robaxin were discontinued, as was a prescription for Percocet, which Dr. A had prescribed as a Norco substitute for several months. Dr. A re-prescribed Wellbutrin and Lexapro at a subsequent visit when the patient complained of difficulty without those medications.
The patient continued to see Dr. A monthly throughout the next year, reporting pain ranging from 6-8/10. Dr. A continued to prescribe Xanax and Norco. Following a work-related vehicular accident, the patient reported stress in looking for new employment and from his marriage. At one point, the patient specifically asked Dr. A to switch his medication from Norco to Opana ER, stating that Norco was no longer helping. At the next visit, Dr. A prescribed Opana ER for daily use, while decreasing the Norco to twice daily.
The next year brought more stable employment for the patient and a better exercise routine. Dr. A decreased the patient’s Opana ER to every third day while maintaining the Norco and Xanax medications. Monthly visits continued into the next year with the patient reporting mid-year that he had been hit by a car while riding his bike and had been diagnosed with a knee contusion. Per the patient, X-rays of the knee were negative for a fracture but he felt pain in his left knee while walking and standing.
With the patient's knee pain continuing, Dr. A ordered an MRI, which showed a meniscus tear. Dr. A maintained the patient’s pain medications while the gentlemen pursued physical therapy and orthopedic treatment.
In the first half of the next year’s treatment with Dr. A (now at year five), Dr. A was alerted by a pharmacy that his patient was receiving Methadone from several providers. A CURES report run by Dr. A revealed the patient was receiving Norco, Xanax, and Methadone from several providers. When Dr. A asked the patient about the CURES report at the next visit, the patient told Dr. A that his stepbrother had been using his identification to get pain medications from other physicians. Dr. A documented the discussion and continued the patient’s medications without change until several months later, when he decreased the Opana ER to every fourth day.
Monthly visits continued into the next year. Late in year six, Dr. A received a medical record request from a deputy public defender, who explained that he was representing the patient in what appeared to be a criminal matter.
Early in year seven, the patient reported that he had been in an automobile accident and complained of increased neck stiffness and spasms in the neck and right upper back. Dr. A requested that the patient continue the physical therapy as prescribed by the urgent care facility that he had visited. Dr. A maintained the patient on his medications and also prescribed Tizanidine, a muscle relaxant.
After a two-month hiatus, the patient returned to Dr. A, reporting that he had been called to active military service until being placed on disability status. Dr. A wrote his regular prescriptions for Opana ER every three days, Xanax daily, and Norco four times a day. Later that day, the gentleman returned to Dr. A’s office, reporting that he was tired and needed to sleep. Dr. A found a place for the patient to sleep. After finishing with his other patients, Dr. A awoke the patient and called the patient’s wife, who picked him up.
Later that day, the patient was found blue with shallow breathing and after a 911 call, was taken by ambulance to the community hospital after receiving Narcan in the field. His diagnosis at the hospital was possible opiate overdose and aspiration pneumonia. Dr. A was not contacted regarding the admission.
When the patient returned to Dr. A two months later, Dr. A confronted the patient with a new CURES report that he had run showing the patient getting medications from various other providers. The patient claimed that his cousin had been using his identity to get medications from other physicians. Dr. A told the patient that he needed proof of the identity theft and that he would start weaning the patient off his medications. Dr. A reduced the Norco and Opana ER, discontinued the Xanax, and told the patient that he would be discharged from his care without proof of the claimed identity theft. The patient never returned.
In a subsequent lawsuit, the patient claimed that Dr. A’s treatment caused him to become addicted to pain medications. This addiction caused him to lose his job as delivery truck driver and ultimately his driver’s license. In the lawsuit itself, the patient referred to the day of his hospitalization and alleged that he “collapsed at [defendant’s] medical office . . . because of the pain medications and [defendant] then failed to render appropriate medical care to him.” He also claimed that his addiction resulted in two felony convictions, which severely impacted his employment opportunities. Other damages alleged included medical expenses he incurred while in jail and restitution that he owed as a result of his criminal convictions. (As it turned out, the two months of military call-up that he told Dr. A about was actually time spent incarcerated.) The patient testified in deposition that he had used illicit drugs during the time of his treatment with Dr. A but that Dr. A never requested that he submit to a drug test. The lawsuit was resolved informally.
Do physicians treating pain with medications need to be constantly suspicious of their patients? That’s a question best left to individual situations. Certainly, though, physicians who use patient drug contracts, consult with specialists to determine underlying causes for their patients’ pain, screen for other drug use, and act decisively after suspicious CURES reports can help avoid exposure when a patient’s next pursuit is them.
Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.