Over the past 25 years, physicians have faced a distinct change in attitudes on prescription pain medication. Policy discussions in years past to promote more liberal use of narcotics have been replaced by the current war on opioid addiction. To be sure, a physician attempting to assist a patient on long-term pain medication faces special challenges.
Dr. FP, a family practitioner, had been treating his patient for a number of years for a variety of medical complaints, including back pain. When the back pain became chronic, Dr. FP’s initial treatment plan included Oxycontin 40 mg three times a day and Flexeril. Two months later, Dr. FP received a letter from the patient’s orthopedic surgeon, who noted the patient had a tolerance to narcotic medication and who urged Dr. FP to take the patient off pain meds while he prescribed a Lidoderm patch. Shortly afterward, the patient refused Oxycontin and Dr. FP prescribed Ultracet and Tramadol for pain.
On Dr. FP’s referral, the patient saw a pain management physician a year later. That specialist advised Dr. FP that their patient was on Norco for breakthrough pain, plus Cymbalta and Soma. The patient did not continue to treat with the pain specialist, and about three years later, Dr. FP had to disapprove a refill for Soma until the patient agreed to stop taking the medication in excess of prescribed amounts.
The next year, the patient’s health insurer wrote to Dr. FP about the possibility of the patient’s inappropriate use of controlled substances and an indication that the patient was receiving Norco from a different physician. Though Dr. FP discussed that he would not prescribe medications in addition to those she was receiving from another physician, Dr. FP’s chart did not reflect such discussion.
Two years on, a neurosurgeon wrote to Dr. FP detailing an exam of the patient showing stenosis and facet disease at L4-5 and L5-S1. The neurosurgeon spoke to the patient about her seeing a pain medicine specialist to wean her off oral opiates. Dr. FP’s chart did not show any efforts to taper her off pain medications, but on Dr. FP’s referral, the patient saw another pain management specialist several months later.
That specialist’s assessment was that the patient was dependent on Dilaudid and his plan was to stop the Dilaudid and change her to Methadone. The specialist expressed his view that based on his exam and MRI, the patient did not warrant using excessive narcotics to control pain.
The patient continued to treat with Dr. FP and on several occasions, expressed a desire to get off her medications. The patient’s daughter told Dr. FP of her concerns about her mother’s use of narcotics. At one point, approximately 10 years into the back pain issue, Dr. FP unsuccessfully attempted to taper the patient’s opioids by prescribing Clonidine and Propranolol. In year 11 of the issue, Dr. FP prescribed Oxycodone 100 mg four times a day, 350 mg of Soma three times a day, 75 mg of Lyrica twice a day, and 250 mg of Zoloft daily. At this time, Dr. FP referred his patient back to the second pain management specialist because of his concerns over the patient’s drug dependency.
Five days later, the patient’s daughter found her at home face down on the couch, unresponsive. The coroner characterized the patient’s death as accidental and attributed Oxycodone toxicity as the cause. In a subsequent lawsuit, the daughter alleged Dr. FP prescribed medication at fatal dosages and missed multiple opportunities to make things better. In his deposition, Dr. FP said he disagreed with the coroner’s conclusions, testifying he believed his patient’s death was from a heart attack or suicide. The lawsuit resolved informally without a trial.
Whatever the public policy environment on pain relief, when a family practitioner’s treatment triggers alerts from consulting specialists, pharmacies, and health insurers about a patient’s potential for drug dependency and abuse, a specific plan or “contract” may be a benefit to both.
Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.