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Dr. Standiford Helm offers physicians advice on prescribing opioids safely.
Every good doctor providing care knows that pain management – sometimes on an ongoing and chronic basis – is essential.
And for a number of years, the consensus was that doctors were not doing enough. “For a time, beginning in the 1980s through the 2000s, there was a belief that patients were undertreated for pain. Many believed providing opioids for pain would not have serious risks,” explains Dr. Standiford Helm, founder of The Helm Center in Laguna Woods, California.1
But recent data is troubling and has led to serious reevaluation by medical boards everywhere.
- Between 1999 and 2011, deaths from prescription painkillers quadrupled.
- In 2009, painkiller overdoses surpassed traffic accidents as a major cause of deaths.
- According to the Centers for Disease Control and Prevention (CDC), every day 44 people in the U.S. die from overdoses of prescription painkillers, and many more become addicted.2
In 2011, the CDC declared it an epidemic. And the focus isn’t just on teenagers raiding their grandparents’ medicine cabinets, or addicts breaking into pharmacies.
Growing Scrutiny of Doctors
The media and government are looking harder at the medical community. At the Cooperative of American Physicians, we’re seeing a small but concerning pattern of claims and MBC actions involving excessive or inappropriate prescribing of pain medications.
According to a 2012 Los Angeles Times study, “physicians played an important role in prescription drug overdoses. The Times analysis of 3,733 fatalities found that drugs prescribed by physicians to patients caused or contributed to nearly half the deaths.”3 And a study by JAMA Internal Medicine says opioids prescribed by doctors led to 92,000 overdoses in ERs in one year.4
In late 2014, the Medical Board of California (MBC) issued new opioid treatment guidelines, with much more rigorous requirements for how doctors must comply when prescribing them. “There are issues with doctors not adequately supervising patient levels, and complaints from families about prescribing into abuse being ignored,” says Dr. Helm. “It’s critically important that doctors take the new guidelines quite seriously. But what’s also concerning is how many conscientious physicians – who are really working very hard to stay in compliance -- are being criticized or having lawsuits brought after the fact. For example, if there is a death, family members who didn’t complain prior blame the doctors afterward.”
What Should Doctors Do?
In our interview, Dr. Helm offered the following advice.
- Think before you prescribe. Some doctors have been prescribing opioids for sprains and strains and that should be seriously reconsidered. It is simply not worth the risk in this environment.
- Know the guidelines in detail. Make sure you are fully aware of exactly what the current medical board guidelines are and how they are enforced. Before 2014, doctors were supposed to conduct physical/psychological function tests and ensure there were no substance abuse issues. If we’re honest, we know that many doctors didn’t do it. But today, a zealous medical board expert may see this as a departure from the standard of care and that can lead to sanctions.
- Be diligent about compliance. Get the right records, the right drug screens, be able to document improvement with medications, be very clear about why medications are given, and be very clear about whether there is any history of substance abuse. Your duty now goes beyond being a good physician – you must get the technical details right.
- Be smart about referring out. If you do not routinely prescribe opioids, consider referring that task out if you are doing anything more than a short-term course of medication. For patients who need pain management on a chronic basis, too much monitoring needs to be done. Try to find a pain management physician you have confidence in.
- Don’t get complacent. Even the best doctors are at risk. If your charts are reviewed zealously, any physician can be found to have shortcomings and will have to defend him or herself. This is very time consuming.
- Pay attention to complaints. If you get a complaint from a family member about the care you are providing, do not ignore it. Assume they will complain to the medical board.
In the event of a medical board complaint, the board will evaluate it internally with an expert. If further investigation is deemed necessary, the board will inform the complainant, and will likely seek other patients to approach and speak with the coroner if there had been a death.
“These are very detailed investigations, with as many as 50 different tabs including interviews with doctors, pharmacies, prescribing histories, and more before it is ultimately sent out to reviewers,” explains Dr. Helm. “It consumes a lot of the doctor’s time working to defend the case, and the sanctions can range from losing your patient flow or insurance from certain companies. In the worst case, it can be career-ending and civil actions can arise.”
Stay Safe
The changes may seem daunting at first, but if you follow Dr. Helm’s guidelines, it will help protect you, your practice, and your patients. In the end, it’s all about doing what you have always worked hard to do: provide the best possible care and avoid preventable deaths.
1 The Helm Center website
http://www.thehelmcenter.com/
2 Centers for Disease Control and Prevention, “Injury Prevention & Control: Prescription Drug Overdose”
http://www.cdc.gov/drugoverdose/
3 Los Angeles Times, Nov. 11, 2012, “Dying for Relief, a Times Investigation: Legal drugs, deadly outcomes,” Part 1 of 4
http://graphics.latimes.com/prescription-drugs-part-one/
4 The JAMA Network, Oct. 27, 2014, “Prescription Opioids Involved in Most Overdose Seen in Emergency Departments”
http://media.jamanetwork.com/news-item/prescription-opioids-involved-in-most-overdoses-seen-in-emergency-departments/