New Prescribing Regulations Bring Challenges for Doctors

Gregory A. Hood, MD


March 28, 2017

Primary Care Physicians Have Burden for Educating Patients

The legal requirements for prescribing controlled substances that have been enacted in many states during the past decade have presented a steep learning curve for doctors, particularly primary care physicians.

These physicians have shouldered the burden for educating patients about the new regulatory environment. Still, many patients stymied by the rules don't abide by these agreements, putting physicians' practices in jeopardy and potentially putting drugs on the street. Should primary care doctors dismiss these patients?

What constitutes chronic prescribing?

The definition of chronic prescribing of controlled substances takes on different meanings in different jurisdictions. Most agree that prescribing the ongoing availability of controlled substances beyond 90 days constitutes chronic prescribing. Increasingly, states expect those who prescribe controlled substances in a chronic manner to have signed prescribing agreements with patients that are documented in medical records.

Albeit on a learning trajectory, practices have shown that they are capable of process improvement in this area.[1] But the learning curve has been toughest for patients, even though efforts have been made to educate them about this new regulatory environment. Most sample agreements[2] require the patient to agree to stipulations such as this example phraseology: "I will not request or accept controlled substance medications from any other physician or individual while I am receiving such medications from this office. I will not give, share, or sell my medications to any other person."

Nevertheless, significant hurdles remain in ensuring a smooth process. One particularly recalcitrant problem in primary care practice is the acute prescribing of pain medicines by dentists, dermatologists, and other healthcare professionals who perform minor procedures. Sometimes the prescribing appears questionable, such as when a dermatologist recently prescribed 2 days of hydrocodone for a patient in our practice after a mole was removed.

The patient had signed a controlled substance agreement. If the prescriber checked our state prescription drug monitoring program (PDMP) report, as is required, then a pre-existing relationship with primary care chronically prescribing a controlled substance would have been plainly evident.

It is not just good regulatory medicine, it is good medicine in general when proceduralists check PDMP reports prior to prescribing controlled substances. This dermatologist's office stated that they do not have a way to track which patients have agreements with other offices. However, this should be moot if they are checking the PDMP.

In the past, we have had dentists tell patients that they "did not care" if there was a prescribing agreement in place—and then they prescribed pain medication in addition to medication the patient already had. These two examples place the patient in the unfamiliar and uncomfortable position of refusing a medical professional's instructions in order not to violate the terms of a legal agreement into which they have entered. Given that many of these patients are low-risk patients for whom legal constructs pertaining to diversion or improper use are alien concepts, the rates of technical contract violations remain needlessly high.

When consulting, emergency, or otherwise acute care-only practitioners do not perform their due diligence with PDMPs, patient questionnaires, and care coordination with primary care offices, they increase the risk for excessive amounts of medication hitting the streets.

Furthermore, they make their primary care colleagues' jobs much more difficult. When a care provider with a Drug Enforcement Administration license does not police their actions and practice policies, they place an unfair burden upon other providers who also prescribe for these patients. Not only do these other providers have to police the patient and their office, they also have to monitor the potentially derelict office.

Our medical board has publicly stated that it expects patients to notify physicians and dentists when there is a controlled substance contract in place. It has also acknowledged publicly that it cannot expect patients to reliably report. The board had been equally clear that it expects prescribers to monitor the PDMP and proactively consider that if there are signals that there is chronic prescribing from one office (typically primary care, psychiatry, or pain management) on the PDMP, they should perform their duties accordingly. In plain English, this means to check with the other office or do not prescribe, deferring to apparent current pill supplies.


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