New Prescribing Regulations Bring Challenges for Doctors

Gregory A. Hood, MD

Disclosures

March 28, 2017

Watch for Patients Already on Controlled Substances

It is also noteworthy that it is not only the prescription of like substances that is a consideration. I've seen patients whose dentists prescribed medium-dose hydrocodone/acetaminophen (APAP) tablets when the patients were already on controlled substance contracts for higher potency hydrocodone/APAP.

The more subtle point can be when substances from different groups are prescribed. For instance, the addition of a benzodiazepine to a patient on chronic opiate therapy, or vice versa, increases the risk for respiratory suppression. For this to be done in a manner in which the practices are not coordinating care is particularly suspect in today's world.

Given that comorbidities such as sleep apnea can compound the effects of polypharmacy, and these conditions often are underreported to dentists and medical/surgical specialists, the amount to which uncoordinated controlled substance prescribing incurs additional risks to the patient and liability to the prescribers should be clearly understood by all healthcare professionals.

Should You Dismiss a Patient?

A knee-jerk response might be simply that primary care, psychiatry, and pain management offices should dismiss patients who fail to abide by their agreements. However, we are correctly advised by our specialty organizations that this should be the last resort.[3]

You may be faced with a circumstance in which your patient's infractions are truly violations of the terms of the agreement and may be either medically consequential or inconsequential. While the pendulum has firmly swung towards the legal side of medicolegal, it is not clear in many such instances that the patient is engaging in drug-seeking behavior.

Handling this scenario prudently is simply black and white. A patient who fills a prescription without notifying the contracted office or who has not followed the letter of the law with a prescription can be dismissed. However, given the severe shortages of primary care access in many areas and the ripple effects through the practice and the patient's life, dismissing the patient isn't a measured, common-sense, or universally appropriate response.

Although you have the right to dismiss patients, you must make sure that the dismissal is carried out in accordance with the laws of your state. If there are questions about dismissing patients, the legal department of your medical liability carrier may be able to offer advice.

The American College of Physicians Center for Ethics and Professionalism cautions that should dismissal of a patient be contemplated, one should think about the circumstances from the point of view of the patient. Patients who are ill or who are in pain may not process everything that is happening or understand what drugs they are prescribed. That is why our practice routinely offers patients a copy of their controlled substance agreement when the agreements are initiated and renewed or when they request a copy.

Ironically, a patient in this situation may lose their relationship with their primary care physician or their pain specialist (both specialties that are in short supply). Yet, the relationship with the offending provider who instigated the violation by writing their prescription (in the example above, their dentist) may remain extant.

Of course, if enough examples of such prescribing by such an individual health provider come to the attention of their own state licensing board, then that patient-provider relationship may come into jeopardy, and restriction of licensure or other actions are potentially possible.

Even when a violation, or a pattern of violations, is deemed sufficient to end controlled substance prescribing for a patient, it does not have to result in the loss of the patient's primary care relationship. One option is to offer to keep the patient in the practice but only for matters that do not involve prescribing controlled substances. Then you will need to make a referral to an appropriate specialist, such as a psychiatrist or someone who specializes in pain management or addiction.

The best solution is for all healthcare providers to proactively and appropriately engage in full coordination of care for all patients.

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